HomeMy WebLinkAboutSWG2022-00057 - SWG As-Built - 3/16/2023 CLEAR FGRM C. . C
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2022-00057 Parcel # 322147501000
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 21 NE Cady Ln, Belfair Designer Name Jim Zimny
INSTALLATION CHECKLIST
f Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type Pressure Distribution Pretreatment Type
>5 ft. from foundation? - - ❑N/A ®YES ❑ NO
•
>50 ft. from wells? - - - ❑ II
Y >50 ft. from surface water? - i J �-
I -=-- El ® El
HCleanout between building and tank? --- rr- -r-�g - 0 ® 0
U Tank baffles present? - ❑ ® ❑
a 24"access risers over each compartment? ❑ ® ❑
t
W Effluent filter installed?- By ..._.---/
—-- -- ❑ ® ❑
U)
Septic tank capacity (working) 1200 gal Manufacturer Hagerman
`13 D-box water level and speed levelers used? - - ❑ N/A IIIYES ❑ NO
XO Manifold/D-box accessible from surface?- - ❑ II 0
u.
m 2 Check valves installed? - - ® 0 0
OQ
2 Transport Line Size 2" Schedule/Class Sch 40
Bedrooms installed (check one) ❑ 2 ❑■ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A NO YES ❑ NO
0 >100 ft. from wells?- - ❑ ® 0
WIN CI>100 ft. from surface water? - - 0
u.. >10 ft. from potable water lines?- - ❑ ® 0
Z > 5 ft. from property lines and easements?- - 0 ill
d > 30 ft. from downgradient curtain/foundation drains? - - ❑ ® 0
ci
Drainfield level and observation ports present - - ❑ ® ❑
❑ Graveless chambers or IE Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ ® ❑
Pump tank setbacks consistent with septic tank?- - ❑ N/A It YES ❑ NO
• Pump tank capacity (flood) 1000 gal Manufacturer Hagerman
< 24" access riser(s) and accessible from surface?- - ❑ I ❑
I--
a Alarm or Control Panel Installed? - - 0 0 0
2 Control Panel equipped with Timer/ ETM/Counter- - 0 ❑ 0
m
a Pump installed in ❑ Bucket or ® On Block or ❑ Other
a• Pump Make/Model Liberty 280 I Floats or ❑ Transducer
d Tank draw down 1 'ci in/min Pump capacity -U gpm Squirt Height '/ ft
Pump on time J►'lo o O Pump off time v.\ r s Daily flow set at Z 7v gpd
Updated 8/21/2018
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Mason County OSS Installation Report pg. 2 Parcel
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - 0 YES .-iii1—NO
If yes,please describe:
Were all components pumped out and property abandoned per WAC246-272A-0300?- - 0 YES 0 NO
RECORD DRAWING
This is a permanent record and must be accurate and descriptive enough to reaocate in the need of maintenance activities and future development. Typrcal Record
Drawings conlan. Drainfield&nrandotd onentabon&leyaA.Sat,b peen.lard.location.North armor.reserve dramrieid.smuttrg and proposed buildings.heat on of wets,waterlines.
wells.observation ports.ckrarouls.and other mainterarce access pistils, ter fete Record Oraamgs may create additional delays in he teslaltatton approval and related pernalS
APPROVE
MARM N COUNTY ENVIRONMENTAL HEALT.y
JBVy
GI-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
1 further certify that all information contained on this 1 further certify that all information contained on this
fo :nd aft lied Record Drawing is accurate. form and attached Record Drawing is accurate.
s
re of Installer Date of
f �.
v CAC. +ID V)S inYl $ %
Printed Name of Signee
/, 4 "GI
MASON COUNTY PUBLIC HEALTH �' ,r •., "If
� •
The undersigned approves this Installation Report and _ L ' DESIGNER le
+
Record Drawing on behalf of Mason County Public EARirSICW 7/. b
Heal
J.4
CJ i� 3( -23
Signet a in'ronmental Health Specialist Date (stamp.signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE urd,u,d a21.2"18
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