HomeMy WebLinkAboutSWG2022-00311 - SWG As-Built - 3/20/2023 (2) C- c
Mason County OSS Installation Report pg. 1
MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG zo 7.--2- (L 3
Parcel # jtJ2LIT( • (.•,(2)��
Applicant Name .fy,f(5n 64- Subdivision (Name/Div/Block/Lot)
Applicant Address 3 3\.\ S Z oq 41b
City, State. Zip
\t��f,�fl�o � C41 U Installer Name
Site Address Designer Name
t.
INSTALLATION CHECKLIST
® Full System Installation 0 Tank(s)Only 0 Drainfield Only ❑Repair ❑Other
System Type Pretreatment Type
�S; �/A ❑YES ❑ NO
>5 ft. from foundation? - � El
ft. from wells?
0
0
• >50 ft. from surface water? - '-`v Vil ❑
Zbuilding -- _ �/ ❑
• Cleanout between and tank. _ = ❑ ❑
U Tank baffles present? - 0
a24" access risers over each compartment? - - El ❑
W Effluent filter installed?- 0 d
Septic tank capacity (working) ‘25 b gal Manufacturer N0�'> (JI D
�� D-box water level and speed levelers used? �N1A ❑ YES ❑ NO
- Ea' ❑
O Manifold/D-box accessible from surface?- El Ea' Elapt Check valves installed? Eln-
oQ � ) r') Schedule/Class `1C
E Transport Line Size
Bedrooms installed (check one) ❑ 2 �3 ❑4 ❑ 5 0 6 0 ommercial/Other
>10 ft. from foundation? - - N/A ❑ YES ❑ NO
0
>100 ft.from wells? El9 0
W >100 ft.from surface water? 0 El
Er ❑
>10 ft. from potable water lines?- 0 ❑
z• > 5 ft. from property lines and easements?• - ❑ /
ce > 30 ft.from downgradient curtain/foundation drains? - L J IN 0 CI
El
level and observation ports present
0 Graveless chambers or 0 Clean gravel used? (check one) El
cover installed over drainfield?- - 0
19/Pump tank setbacks consistent with septic tank? - - ❑ N/A
El/YES 0 NO
Y Pump tank capacity (flood) l 2_SO gal Manufacturer f lo..'Sc %J z 24'. access riser(s) and accessible from surface? - - 0 E/ 0
~0. Alarm or Control Panel Installed? ❑ Er 0
2 Control Panel equipped with Timer/ ETM I Counter
0
Cl- Pump installed in 0 Bucket or SkOn Block or 0 Other
l CI Floats or >�ansducer
Pump Make/Model Ay ►'+c�aft G!(Jl ft
a Tank draw down in/min Pump capacity q 5 qpm Squirt Height
/}-1 b gpd
Pump on time
0-0 (9ci.v Pump off time ) 0 ,0 Daily flow set at_______
Mason County OSS Installation Report pg. 2
Parcel#
ABANDONMENT RECORD
_ ❑ YES ❑ NO
•
Were existing septic components abandoned as part of this project?
If yes, please describe: ❑ No
Were all components pumped out and properly abandoned per WAC246-272A-0300? ❑ YES
RECORD DRAWING
development. Typical Record
This is a permanentp nd buildings, of wells.waterlines,
record and must be accurate and descriptive enough to re-locate in the need of maintenance activities and future y
tank location.North arrow,reserve
drainfield,existing and proposed and related d permits.
Drawings s contain Orainfl e n manifold orientation&layout.Septic/pump
wells,observation pots,cleanouts.and other maintenance access points. Incomplete Record Drawings maycreate additional delays in final installation approval
s;_
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0 ci 1-0 h ,i ‘ c,..2
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0 Record ki... mg Attached
. ._ .
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
1 certify that 1 installed the system in accordance with 1 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 M. on County Public Health and meet all State myself and Mason County Public Health and meet all
and . ••n Cou ty Codes. State and Mason County Codes
I furt - ertify t at all information contained on this I form urt and attachedr certify tl Record Drahwing is on tained on accurate.this
for • attach=d Record Drawing is ac• rate.
II !/1 I 9( ii..6WW. ,.,,,.
t ';r;
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Signature .if lnst� Date
ll�r w• C. c,-;'•,� 3/4,/!�3
,' ALA 4VF r x.�..
Printed Na 1 e of Signee
MASON COUNTY PUBLIC HEALTH 4.• .
The undersigned approves this installation Report and -•
?Q.: ADAF.1 J.HUNTER
Record Drawing on behalf of Mason County Public f :l is �"'? ,,�fY,,, ,.,
Health:
�', ( Ik�, A
'" " ' tore and date)
Signatu o' onmental Health Specialist Date (stamp, signa
U dated BIZU2018
/ THIS FORM MAY RF SC.ANNFO ANn AVAII ARI F FOR PI IRI IC.VIEW ON THE MASON COI INTY WFR SITE P