HomeMy WebLinkAboutSWG2023-00080 - SWG As-Built - 4/25/2023 Mason County OSS Installation Report pg. 1 . C. MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 20 z, ' 0°0'5'0 Parcel # 222101100070
Applicant Name EDWIN S&MARY MCRORYTRSE IRENE MCRORY Subdivision (Name/Div/Block/Lot)
Applicant Address 5119 NE 42ND STREET
City, State, Zip SEATTLE WA 98105 Installer Name Franklin Clark
Site Address 5341 NE North Shore Rd,Belfair,WA 98528 Designer Name Franklin Clark
IINSTALLATION CHECKLIST
II Full System Installation ❑ Tank(s) Only ❑ Drainfield Only ❑ Repair ❑ Other
System Type OSCAR XO2 Pretreatment Type
>5 ft. from foundation? - ❑ N/A .YES ❑ NO
>50 ft. from wells? - - Ill ❑ ❑
Z >50 ft. from surface water? - - ❑ II ❑
• Cleanout between building and tank? - - ❑ . ❑
o Tank baffles present? - - ❑ MI ❑
4 a 24" access risers over each compartment?- - ❑ MI ❑
W Effluent filter installed?- - • ❑ ❑
cn
Septic tank size 1,200 gal Manufacturer Infiltrator Systems
0 D-box water level and speed levelers used? - - N/A ❑ YES ❑ NO
J
�O Manifold/D-box accessible from surface?- -
❑ ■ ❑
DOZ Check valves installed? - - II ❑ ❑
tl thQ
2 Transport Line Size 2" -4" Schedule/Class 40
Bedrooms installed (check one) 112 ❑ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
a >10 ft. from foundation? - - ❑ N/A gi YES ❑ NO
o >100 ft. from wells? - - . ❑ ❑
,f W >100 ft. from surface water? - - ❑ ❑ 111
t� >10 ft. from potable water lines?- - ❑ III ❑
z > 5 ft. from property lines and easements?- - ❑ • ❑
ce > 30 ft. from downgradient curtain/foundation drains? - - MI ❑ ❑
ci
Drainfield level and observation ports present - - ❑ III ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one) • Low Ridge Technologies Speced Sand
Proper cover installed over drainfield?- - ❑ MI ❑
Pump tank setbacks consistant with septic tank? - - ❑ N/A 1.1 YES ❑ NO
• Pump tank size 1,200 gal Manufacturer Infiltrator Systems
Q24" access riser(s) and accessible from surface?- - ❑ MI ❑
1--
Alarm or Control Panel Installed? - - ❑ I ❑
a
E Control Panel equipped with Timer/ ETM / Counter- - ❑ 1111 ❑
D
n- Pump installed in ❑ Bucket or ❑ On Block or II Other Pre Low Ridge Technologies
Q. Pump Make/Model AY McDonald //22050E2AJ si Floats or ❑ Transducer
2
a
Tank draw down N/A in/min Pump capacity 1.4 gpm Squirt Height N/A ft
Pump on time 22 Secs Pump off time 3 Mins 38 Secs Daily flow set at 240 gpd
Updated 8/2 1120 1 8
Mason County OSS Installation Report pg. 2 Parcel# 222101100070
ABANDONMENT RECORD
Were any existing septic components abadoned as part of this project? - - YES NO
If yes, please describe: Existing Septic and Pump Tanks pumped out and abandoned.
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - YES 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: Drainfield&manifold orientation&layout,Septic/pump tank location,North arrow,reserve drainfield,existing and proposed buildings,location of wells,waterlines,
wells,observation ports,cleanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
1. 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
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 accurate.
18 April 2023
Signature of Installer Date
Franklin Clark t''t
Printed Name of Signee ;roc: It
Printed
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and 9100/"�'. FRlWKDN J CINAK ':• 'I
•
Record Drawingon behalf of Mason CountyPublic
+E910i28i2024
Health:
kiV\eev-f(Cyy)
Signature of Environmental Health Specialist Date (stamp, signature and date) 18 April 2023
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8/21/2018
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