HomeMy WebLinkAboutSWG2020-00142 - SWG As-Built - 4/27/2023 0
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son County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 222O•00/g2. Parcel # '{21Z7- 1 1 —90026
Applicant Name k tgr l.00.1 CAIZNI Subdivision (Name/Div/Block/Lot)
Applicant Address 11 E iJaWirrtAl $Kq (z •
City, State, Zip QvjiD/11 104 Vrtezi Installer Name '•4'f.tla rk._ LL.C.-
Site Address 10 6,Adaarra $ . G ' Designer Name jell Nut
INSTALLATION CHECKLIST
IStiFull System Installation ❑Tank(s)Only El Drainfield Only ❑ Repair ❑ Other
System Type 64/014 1>f Pretreatment Type
>5 ft. from foundation? - ` AJQ vizg - 6N/A ❑ YES ❑ NO
>50 ft. from wells? - - ❑ ❑
Z• >50 ft. from surface water? R - -8 - - - - ❑ ElH Cleanout between building and tank? - - U - - CI ❑
U Tank baffles present? _APl _1 9 2023_ ❑ V ❑
F- 24"access risers over each compartmen . - - - -it - ❑ A ❑
t.0 Effluent filter installed?- B - - - ❑ N ❑
rn I
Septic tank capacity (working) Wei gal Manufacturer yyyk3,n 1
O D-box water level and speed levelers used? - - ❑ N/A o'YES El NO
oO Manifold/D-box accessible from surface?- - CI21 ❑
u.
o0Z Check valves installed? - - ❑ El X
ctQ ..12 Transport Line Size Schedule/Class &j
Bedrooms installed (check one) ❑ 2 0 3 r2j4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation? - - 6 N/A Rr
YES ❑ NO
O >100 ft. from wells? - - CI ❑
W >100 ft. from surface water? - - ❑ ❑
u. >10 ft. from potable water lines?- - ❑ kia. ❑
Z > 5 ft. from property lines and easements?- - ❑ ❑
Ix > 30 ft. from downgradient curtain/foundation drains? - - ❑ ❑
• Drainfield level and observation ports present - - ❑ ❑
❑ Graveless chambers or 4 Clean gravel used? (check one)
Proper cover installed over drainfield?- - El X ❑
Pump tank setbacks consistent with septic tank? - - is N/A ❑ YES ❑ NO
. ' Pump tank capacity (flood) gal Manufacturer
Q 24" access riser(s) and accessible from s ce?- - ❑ ❑ ❑
~ Alarm or Control Panel Installed? - _- -D ❑ Cl
2 Control Panel equipped with Timer/ ETM / Counter- - — - ❑ El ❑
n
4- Pump installed in ❑ Bucket or ❑ ock or ❑ Ot
a• Pump Make/Model oats or 0 Transducer
a
Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Urdated 8 21:2018
Mason County OSS Installation Report pg. 2 Parcel # '123""I I-' b 20
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES X NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ YES k ❑ 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 lank location.North arrow.reserve dramfieid.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.
1PPRovE
0 API? 97 2n9.4
SON er-
__ .: ... ... .
❑ Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ ENGINEER
I certify that 1 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
`')unty Public Health and that any deviations shown Mason County Public Health and that any deviations
have been cleared/approved by both the designer shown here have been cleared/approved by both
„rd Mason County Public Health and meet all State myself and Mason County Public Health and meet all
'Id Mason County Codes. State and Mason County Codes
•r--ther certify that all information contained on this I further certify that all information contained on this
,rI and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
�' 2 .,, ,. •
. 40IP
Signature Installer Date 4;,; l , ./11.7/1,;
Cti1t fiCA , .i� "'74#
Printed Name of Signee v a,, r,,
MASON COUNTY PUBLIC HEALTH ' 'ti',!1
ram: 51u0.312 •:..
The undersigned approves this Installation Report and 0 0.•. •
ADAM J.HUNTER /
Record Drawing on behalf of Mason County PublicLir Nom% wt. . - ,
ta.i-,H:J u;,ty '
Health
V- 7 -. 3
Sig :tut Environmental Health Specialist Date (stamp, signature and date)
Updated 8;21 201A
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE
RECORD DRAWING (continued)
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