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HomeMy WebLinkAboutSWG2021-00464 - SWG As-Built - 4/14/2023 CLEAR FORM Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT! PERMIT INFORMATION Permit Number SWG -2021-00464 Parcel# 223315000061 Applicant Name Jerry Loudon Subdivision (Name/Div/Block/Lot) Applicant Address 7754SE Monte Bella PI Collins Lake#1 TR 61 CO, State, Zip Port Orchard WA 98366 Installer Name Jason Shauer Site Address 21 NE Creek view PL,Tahuya WA 98588 Designer Name Jim Zimny INSTALLATION CHECKLIST ® Full System Installation ❑Tank(s)Only ❑ Drainfieid Only 0 Repair ❑Other System Type Oscar!! Pretreatment Type >5 ft. from foundation? - - ❑ NIA ®YES ❑ NO >50 ft.from wells? - - 0 e 0 m Z >50 ft. from surface water? - - 0 ® 0 1 x.. 1M < Cleanout between building and tank? - - 0 U El U Tank baffles present? - - ❑ IN 0 t �`� t a24"access risers over each compartment?- - ❑ IN 1 tv WI Effluent filter installed?- - 0 ® 0 i <o c4 Septic tank capacity (working) /coo al Manufacturer Hagerman i f�'1 `0 D-box water level and speed levelers used? - - ® N/A ❑ YES ❑ No" �� *O Manifold/D-box accessible from surface?- - El © 0 u. mZ Check valves installed? - - ❑ IS ❑ 0Q Transport Line Size 1" Schedule/Class Sch 40 Bedrooms installed (check one) ❑ 2 LI 3 ❑4 ❑5 ❑6 ❑Commercial/Other >10 ft.from foundation?- - ❑ NIA ® YES ❑ NO O >100 ft. from wells?- - ❑ ® ❑ W >100 ft. from surface water? - - El IN u. >10 ft.from potable water lines?- - ❑ ® ❑ Z > 5 ft. from property lines and easements? - - - - El ® El id > 30 ft.from downgradient curtain/foundation drains?- - ❑ U ❑ Ca Drainfield level and observation ports present - - ❑ ire IN El 0 Graveless chambers or 0 Clean gravel used? (check one) Proper cover installed over drainfieid?- - 0 Nil ❑ Pump tank setbacks consistent with septic tank?- - 0 N/A ii YES ❑ NO • Pump tank capacity(flood) 1200 gal Manufacturer Hagerman Q 24"access riser(s)and accessible from surface?- - 0 ® 0 1-- Alarm or Control Panel Installed? - - ❑ ® ❑ a 2 Control Panel equipped with Timer/ETM/Counter- - 0 ® 0 m a- Pump installed in ❑ Bucket or IN On Block or ❑ Other n. Pump Make/Model Ay McDonald 22050E2AJ 1/2 HP e Floats or ❑ Transducer eL Tank draw down 25 in/min Pump capacity 30 gpm Squirt Height NA ft Pump on time 22 sec Pump off time 3 min 38 sec Daily flow set at 2 gpd updated 5'22 1'C18 Mason County OSS Installation Report pg. 2 Parcel# ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - 0 YES jar,NO If yes. please describe: — Were all components pumped out and properly abandoned per WAC246-272A-03OO? ' - 0 YES a NO RECORD DRAWING This is a permanent record and must be occur**and dsscript ve enough to re-locate In the need or maintenance ectrvltles and future devdapntatrt. Typical Record Drawrntjs contain: Dii anireld d manifold orientation i tayouT Septv-.'aat'p Urr In+`unn NnrT arrow,'seem,drarrrfietd,ew'sb,rg and propoaod budderys,location al weal,waterlines, weds,observation ports,ceanouts.and other maintenance access pants. Incxr:pete Rrecord Oraeings may crest addXiard delays w final rnstaaaion approval and related permits, APR 14 2023 1IPPROVE MASON COUNTY ENVIRONMENTAL HEALTH JB W 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 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. 91.14 Jam._ r. _ i/ Z I Signature of Installer Date 1 6c SC.,44C4 - '." Printed Name of Signee MASON COUNTY PUBLIC HEALTH : d. ter, The undersigned approves this Installation Report and 'a i. E Re • • Drawing on behalf of Mason County Public t ,mAEri ealth. LJ1L„��,, 1 Sig -t VS vironmentat Health Specialist Date (stamp, signature and date) -THIS S-OfiM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE UixdiOed W2112618 M . (NI O Lri �'��Jaaa r44- it J cu • O y rrnt a 1 p rs 1 >! k I` a� awoq wowpaq E I APPROVE APR 14 2023 MASON COUNTY ENVIRONMENTAL HEALTH JBW ca. Lo — 0 D-C o °' o 0 v) Q c -0 aQo L 01 v p U rci '-1 0 0 C1 J W M v, c\ F- *k rt j 8C .� • n, 0o0 g 00 U 64- %o o., c �;, v N 3 . b 00 \` Q Q � � Q 1