HomeMy WebLinkAboutSWG2022-00058 - SWG As-Built - 3/16/2023 rrr
CLEAP FORM
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2022-00058 Parcel # 322147501100
Applicant Name David Cooper Subdivision (Name/Div/Block/Lot)
Applicant Address 4826Se Sleepy Hollow Ct
City, State, Zip Port Orchard Wa 98366 Installer Name JACK JOHNSON
Site Address 20 NE Cady Ln, Belfair Designer Name Jim Zimny
INSTALLATION CHECKLIST
—
® Full System Installation ❑Tank(s)Only D Drainfield Only ❑Repair ❑Other
System Type Gravity Pretreatment Type
>5 ft. from foundation? - ntt C ❑ N/A III YES ❑ NO
>50 ft. from wells? - � 11 0 ® ❑
Z >50 ft. from surface water? --0,R-(r- t - 0 III
HCleanout between building and tank? ----' . - El ® 0
U Tank baffles present? - By -________---------"Kr - ❑ III
E- 24" access risers over each compartment?- - ❑ I ❑
a
W Effluent fitter installed?- - 0 ® 0
cn
Septic tank capacity (working) 1200 gal Manufacturer Hagerman
—
O D-box water level and speed levelers used? - - ❑ N/A ❑ YES ❑ NO
00 Manifold/D-box accessible from surface?- - 0 0 0
m 2 Check valves installed? - - ❑ 0 ❑
0Q
• Transport Line Size Schedule/Class
Bedrooms installed (check one) ❑ 2 0 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A ® YES ❑ NO
• >100 ft. from wells?- - 0 ® 0
ill >100 ft. from surface water? - - ❑ IN
LL >10 ft. from potable water lines?- - ❑ I 0
z > 5 ft. from property lines and easements?- - ❑ ® 0
E > 30 ft. from downgradient curtain/foundation drains? - - ❑ ® ❑
CI
Drainfield level and observation ports present - - 0 I ❑
❑ Graveless chambers or III Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ II 0
Pump tank setbacks consistent with septic tank?- - ❑ N/A 0 YES ❑ NO
• Pump tank capacity (flood) qal Manufacturer
< 24" access riser(s) and accessible from surface?- - 0 0 ❑
h-
a Alarm or Control Panel Installed? - - El El
M Control Panel equipped with Timer/ ETM/Counter- - 0 ❑ 0
m
a Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
a-• Pump Make/Model ❑ Floats or ❑ Transducer
EL
a Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 8/21/2018
Mason County OSS Installation Report pg. 2 Parcel#_ ,Z 2
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - 0 YES 't40
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300?' 0 YES 0 NO
RECORD DRAWING
This is a permanent record and must be accurate and descriptive enough to re-locals In the need of mainOwance activities and future development_ Typrad Reoord
Drawings contain.Drainfeld&mandold odentaeon&tayWl.SW:in:v.o 1.t.v&location.North anew.reserve d,areletd.e104tn9 and Proposed bwid'cgs.bcai on or reds.grate then•
webs.observation ports.deanoub.and otter maintenance access prarrs inccmpiete Record Drawings may create aatdiorol delays in co,*rnlaltatcn approval and related pemhts
4
APPRov
MAR t b 7U�3
il
MASON COUNTY ENVIRONMENTAL HEALTH
JBW
[ Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
41
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
1 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 I further certify that all information contained on this
forMind att had Record Drawing is accurate. form and attached Record Drawing is accurate.
/� L
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a
Sig" : of installer Date firtf.•
ts 'ffPrinted Name of Signee • a
1 MASON COUNTY PUBLIC HEALTH s _ f
fc,.. rfI
The undersigned approves this Installation Report and ttf
Record Drawing on behalf of Mason County Public Expire=BM/7-
Heal! .
t\A L0ii 3/6-23
Signal f n •ronmental Health Specialist Date (stamp.signature and date)
4 THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE U"d t`d&71'2U18
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