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HomeMy WebLinkAboutSWG2020-00347 - SWG As-Built - 4/27/2023 - 1401 CLEAR FORM Mason county OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2-o -O - 3`f - Parcel# 32 021 S 3 o3 60/ Applicant Name e.,44,`Sli. , /!(rh-/( Subdivision (Name/Div/Block/Lot) Applicant Address / O. / ),,' t 320 rSlI inC-L'u � GP _ City, State, Zip S74 tA Installer Name �jd/ /UUj� lx- Site Address 2`h2 SllL✓rre Sr Designer Name --�;'Iv/1-&,11t!Z-V INSTALLATION CHECKLIST [Kill System Installation ❑Tank(s) Only ❑ Drainfield Only ❑ Repair ❑Other System Type Pretreatment Type >5 ft. from foundation? - - 0 NIA 1 YES ❑ NO >50 ft. from wells? - A9 0 ar 0 >50 ft. from surface water? - -/--- ❑ Er ❑ H Cleanout between building and tank? - 1 -M2-Il- Ela- 0 [Y El U Tank baffles present? - n El a 1-- 24"access risers over each compartment?- ..- .►I+ -.4J� - ❑ 13v ❑ W Effluent filter installed?- - 0 l3 0 (I) Septic tank capacity (working) lZeP gal Manufacturer //1 LF3:4e- ✓ O D-box water level and speed levelers used? - - ❑ NIA ©-YES ❑ NO 0O Manifold/D-box accessible from surface?- - 0 f?z Check valves installed? - - El El El C3Q "" Schedule/Class ivy 2 Transport Line Size ti Bedrooms installed (check one) ❑ 2 Q ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft. from foundation?- - ❑ NIA [ -YES ❑ NO C1 >100 ft. from wells?- - ❑ ❑ W El>100 f. from surface water? - - 0 EV w >10 ft. from potable water lines?- - 0 ❑ Z > 5 ft from property lines and easements?- - ❑ ar 0 d > 30 ft. from downgradient curtain/foundation drains?- - 0 EV 0 Drainfield level and observation ports present - - ❑ ❑ 0 ❑ Graveless chambers or []Clean gravel used? (check one) Proper cover installed over drainfield?- - 0 td ❑ ~ /.�/[?/9 k6 Pump tank setbacks consistent with septic tank?- N/A 0 YES ❑ NO Pump tank capacity (flood) gal Manufacturer Z < 24" access riser(s)and accessible from surface?- - ❑ ❑ 0 ~ Alarm or Control Panel installed? - - El El El a 2 Control Panel equipped with Timer/ ETM/Counter- - 0 El ElM a. Pump installed in 0 Bucket or ❑ On Block or El Other a' Pump Make/Model ❑ Floats or 0 Transducer 2 a. Tank draw down in/min Pump capacity gpm Squirt Height ft a Pump on time Pump off time Daily flow set at gpd Updated srzv2018 Mason'County OSS Installation Report pg. 2 Parcel# ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - ❑ VGS ❑ NO If yes, please describe: Were all components pumped out and properly abandoned per WAC246-272A-0300? - - 0 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. PpROVE r c�ApR 17 2023 YENVIRONMENTA1 y JBW EAiTy ecord 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 D ing is accurate. form and attached Recf rd Drawing is a• urate_ � 30/2Z /ice /Signature of Installer Date ---13 -23 Illy Lltit/vt 6 ArL�LL.e,c(il� S T�`4 ',, Printed Name of Signee i•, ,.s. D ,? 0 V?, f MASON COUNTY PUBLIC HEALTH �� ' r$ Z '�e The undersigned approves this Installation Report and ..�� 5l own � �, t! Q LAMES R.HUNTER ti Record Drawing on behalf of Mason County Public =""ctrisfb►t*IGivrR 4 Heal 'Sx s.2i ...\16%111.4 MPIRES: 08/22/ akii, (-('2-7--2-3 Signs En ronmental Health Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 821/2018 -s- , --.1_,.,- il I i 1— —1 A . .1 ,7\1 r 1 ioo a \ = f a C7 r \ 3 Ilit61 4 \ o r I )c. � '� . 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