HomeMy WebLinkAboutSWG2022-00229 - SWG As-Built - 2/22/2023 CC-
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2022-00 j,7,G\ Parcel # 12316-50-00903
Applicant Name Debra Griswold Subdivision (Name/Div/Block/Lot)
Applicant Address 70 NE Emerald Glen Lane
City, State, Zip Belfair, WA 98528 Installer Name Daryl Hemley
Site Address 101 NE Emerald Glen Lane, Belfair Designer Name Rod Left
INSTALLATION CHECKLIST
® Full System Installation 0 Tank(s)Only 0 Drainfield Only ❑Repair 0 Other
System Type_____AMSS LA Pretreatment Type
>5 ft. from foundation? - - ❑ N/A ❑■ YES ❑ NO
>50 ft. from wells? - - ❑ 0 0
Z >50 ft. from surface water? - - 0 ❑■ 0
H Cleanout between building and tank? - - 0 0 ❑
U Tank baffles present? - - ❑ ❑■ 0
a24" access risers over each compartment?- - ❑ 0 ❑
W Effluent filter installed?- - 0 0 0
cn
Septic tank size 1250 gal Manufacturer Hagerman
0 D-box water level and speed levelers used? - - 0 N/A 0 YES 0 NO
OO Manifold/D-box accessible from surface?- - 0 0 ❑
002 Check valves installed? - - 0 0 IN
0Q
2 Transport Line Size 2" Schedule/Class 40
Bedrooms installed (check one) El 2 0 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A 0 YES ❑ NO
0 >100 ft.from wells?- - 0 El 0
W >100 ft. from surface water? - - 0 0 ❑
u. >10 ft.from potable water lines?- - 0 El 0
Z > 5 ft. from property lines and easements?- - 0 0 0
Q
lY > 30 ft.from downgradient curtain/foundation drains? - - 0 0 0
Drainfield level and observation ports present - - 0 [11 0
0 Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - 0 ❑ 0
Pump tank setbacks consistant with septic tank? - - ❑ N/A li] YES ❑ NO
• Pump tank size 1000 gal Manufacturer Hagerman
Q 24" access riser(s)and accessible from surface?- - ❑ 0 ❑
^a Alarm or Control Panel Installed? - - ❑ IN
2 Control Panel equipped with Timer/ETM/Counter- - 0 0 0
m
d Pump installed in 0 Bucket or ❑ On Block or ❑ Other
a• Pump Make/Model Liberty 290 0 Floats or ❑ Transducer
d Tank draw down 1.75" in/min Pump capacity 38.5 _gpm Squirt Height 6'+ ft
Pump on time 46sec Pump off time 3hr Daily flow set at 239.72 gpd
Updated 8/212018
Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - El YES tig NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - YES El 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 contain: Drainfield d manifold orientation d layout,Septic/pump tank location.North arrow.reserve drainfield,existing and proposed buildings.location of wells,waterlines.
wells.observation ports,deancuts.end other maintenance access points. Incomplete Record Drawings may create additional delays in Mal nstalation approval and related permits.
RI-Record 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 contained on this 1 further certify that all information contained on this
and attach d Record Drawing is accurate. form and attached Record Drawing is accurate.
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Signet a of Installer Date
Printed Name of Signee y'
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L.oe rr..
MASON COUNTY PUBLIC HEALTH / ' ' .
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public •
LIFT
Health: y
EXPIRE;; I�"t 5"?i l
Signature of Environmen al Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED ANC AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated antnota
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