HomeMy WebLinkAboutSWG2023-00027 - SWG As-Built - 4/28/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT 100.1WATION
Permit Number SWG 2023-00027 Parcel # 42216-53-00035
Applicant Name Derek McMasters Subdivision (Name/Div/Block/Lot)
Applicant Address 130 E. Hilldale Rd. Lake Cushman Div.16 Lot 35
City, State, Zip Union, WA 98592 Installer Name T.J. Goos
Site Address 61 N. Bass Place, Hoodsport, WA Designer Name Dale L. Tahja
INSTALLATION CHECKLIST
0 Full System Installation IN Tank(s)Only ❑ Drainfield Only ❑ Repair ❑ Other
System Type Holding Tank Pretreatment Type
>5 ft. from foundation? - - ❑ N/A II YES ❑ NO
>50 ft. from wells? - [II 0
>50 ft. from surface water? - 21. .L Q-�.LE I] ❑
Z
Q Cleanout between building and tank? -
E- -A R" 4 202- ® 0
U Tank baffles present? - ® ❑
a24" access risers over each compartment?- - - By -- Vt .--- - - ® ❑
!W Effluent filter installed?- ❑ ❑
Septic tank capacity (working) 1.200 gal Manufacturer Hagerman
el D-box water level and speed levelers used? - - 0 N/A ❑ YES ElNO
OO Manifold/D-box accessible from surface?- - E] ❑ 0
C9E Check valves installed? - 0 0 0
OQ
2 Transport Line Size Schedule/Class
Bedrooms installed (check one) ❑ 2 ❑3 ❑4 0 5 ❑6 0 Commercial/Other
>10 ft. from foundation?- - El N/A ❑ YES ❑ NO
0 >100 ft. from wells?- - ❑ ❑ ❑
W >100 ft. from surface water? - - ❑ ❑ ❑
LL >10 ft.from potable water lines?- - ❑ 0 ❑
2Q > 5 ft. from property lines and easements?- - ❑ ❑ ❑
tr >30 ft. from downgradient curtain/foundation drains? - - ❑ ❑ ❑
Drainfield level and observation ports present - - ❑ ❑ ❑
0 Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ ❑ ❑
Pump tank setbacks consistent with septic tank? - - ❑ N/A ❑ YES 0 NO
2 Pump tank capacity(flood) gal Manufacturer
< 24" access riser(s) and accessible from surface?- - 0 ❑ 0
0. "Alarm or Control Panel Installed? - - ❑ ❑ ❑
• Control Panel equipped with Timer/ETM /Counter- - ❑ ❑ 0
n- Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
O.• Pump Make/Model ❑ Floats or ❑ Transducer
a Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 8121i2018
s
Mason County OSS Installation Report pg.2
Parcel#LVrWn I\ l-00ciTh
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - 0 YES I NO
if yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - 0 YES 0 NO `
RECORD DRAWING
This is a permanent record end must be accurate and descriptive enough to re-locate in the need of maintenance activities and future development Typical Record
Drawings°ordain: Drahttleld&manifoid odentalion&layout,Sepddpump tank location,North arrow,reserve d►at tteid,erdattng and proposed buildings,location of wells,waterlines,
milk,obeetwtlen pots,deanouta,and°firer maintenance access points. Incomplete Record Drawings may onside additional delays in final Installation approval and related permits.
APPROVE
APR 2 8 2023 0
MASON COUNTY ENVIRONMENTAL HEALTH
JBW
■ 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
hem 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. curate. form and attached Record Drawing is accurate.
Signature Installer Date , .`it- .��f!
t�> =' -' s ,...el, I\#
Printed Name of Signee 41,k 04 r`yc.?2 4 1
MASON COUNTY PUBLIC HEALTH
..'' 4,, s111
The undersigned approves this Installation Report and 5100214 ale' !1
Record Drawing on behalf of Mason County Public i 4> DALE L. TAHJA -�? 1+
LICENSED DESIGNER v
W
. ;1! of Environmental Health Specialist Date
pe (stamp, signature and date)
THIS FORM MAY BE SCANNED AM)AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE UPI"8121/2018
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