HomeMy WebLinkAboutSWG2022-00536 - SWG As-Built - 1/27/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2 0-1 . - t"336 Parcel# 22221-53-00072
Applicant Name Bruce Blackburn Subdivision (Name/Div/Block/Lot)
Applicant Address 2660 E Mason Lake Dr W Twanoh Falls Div 1/ Lot 72
City, State, Zip Grapeview, WA 98546 Installer Name Daivd Hromjak
Site Address 70 E. Hillside Dr; Belfair 98528 Designer Name Tom Weaver
INSTALLATION CHECKLIST
® Full System Installation 0 Tank(s)Only ❑ Drainfield Only 0 Repair ( OtherBOttomless sand fill r
System Type f" I-i1 - Pretreatment Type
>5 ft.from foundation? - ❑ N/A ]YES 0 NO
>50 ft.from wells? - - ❑ n 0
Z >50 ft.from surface water? - - ❑ M 0
H• Cleanout between building and tank? - - 0 in Cl
✓ Tank baffles present? - - Cl KI 0
d 24"access risers over each compartment?- - ElKI ❑
W Effluent filter installed?- - - - - ❑ ® ❑
N
Septic tank size 1,000 gal Manufacturer Hagerman
0 D-box water level and speed levelers used? - - ] N/A ❑YES ❑ NO
ou.
O Manifold/D-box accessible from surface?- - X 0 El
mZ Check valves installed? - ❑ 0
enE Transport Line Size 2" Schedule/Class SCh 40
Bedrooms installed (check one) g 2 ❑3 ❑4 ❑ 5 0 6 0 Commercial/Other
>10 ft.from foundation?- - ❑ N/A ® YES 0 NO
>100 ft.from wells?- - ❑ Z ❑
W >100 ft.from surface water? - - IDEl
u. >10 ft.from potable water lines?- - 0 ® 0
>5 ft.from property lines and easements?- - El ® El12 >30 ft.from downgradient curtain/foundation drains?- - ® 0 ❑
ci
Drainfield level and observation ports present - - ❑ ® ❑
❑ Graveless chambers or V] Clean gravel used? (check one) Bottomless Sand Filter
Proper cover installed over drainfield?- - ❑ ® 0
Pump tank setbacks consistant with septic tank?- - ❑ N/A Ki YES ❑ NO
• Pump tank size 1 ,000 gal Manufacturer Hagerman
< 24"access riser(s)and accessible from surface?- - ❑ n ❑
aAlarm or Control Panel Installed? - - 0 $] ❑
• Control Panel equipped with Timer/ETM/Counter- El Z] 0
a- Pump installed in ❑ Bucket or ® On Block or ❑ Other
G' Pump Make/Model Libert 28( . . I] Floats or ❑ Transducer
d Tank draw down 2.25 Pu p a r ' ,gym Squirt Height 6 ft
Pump on time 27 Seconds P �o tine.12 HO Daily flow set at 240 qpd
MA. t;,[3 r` Updated8121rzo16
SON COUNTY
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ENVIRONMENTAL HEALTH
mason County OSS Installation Report pg. 1 vane► 2Z a Z - S 3- o v 2
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - 0 YES [3 NO
If yes, please describe:
Were all components pumped out and property abandoned per WAC246-272A-0300? - 0 YES ❑ NO
RECORD DRAWING
This is a permanent record and must be accurate and descriptive enough to re-locate In the need of maintenance activities and future development Typical Record
Drawings Domain Dranbeid a manifold orientation&layout.Septic/pump tank location,North arrow reserve Grainfield,eu•sting and propmed Du7dTga,location o'.wie@s•waterirtes•
wens,observation parts.deanouts.and other ma,ntenance access points Incomplete Record Drawings may create addvoned delays in final mstallalwn approra1 and rotated permits
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0 Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that I installed the system in accordance with I certify that the system has been installed in accor-
the septic design stamped"APPROVED"by Mason dance with the septic design stamped'APPROVED"by
County Public Health and that any deviations shown Mason County Public Health and that any deviations
here have been cleared/approved by both the designer shown here have been cleared/approved by both
and Mason County Public Health and meet all State myself and Mason County Public Health and meet all
and Mason County Codes. State and Mason County Codes
I further certify that all information co tained on this I further certify that all information contained on this
form an ttache ec Drawing accurate. form and attached Record Drawing is accurate.
7 0,
Signature of Install r ate
DAV ( I) 4Q--00VA(14)(- ..
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH 1 g..
approves this Installation Report and %
..
The undersignedPP 5100333 •
Record Drawing on behalf of Mason County Public 1rloMtis E.WEAVER.
't)C 35008''I NES-
He h: EXPIRES 01/25i
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Sidnad/e of Environmental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8112018
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