HomeMy WebLinkAboutSWG2021-00148 - SWG As-Built - 3/22/2023 `,, C, C,
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2021-00148 Parcel# 321051490010
Applicant Name DENNIS JONES Subdivision (Name/Div/Block/Lot)
Applicant Address 4125 S. SETTLER#249
City, State, Zip RIDGEFIELD, WA 98462 Installer Name ABBA EXCAVATING LLC
Site Address 220 E ALDERBROOK RIDGE RD Designer Name DALE TAHJA
INSTALLATION CHECKLIST
] Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type GRAVITY Pretreatment Type
>5 ft. from foundation? - - El N/A 0 YES ❑ NO
>50 ft. from wells? - - 0 ® ❑
Z >50 ft. from surface water? - I-f -i-{l-r1-- ❑ ❑
N Cleanout between building and tank? -- --- l� IJ V - 2 ® 0
O Tank baffles present? - -. - —WW1-6 Ion-- D II ❑
a24"access risers over each compartment?- - -.f MI
`W Effluent filter installed?- t- - 0 E. ❑
By
Septic tank size 1250 gal ' Manufacturer HAGERMAN PRECAST
CID-box water level and speed levelers used? - - ❑ N/A ifYES ❑ NO
DO Manifold/D-box accessible from surface?- - ❑ III
u.
QQCheck valves installed? - - 111 E.] ❑
2 Transport Line Size 4" Schedule/Class 3034
Bedrooms installed (check one) ❑ 2 ❑4 0 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ® N/A ❑ YES ❑ NO
O >100 ft.from wells?- - 0 ® ❑
W >100 ft.from surface water? - - ❑ Ill
EL- >10 ft.from potable water lines?- - 0 ] 0
Z > 5 ft.from property lines and easements?- - ❑ MI
li > 30 ft. from downgradient curtain/foundation drains?- - ® 0 ❑
0 Drainfield level and observation ports present - - ❑ II ❑
❑ Graveless chambers or go Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ ] ❑
Pump tank setbacks consistant with septic tank?- - ] N/A ❑ YES ❑ NO
Pump tank size gal Manufacturer
Z
< 24"access riser(s) and accessible from surface?- - E. ❑ ❑
I—
a. Alarm or Control Panel Installed? - - NI El
j Control Panel equipped with Timer/ETM/Counter- - IN ❑
C- Pump installed in ❑ Bucket or • On Block or ❑ Other
a-
g Pump Make/Model Floats or ❑ Transducer
p lank araw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
uptlatea a/27r10lb
Parcel# 321051490010
Mason County OSS Installation Report pg. 2
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - El YES ® 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&manifold orientation&layout,Septic/pump tank location,North arrow,reserve drainfield,existing and proposed buildings,location of wells,waterlines,
wells,observation ports,deanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
II Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
l certify that!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 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
, form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
3-8-2023 oll.wi
Signature of Installer Date - , ,
. •
PAM M BUSEK `Q' s 9,
44
Punted Name of Signee ��• `tin
MASON COUNTY PUBLIC HEALTH wr;V \Vet
The undersigned approves this Installation Report and `�. Si txJ714 •
Record Drawing on behalf of Mason County Public '1rr0 DALE L. TAH)A
Health: ea,�
.
‘OiNr.Nc,_eivy -(64 T-1,
Signature of Environmental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE uperztaote
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