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HomeMy WebLinkAboutSWG2020-00500 - SWG As-Built - 4/7/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2020-00500 Parcel # 5200922U00Z0 Applicant Name Taylor Johnston Subdivision (Name/Div/Block/Lot) Applicant Address 600 Capitol Was N City, State, Zip Olympia, Wa 98501 Installer Name CXT Site Address 12830 W Shelton Matlock Road Designer Name Webster Bergford INSTALLATION CHECKLIST • Full System Installation ❑Tank(s) Only ❑ Drainfield Only ❑ Repair ❑ Other System Type Concrete CXT Vault Toilet Replacement Pretreatment Type n/a >5 ft. from foundation? - - ❑■ N/A ❑ YES ❑ NO >50 ft. from wells? - - 0 ❑ ❑ Z >50 ft. from surface water? - - ❑ ■❑ ❑ • Cleanout between building and tank? - - 0 ❑ ❑ o Tank baffles present? - - ❑■ ❑ ❑ a24" access risers over each compartment?- - ❑ ❑ ❑ W Effluent filter installed?- - ❑■ ❑ ❑ N Septic tank capacity (working) 1000 gal Manufacturer CXT O D-box water level and speed levelers used? - - 0 N/A ❑ YES ❑ NO oOJ Manifold/D-box accessible from surface?- - ■❑ ❑ ❑ Ca, Z Check valves installed? - - ❑■ ❑ ❑ 0< n Transport Line Size n/a Schedule/Class n/a Bedrooms installed (check one) ❑ 2 ❑ 3 ❑4 ❑ 5 ❑6 ❑■ Commercial/Other >10 ft. from foundation?- - ■❑ N/A ❑ YES ❑ NO O >100 ft. from wells?- - 0 ❑ ❑ W >100 ft. from surface water? - - 0 ❑ ❑ Li >10 ft. from potable water lines?- - 0 ❑ ❑ z > 5 ft. from property lines and easements?- - 0 ❑ LI Q C > 30 ft. from downgradient curtain/foundation drains? - - 0 ❑ ❑ 0 Drainfield level and observation ports present - - 0 ❑ ❑ ❑ Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?- - 0 ❑ ❑ Pump tank setbacks consistent with septic tank? - - ❑■ N/A ❑ YES ❑ NO • Pump tank capacity (flood) n/a gal Manufacturer n/a < 24" access riser(s) and accessible from surface?- - 0 ❑ ❑ ~ d Alarm or Control Panel Installed? - - 0 ❑ ❑ E Control Panel equipped with Timer/ ETM / Counter- - 0 ❑ ❑ 0 a Pump installed in ❑ Bucket or ❑ On Block or ® Other n/a n'• Pump Make/Model n/a ❑ Floats or ❑ Transducer a Tank draw down n/a in/min Pump capacity n/a gpm Squirt Height n/a ft Pump on time n/a Pump off time n/a Daily flow set at n/a gpd Updated 8/21/2018 FT Mason County OSS Installation Report pg. 2 Parcel# 52009220020 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - - - - ❑ YES E■ NO If yes, please describe: Were all components pumped out and properly abandoned per WAC246-272A-0300? - - no components abandoned 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,cleanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits. IN 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. W /A 4/6/2023 Signature of Inst,ler Date 01\RLF.S ��wAs,/ t .r Todd Weger �w > ;t Printed Name of Signee � b - C �` - MASON COUNTY PUBLIC HEALTH Y approves this Installation Report and ; 3' 2 The undersigned pP p S, FcrsT��' G��' Record Drawing on behalf of Mason County Public 'r70NALt't4 Health: 13)(I \QPY'all � hlz3 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 Updated 8/21/2018 • m o O 0 V. O rn �� �A C O O W �v mo i o Cl) �` \ O rN �� ,\ \ O 0o C— \ I 12 1 y \:\ 2g 1 �� N '9 ` 1 ~ w 1 _ _PROPERTY UNE 210'f yr -z y 7C 11 y Z m m g:\ 1\ c oor \ \ gec $ 7 � c \li P \ \ \ m t a G Az > k4. 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