HomeMy WebLinkAboutSWG2022-00133 - SWG As-Built - 3/17/2023 CLEAR FORM C, C
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT! PERMIT INFORMATION
Permit Number SWG 2022-00133 Parcel# 220055100099
Applicant Name John Bycznski Subdivision (Name/Div/Block/Lot)
Applicant Address 491 E Phillips Lake Lp RD
City, State, Zip Shelton Installer Name Eric Gregory
Site Address 491 E Phillips Lake Lp RD Designer Name Jim Zmny
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type Gravity. Bed Pretreatment Type
>5 ft. from foundation? - - 0 N/A ®YES ❑ NO
>50 ft. from wells? - - 0 ® ❑
Z• >50 tt. from surface water? - - ❑ NI LI
H CI III CI
between building and tank? - -
U Tank baffles present? - - ❑ ® ❑
a24" access risers over each compartment?- - El ® 0
LU Effluent filter installed?- - ❑ ® El
Septic tank capacity (working) 1200 gal Manufacturer Hagerman
a D-box water level and speed levelers used? - - ❑ N/A gm YES ❑ NO
XO Manifold/D-box accessible from surface?- - El IN
cou.
z Check valves installed? - - 11 ❑ 0
Ch Q
2 Transport Line Size 4 �f Schedule/Class 3( I- c1
Bedrooms installed (check one) 0 2 0 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - - El N/A ® YES ❑ NO
O >100 ft. from wells?- - ❑ ® ❑
W >100 ft. from surface water? - - CI MI ID
u. >10 ft. from potable water lines?- - ❑ ® El
Z > 5 ft. from property lines and easements?- - ❑ ® ❑
C > 30 ft. from downgradient curtain/foundation drains? - - ❑ IN ❑
Drainfield level and observation ports present - - 0 0 ❑
® Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ 0 ❑
Pump tank setbacks consistent with septic tank? - - 0 NIA ❑ YES El NO
• Pump tank capacity(flood) gal Manufacturer
Q 24" access riser(s)and accessible from surface?- - 0 0 ❑
H
d Alarm or Control Panel Installed? - - El El El
• Control Panel equipped with Timer/ ETM /Counter- - ❑ ❑ El
n
n- Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
n'• Pump Make/Model 0 Floats or 0 Transducer
a.
a Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
updatod 8r112018
Mason County OSS Installation Report pg. 2 Parcel# < 7-0O SS—) 00o
ABANDONMEt4T RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES Ei NO
If yes, please describe:
Were all components pumpsd out and properly abandoned per WAC246-272A-0300? YES NO
RECORD DRAWING
This I.a permanent record and must be accurate and descriptive enough to re-locate In the need of maintenance activities and future development. Typ.cal Record
Drawings contain: D•atnttelI&mandok;crientaton 3 leyou..Sep+G'ptrrmp tank loca!ton.No•th anew.res&'a dratnfetd,edsUng and propaa d IXOCIngrs txatton of welts,waterlines,
waist,onenrva:ron ports cieencuts.and other maintenance access points. Incomplete Recard Drawings may create additional Malays in(mat netallat,00 epprcr.at and rotated permits.
'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 I further certify that all information contained on this
form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
Signature of Insta , Oate
Punted Name of Signee
MASON COUNTY PUBLIC HEALTH
1 to
The undersigned approves this Installation Report and �•
1 �,1
Record Drawing on behalf of Mason County Public :� LICE;1 • or s fry r
Health: E`Niruxa.;:i I a'
`1 ( l�7 Z,� 73
Signature of Environmen at Health Specialist Dote (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Upeet.d Nr7172o16
Phillips Lake Loop Rd
73 CD /.'...
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