HomeMy WebLinkAboutSWG2022-00122 - SWG As-Built CLEAR FORM
Mason County OSS Installation Report pg. 1 C .C` MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2022-00122 Parcel# 222235106010
Applicant Name TBC Enterprises Subdivision (Name/Div/Block/Lot)
Applicant Address PO Box 2503 TRAILS END DIV#2 LOT 26 BLK 6
City, State, Zip Glq Harbor WA 98335 Installer Name JACK JOHNSON
Site Address 1\iE OLYMPIC VIEW, BELFAIR Designer Name Jim Zimny
INSTALLATION CHECKLIST
IN Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type Pretreatment Type
>5 ft. from foundation? - - ❑N/A ®YES ❑ NO
>50 ft.from wells? - - ❑ I ❑
Z >50 ft. from surface water? - - El II
H Cleanout between building and tank? - - El IN
U Tank baffles present? ❑ ® ❑
0-~. 24"access risers over each compartment?- - ElIDI
W Effluent filter installed?- - ❑ 0 ❑
tn
Septic tank capacity (working) 1000 gal Manufacturer Hagerman
0 D-box water level and speed levelers used? - - ❑ N/A ❑YES ❑ NO
oO Manifold/D-box accessible from surface?- -
❑ 0 0
m 2 Check valves installed? - -- - ❑ 0 0
cQ
Transport Line Size Schedule/Class
Bedrooms installed (check one) ® 2 0 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - 0 NIA 111 YES ❑ NO
O >100 ft. from wells?- - 0 ® El
W ❑
>100 ft. from surface water? - - ❑ II
ti >l o ft.from potable water lines?- - ❑ IS 0
Z > 5 ft_ from property lines and easements?- - 0 ® ❑
ce > 30 ft.from downgradient curtain/foundation drains? - - ❑ II El
CI
Drainfield level and observation ports present - - 0 ® 0
® Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - El ® ❑
Pump tank setbacks consistent with septic tank?- - El N/A ❑ YES ❑ NO
Pump tank capacity(flood) gal Manufacturer
Q 24" access riser(s)and accessible from surface?- - 0 ® ❑
F-
a Alarm or Control Panel Installed? - - ❑ U 0
E Control Panel equipped with Timer/ETM/Counter- - 0 ® El
M
a. Pump installed in 0 Bucket or NI On Block or ❑ Other
n' Pump Make/Model Liberty 280 IN Floats or 0 Transducer
G.
Tank draw down 1.5" in/min Pump capacity 30 gpm Squirt Height 4' ft
Pump on time 1 min Pump off time 4 hrs Daily flow set at 180 gpd
updated em72018
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Mason County OSS Installation Report pg. 2
Parcel# ?'2 7 2., 3> 5 1 O wu i s
ABANDONMENT RECORD rt�.,c,
Were existing septic components abandoned as part of this project? 0 YES
If yes, please descnbe:
Were at components pumped out and property abandoned per WAC246-272A-0300?- -- ----- 0 YES 0 No
RECORD DRAWING
This is a powwows record and.east be accoste and d.wto$Mr emu.to re4ocala in lb.reed or.nd.erseence activities sod rawe d.idopm.nt typical ItaOD4t
Drawings contain: Oraatf.eld&manifold onenta¢m&tay®td,Set`.hcrptep sane location.North amok rpve tean4eet extsirn aro pra?o ed Isilleciwe tucaton vt.aetts,veatedeves,
wens.o0serva►o.s ports.ctesma.ts.and olive rnalnten rce access polotS moss Bete Recant Inv of r9'may create arttoaest lan'ays In bed enlat"atnn apprwat and ratdcd perm*.
Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that!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 1-leach and that any deviations
here have been cleared/approved by both the designer shown hem 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. Slate and Mason County Codes
I further certify that all information contained on this I further certify that all information contained on this
fo( nd att hoc!Record Drawing is accurate. form and attached Record Drawing is accurate.
1 /6 - ! f 2 ) _.
Shire of Installer Date
Printed Name of Signee r%4 l++f+
MASON COUNTY PUBLIC HEALTH f�f
The undersigned approves this Installation Report and I.tiff
t
Record Drawing on behalf of Mason County Public 1 .. '. •+fr
Health: / ud:t7..oesloNER +
Exp4m%dal/et
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 ucdata«s 8121'2°18
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