HomeMy WebLinkAboutSWG2022-00064 - SWG As-Built - 2/9/2023 ut
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2022-00064 Parcel # 52007-75-00080
Applicant Name Chris& Betty Keller Subdivision (Name/Div/Block/Lot)
Applicant Address P.O. Box 3800 TR H OF SURVEY 4/93
City, State, Zip Lacey, WA 98509 Installer Name Russ Construciton, LLC
Site Address 15007 W Shelton-Matlock Rd Designer Name Arrow Septic Designs, Inc
INSTALLATION CHECKLIST
0 Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repar ❑ Other
System Type Sand Lined Pressure Bed Pretreatment Type
>5 ft. from foundation? - - ❑ N/A 0 YES ❑ NO
>50 ft. from wells? - r, ` . - - - ❑ I ❑
z >50 ft. from surface water? - l ��\`2- - - - - ❑� ❑ ❑
NCleanout between building and tan y - - - sq.. - - - - - - ❑ 0 ❑
V
Tank baffles present? - . - -‘ - ❑ ❑
a24" access risers over each compart n , - ��s- - - - ❑ ❑■ ❑
W Effluent filter installed?- ,\�,,\ - ❑ 0 ❑
cn
Septic tank capacity (working) 1,20( L,,; . al Manufacturer Sound Placement
\
i
C1 D-box water level and speed levelers used? - - 0 N/A ❑ YES ❑ NO
0OJ Manifold/D-box accessible from surface?- - E I ❑
u.
oil-2 Check valves installed? - - - - V'"'"e - ❑ 0 ❑
c)Q 40
2 Transport Line Size 2 inch Schedule/Class
Bedrooms installed (check one) ❑ 2 0 3 ❑4 ❑ 5 0 6_— Commercial/Other
>10 ft. from foundation?- ! N/A 0 YES ❑ NO
a >100 ft. from wells?- - - - - ' 0 ❑
J >100 ft. from surface water? - ,D- - - - CI CI
W
E.' >10 ft. from potable water lines?- .' - - - 0 ❑
Z > 5 ft. from property lines and easements?- - - - - - - 0 ❑
Q
eL > 30 ft. from downgradient curtain/foundation drairT? - - - - �r ❑ ❑
a
Drainfield level and observation ports present - - - "� - ❑ A ❑
❑ Graveless chambers or ® Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ 0 ❑
Pump tank setbacks consistent with septic tank? - - ❑ N/A ® YES ❑ NO
• Pump tank capacity (flood) 1,200 qal Manufacturer Sound Placement
< 24" access riser(s) and accessible from surface?- - ❑ II ❑
F-
a. Alarm or Control Panel Installed? ❑ IN CI
2 Control Panel equipped with Timer/ETM /Counter- - El 0 El
D
a- Pump installed in ❑ Bucket or 0 On Block or ❑ Other
a• Pump Make/Model Liberty 290 0 Floats or ❑ Transducer
a.
a. Tank draw down 2 in/min Pump capacity 44 gpm Squirt Height 5 ft
Pump on time 2 min Pump off time 6 hr Daily flcw set at 360 qpd
Updated 8/212018
52
n OSS Installation Report pg. 2 Parcel# C�-]" S�Od
Mason County P
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - [] YES % NO
If yes, please describe:
Were all components pumped out and property abandoned per WAC246-272A-0300? - - ❑ yes ❑ NO
RECORD DRAWING
This le a pemtianant record and must be accosts and dsacrlptive enough to relocate In the road or maintenance activates and inure development. 7Ydcy Record
Draw ngs contain Drainbeid b manifold onentsbon b layout S.P4olpun P tank location,North arrow,reserve&.afield.existing and proposed buArngs location of wee*,waterlines
wells.observation Dort.ckanouts.and other maintensnoe*cases pante Incomplete Record Drawings may watts additional dehya m final installation approval and rutted permits.
Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER) ENGINEER
I certify that I installed the system in accordance with l 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 Meson 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 contained on this I further certify that all information contained on this
form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
D l///2 2
of Installer 1 'Date �-r
Signature Q�t
-
Printed Name of Signee ��?��
Ot N 11
MASON COUNTY PUBLIC HEALTH ,,�V. �
The undersigned approves this Installation Report and . 1/1-e..
; '
Record Drawing on behalf of Mason County Public + PAULA JOY JOHNSON
Hea L'td.rtJSE yi'?i'EiGi_6
Fax4EXPIRES
nature of Environmental Health Specialist Date (stamp, signature and date)
2y1 70,
CkriS t ? ` 1i-elr 1
co. I $52o0 - 75-000$0 11
in:: Audio-Visual Alarm
S (alt: I = (PO' / N
0 30 60
9 o 120 3 Cleanout
I N
3 1.200 Gallon Sept Tank
f 2 Comma- ,,ent with 4
I Effluent Filter i
0 1200 Gallon Pump Champ I
1(
APPROVE .V
1
FEB 0 4 2023 7
i ' MASON COUNTY ENVIRONMENTAL HEALTH
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4PAULA JOY JOIiNSON ''�Il)
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