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'm .ason County OSS Installation Report p �� `"
9 .1 MASON COUNTY PUBLIC HEALTH
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APPLICANT/ PERMIT INFORMATION
Permit Number SWG 7�G1- Gb�/ .77 Parcel # ' IZ3^ Sp — bO/{•�
nlicant Name AA1IKC 5i i (IIN*J� Subdivision (Name/Div/Block/Lot)
,)ilcant Address *V E. `"ra•+sNdlI PeRrY DO g —
City, State, Zip s Aolesiv,CA ooloi Installer Name +M'= 2114.2 ILE
Site Address oZ4°J ) as! 014.ii /O/ Designer Name
INSTALLATION CHECKLIST
XI
Full System Installation 0 Tank(s)Only ❑ Drainfiekt Only ❑Repair 0 Other
System Type_____VAny _ _ Pretreatment Type
>5 ft. from foundation? -
❑ N/A IN YES ❑ NO
>50 ft. from wells? - .- _. 0
. -. X >50 ft.from surface water? - 0
z - - - 0
Cleanout between building and tank? - - -- _ _ _ ._ _ _ _ _ _. 0 Pr ❑
V Tank baffles present? - El 0
P
O. .24"access risers over ea c�tlhl '?_ - _ _ CI
Sp sp Effluent filter installed?- -Of- --t - - - - _ ElS� tic tank 0la
capacity(working) l?.sacS _ gal Manufacturer SD'*'. O ��prCAJrC[�
. ^ lox water level and speed levelers used?
❑ N/A OYES ❑ NO
MdnitoldlD-box accessible from surface?- 0 0
Check valves installed? -
r Transport Line Size >L� Schedule/Class go ,
Bedrooms installed (check one) ❑ 2 50 3 ❑4 0 5 ❑6 ❑Commercial/Other
>10 ft. from foundation'?-
N/A YES ❑ NO
G >100 ft.from wells?- _. V _F
--I >100 ft.from surface water? - 0
ZW �� 0
>10 ft. from potable water lines?- - -A-P -2.1 -282-3- L [ 0
Z > 5 ft. from property lines and easements?- - _ _ _ _ . 14 El
>30 ft. from downgradient curtain/foundation rains? - _ _ _
-» By - 0
Drainfield level and observation ports present ❑
3raveless chambers or Clean gravel used? (check one)
rroper cover installed over drainfield?- _ _ ❑ k
r
r'u1r'•p tank setbacks consistent wit ^^+;^+-J ? - - - - -
❑ N/A 0 YES 0 NO
Pum tik capacity (flood)_ yam,
Manufacturer [.�I WC �� "�o .2- -
i . ' ,y ''24"accessti,.riser(s)and accessibl ace?-
❑ ❑
Alarm Or-Control Panel Installed"? - - ❑
:on'rol Panel a ui - ill
❑_ q piled witty Timer !ETM, Counter - - - -. _ _ - 0 rd ❑
`� Purnp installed in ❑ Bucket or (g On Block or ❑ Other Ir�l
a Pump Make/Model Tt,L�C^- W.-/(Q / r
g j f,-- I L�[Floats or ❑ Transducer
Tank draw down , /
a. ._ 1_-__--.m/rnin Pump capacity 33 gpm Squirt Height A/�A ft
Pump on time /, j✓_ Pump off time 35
Daily flow set atOGY gpd
:lpdAted erzinoie
r ,..._ .
,..tin County OSS Installation Report pg. 2 Parcel # � CI t !S'
} ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ECYES NO
If yes, please describe: Jih( j1014 ebA*02--,
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - 'YES 0 NO
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: Dramield&manifold onentetion&layout,Septin pump tank location.North arrow,reserve dramtiaid,existing and proposed buildings.locallo^of wells waterlines,
wells.observation ports.clennouts,and other mtuntonanco access points. hn.omplete Record Drawings may create additional delays in final installation approval and related permits.
NSA/6014 cif
Pf t a/Pr Of"
III
'Er Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that i 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 Mason County Public Health and meet all State myself and Mason County Public Health and meet all
in,'f Mason County Codes. Stale and Mason County Codes
„r-tlrer certify that all information contained on this 1 further certify that all information contained on this
.,.din and attached cord Drawing is accurate. form and attached Record Dra _'ng is accurate.
i 0
l algal
ell
grotto of installer Date
L
9411
J 4trrrjc1 . a P� 'P'I i.
F s 9� 1
Printed Name of Signee °�,W���i .yo �'
MASON COUNTY PUBLIC HEALTH s e? ~� a a a\
The undersigned approves this Installation Report and v02 Y E AITE SDI
�. LICENSED DESIGNER ri
Record Drawing on behalf of Mason County Public v.
�.. %N. % " ` la""fir
Health: Exr IRIS o ,tu
Signature of Environm ntal Health Specialist Date
(stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated ei?tnottt
RECORD DRAWING (continued)
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_ 4`222-so- 06 'l.c
eva..3 C a9 3 A
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1. Existing Cabin
2. Boat Launch
gallon septic tank . •so_ 4 Aid Place•ne4
� 3. 1200 ,
tscem
tank 1 So�.v✓ r'
.sue
4. 1200 gallon pump �-
j 5. Audio/visual alarm
` 6. Transport line
7. Clean Out
k. l
8. '-�''1'x110' envelope for
primary/reservedrainfield and
attenuation zone.
i It9. Proposed garage with bathrooms tt�d�
10. 1200 gallon septic tank 11SD q
• 11. Clean out for garage
. \
12. 4" line from proposed
garage septic tank to the first D-Box
1 13. Attenuation Zone
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