HomeMy WebLinkAboutSWG2021-00529 - SWG As-Built - 3/29/2023 v
CLEAR FORM
Mason County OSS Installation Report pg. 1 C.0_, MASON COUNTY PUBLIC HEALTH
APPLICANT! PERMIT INFORMATION
Permit Number SWG 2021-00529 Parcel # 122072190062
Applicant Name Subdivision (Name/Div/Block/Lot)
Applicant Address ED BOOGAERTS
City, State, Zip 1160 RASOR RD BELFAIR,98524 Installer Name JACK JOHNSON
Site Address 1162 RASOR RD, BELFAIR Designer Name Jim Zmny
INSTALLATION CHECKLIST
ill Full System Installation 0 Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type GRAVITY Pretreatment Type
>5 ft. from foundation? - - El N/A IN YES ❑ NO
>50 ft. from wells? - - ❑ ® ❑
Z >50 ft. from surface water? - - ❑ ® 0
F
El ® CI
between building and tank? - -
U Tank baffles present? - - ❑ ® ❑
a24"access risers over each compartment?- - CII ❑
W Effluent fitter installed?- - ❑ El 0
u)
Septic tank capacity (working) 1000 gal Manufacturer HAGERMAN
0 D-box water level and speed levelers used? - - ❑ N/A ❑ YES 0 NO
oO Manifold/D-box accessible from surface?- -
El ❑ 0
m z Check valves installed? - - ❑ 0 0
0Q 2 Transport Line Size 4" Schedule/Class 3034
Bedrooms installed (check one) (] 2 ❑3 ❑4 ❑ 5 El 6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A is YES ❑ NO
0 >100 ft. from wells?- - 0 I ❑
W >100 ft. from surface water? - - El IN
LL >10 ft. from potable water lines?- - ❑ ® 0
z > 5 ft. from property lines and easements?- - 0 I Elc2 > 30 ft. from downgradient curtain/foundation drains?- - 0 ® ❑
CI
Drainfield level and observation ports present - - ❑ I ❑
❑ Graveless chambers or 0 Clean gravel used? (check one)
Proper cover installed over drainfield?- - El ® ❑
Pump tank setbacks consistent with septic tank? - - ® N/A ❑ YES El NO
Pump tank capacity(flood) gal Manufacturer
Q24" access riser(s)and accessible from surface?- - 0 ❑ ❑
HeL Alarm or Control Panel Installed? - - ❑ ❑ 0
2 Control Panel equipped with Timer/ ETM /Counter- - ❑ ❑ ❑
D
a Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
°' Pump Make/Model ❑ Floats or ❑ Transducer
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# I LZ C.. 2 / 9 ooCoZ--
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - 0 YES k-NO
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 perman nt record and must bo accurato and doscriphve enough to relocate in U. nvad of rroanla anc.oodo.ties and future dewlopmont Typ-y Renard
Ora•.r ngs contain: Drainfield&manifold ocientaton&layaul.SET0.7punp tank le-„atria-PArttt arum",reserve d asdlea existing and proposed tradrings location o1 nets•tra(eltnes•
well,.observation ports,clearcos.and o t er maintenance access potrh Inciornplete Record Drawings may create att./local Oe'ays in in;int acne approval and rcl.-ded 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 Comity Public Health and meet all State myself and Mason County Public Health and meet all
and Mason County Codes. Slate and Mason County Codes
1 further certify that all information contained on this i further certify that all information contained on this
lope nd all hed Record Drawinn is accurate form and attached Record Drawing is accurate.
Div\ 3 �- i I -- 2 0 Z3
Sig i re of Installer Date
Printed Name of Signee #r7- .
tet
MASON COUNTY PUBLIC HEALTH .. 1I.
�
The undersigned approves this Installation Report and J #�; i-it
Record Drawing on behalf of Mason County Public • a, VI
fe �,
Health: • L r SKINER
'/� �L1/�/�/J �/ CNA% 11'14-- . .f,
U J� —Y (1 !/11 4 - ' r (ZGt j ExpiroA 811-u Z
Signature of Envnviron`rAtlental Health Specialist/ Date (stamp.signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE ut4-'!"9r21'2°18
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