HomeMy WebLinkAboutSWG2022-00309 - SWG As-Built - 4/12/2023Mb
CLEAR FORM
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2022-00309 Parcel # 321275100146
Applicant Name Ed Day Subdivision (Name/Div/Block/Lot)
Applicant Address 320 E Pensance Rd Lake Limerick 2 Lot 146
City, State, Zip Shelton, WA98584 Installer Name Jerry Uptown
Site Address 320 E Pensance Rd Designer Name Jim Zimny
INSTALLATION CHECKLIST
III Full System Installation ❑Tank(s)Only 0 Drainfield Only 0 Repair ❑Other
System Type Pressure Dist Pretreatment Type
>5 ft. from foundation? - - ❑N/A ®YES ❑ NO
>50 ft. from wells? - - ❑ ® El
• >50 ft. from surface water? - - ❑ ® ❑
Z ���� V
H Cleanout between building and tank? -- - - ❑ II
o Tank baffles present? - A -0-5-K3-- - ❑ ® ❑
a24"access risers over each compartment?- - 0 II
tW Effluent fitter installed?- BY:-_-_,___..------- ..- 0 Ell
Septic tank capacity (working) 1000 gal Manufacturer Hagerman
a D-box water level and speed levelers used? - - Ill N/A ❑ YES ElNO
XO Manifold/D-box accessible from surface?- - El III
m Z Check valves installed? - - ❑ El II
0Q
2 Transport Line Size 2" Schedule/Class Sch 40
Bedrooms installed (check one) 0 2 0 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ NIA ® YES ❑ NO
CI >100 ft. from wells?- - 0 ® El
W >100 ft. from surface water? - - ❑ MI El
ti >10 ft. from potable water lines?- - ❑ ® ❑
Z > 5 ft. from property lines and easements?- - ❑ ® ❑
02 > 30 ft. from downgradient curtain/foundation drains? - ❑ IR ❑
• Drainfield level and observation ports present - - 0 0 ❑
® Graveless chambers or 0 Clean gravel used? (check one)
Proper cover installed over drainfield?- - 0 ® ❑
Pump tank setbacks consistent with septic tank? - - 0 N/A ® YES ❑ NO
• Pump tank capacity(flood) 1000 gal Manufacturer Hagerman
1 Q 24" access riser(s)and accessible from surface?- - 0 ® 0
H
a Alarm or Control Panel Installed? El
0
2 Control Panel equipped with Timer/ETM/Counter- - 0 U El
a Pump installed in ❑ Bucket or II On Block or ❑ Other
a Pump Make/Model Liberty 280 Floats or 0 Transducer
a_
a Tank draw down 1.75' in/min Pump capacity 30 qpm Squirt Height 8' ft
Pump on time 48 Sec Pump off time 4 hrs Daily flow set at 180 gpd
Updated 8/2112C1B
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Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certifythat 1 installed thesystem in accordance with I certify that the system has been installed in accor-
stamped APPROVED"by
the septic design stamped APPROVED'by Mason dance with the septic design
Mason County Public Health and that any deviations
County Public Health and that any deviations shown d by both
here have been cleared/approved by both the designer shown here have been cle Public groraveve and meet all
and Mason County Public Health and meet all State myself and Mason County e
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 accurat��e1/. 2-7--
nature •
o steer Date
cTe r r y OP_ein . ►►►
Printed Namebf Signe� ►►►
MASON COUNTY PUBLIC HEALTH r,' . v►
The undersigned approves this Installation Report and owdI o� -' 3033 st.►►
LICENo IDE GNER ►►
Record Drawing on behalf of Mason County Public .- ,►,
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