HomeMy WebLinkAboutSWG2021-00373 - SWG As-Built - 1/12/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG �--( � �Q 3�3 Parcel# gp-At.; -sb. 00o03
Applicant Name 1.i hMtt Pil/1-4-11>S Subdivision (Name/Div/Block/Lot)
Applicant Address aag369 At vs to C�^"
City, State, Zip �t � � I -ppq , Installer Name -i4c to,J
Site Address An 30_ 1J VS tij,;y lel Designer Name Afenky
INSTALLATION CHECKLIST
Full System Installation ❑Tank(s)OnlyDrainfield Only❑ El Repair El Other
System Type 5kAI[ot,J T Aitssui-[_ Pretreatment Type
>5 ft.from foundation? • - ❑ N/A OYES ❑ NO
>50 ft. from wells? - .. 0 0
Z >50 ft.from surface water? - El
HCleanout between building and tank? - . El 214 i �)
V Tank baffles present? - - ❑ 21 0 z
, g
1 a 24"access risers over each compartment?- ID ❑
`W Effluent filter installed?- _ ❑ 121
�. 0 [(�
a
Septic tank size,4 on gal ' Manufacturer aiSr AMC. +o
0 D-box water level and speed levelers used? - - 0 N/A 2#,S ❑ Ngv S�
Oal Manifold/D-box accessible from surface?. - El ❑
G Q Check valves installed? 0 IQ 0
4 2 Transport Line Size a-K Schedule/Class 1-10
Bedrooms installed (check one) 02 0 3 ❑4 ❑ 5 ❑6 0 Commercial/Other
>10 ft.from foundation?- - ❑ N/A 0YES ❑ NO
G >100 ft. from wells?- - 0 27 0
W >100 ft. from surface water? - - 0 Et El
Er- >10 ft. from potable water lines?- - 0 12 ❑
ierZ > 5 ft.from property lines and easements?- 0 0
12 > 30 ft. from downgradient curtain/foundation drains? - - ❑ [ ❑
Drainfield level and observation ports present - - 0 ❑
Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- 0 ❑
Pump tank setbacks consistant with septic tank?- - 0 N/A OrfES 0 NO
ZPump tank size t gSb gal Manufacturer ,4ou t3►.a-tlt,es.j
< 24"access riser(s)and accessible from surface?- - 0 Z ❑
aAlarm or Control Panel Installed? - - El ❑" ❑
Control Panel equipped with Timer/ ETM/Counter- - 0 RI 0
IL Pump installed in 0 Bucket or �n Block or R Other ugat'T"k
a Pump Make/Model 6 itAco PF f0 j01 a 2<ats or ❑ Transducer
2
0. Tank draw down I. in/min Pump capacity Lfd gpm Squirt Height(72') ft
Pump on time I,bli' hw. Pump off time g fits Daily flow set at 1 0 gpd
Updated 8(21/2018
Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES ja-r81O
If yes, please describe: —/
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - El YES
RECORD DRAWING
This Is a permanent record end must be accurate and descriptive enough to re-locate In the need of maintenance activities and future development. Typical Record
Drawings contain: Drainfield&manifold orientation&layout,Septic/pump tank location,North arrow,reserve dralnfleld,existing and proposed buildings,location of wells,waterlines,
wells,observation ports,cleanouts,and other maintenance access points. incomplete Record Drawings may create additional delays In final installation approval and related permits.
4144‘4Y
P,i N -ZAct 3�6c ❑ 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 M n County Codes. State and Mason County Codes
I furth certify that I nformation contained on this I further certify that all information contained on this
form d attache ord Dr ng is accurate. form and attached Record Drawing is accurate.
to -02s- ?-a—
Si ture of Installer Date
gethittfF
Printed Name of Signee �'`` �� - `''a�f
f
MASON COUNTY PUBLIC HEALTH Wiz' 510001 se 4
i o JIM HENRY 171 f
The undersigned approves this Installation Report and [ICENsED , " �I
EXPIRES: 08/11/2,L
Record Drawing on behalf of Mason County Public
Health:
i- wA k ( \2I z3
Signature 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 8r212°18
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