HomeMy WebLinkAboutSWG2020-00153 - SWG As-Built - 5/10/2023 Mason County OSS Installation Report pg. 1 �,- _, MASON COUNTY PUBLIC l EALTH
APPLICANT/ PERMIT INFORMATION /�
G Parcel # G 1 t � 6NN(G(l
Permit Number SWG �(�Z� — ►
Applicant Name ''Kk \4P r1 (� Subdivision (Name/Div/Block/Lot)
PP
A licant Address Log TL.r 66,.. 0_6 �-
City, State. Zip �� `M k,„ �c\ ci d`13 Installer Name L-(:VJ?s�, Y Ri���1J' NV-
Site Addr
ess 1--��. �'vyNck 1 ) • Designer Name <1 Lw1 \\e h Yl
INSTALLATION CHECKLIST
Full System Installation 0 Tank(s)Only
11 ❑ Drainfield Only ❑Repair 0 Other ;
System Type ?Cc.-S S L�1% I')c mil." Pretreatment Type 10-
>5 ft. from foundation? - -- ❑ N/A YES ■ NO
>50 ft. from wells? - 0 fi ■
• >50 ft. from surface water? - . El •■
Z ■
Q Cleanout between building and tank? ❑
I- El El ■
O Tank baffles present? -
1— 24" access risers over each compartment? - . ❑ •
N Effluent filter installed?- 0 0 ■
Septic tank capacity(working)
I S U C gal Manufacturer i-I 11
o D-box water level and speed levelers used? - - ® YES N/A ❑ ❑ NO
i
‹O Manifold/D-box accessible from surface?- ® 0 !Du. ❑
caE Check valves installed? - - ❑ !
❑Q 1 1
2 Transpor. Line Size Schedule/Class
10
Bedrooms installed (check one) 0 2 ❑ 3 ❑4 gig 5 ❑6 0 Commercial/Other
>10 ft. from foundation? - ❑ N/A la YES 0 NO
0
>100 ft. from wells? El 1/4 El
W ❑ I) El>i 00 ft. from surface water? - :i ❑
LT >10 ft. from potable water lines?. 0
Z > 5 ft. from property lines and easements? " 0rif1 T.:Q - ❑ ]
a > 30 ft. from downgradient curtain/foundation drains?
CI
Drai field level and observation ports present Elraveless chambers or a] Clean gravel used? (check one)
tst
Proper cover installed over drainfield?- ❑ RI I ❑
1
Pump tank setbacks consistent with septic tank? - - 0 NIA a YES ❑ NO
Y Pump tank capacity(flood) /.5 `C; gal Manufacturer H
Z
Q 24" access riser(s)and accessible from surface? - - ❑ ® 0
I- 0
I—
ra. Alarm cr Control Panel Installed? 0 E El
Control Panel equipped with Timer/ ETM /Counter- - 0
D a tpt�Pump installed in ❑ Bucket or + On Block or ❑ Other
n' Pump Make/Model O t cnC t ? 005 0 Floats or ❑ Transducer
2 ft
E Tank draw down 2 in/min Pump capacity 2— qm Squirt Height 5
d m or time 1 9 Pump off time Daily flow set at - --9Pd
Pump 11 I �
Mason County OSS Installation Report pg. 2 Parcel#
IABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - ❑
YES No
If yes. please descrioe •
1 ES
Vvere all components pumped out and properly abandoned per WAC246-272A-0300? Y
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. ->c Del Reco:
J•awrnds con:a^ p'a^field&'nan'cle cr:erta:ton&layout Septrc'pump tank Iccanor.Nor-a•roK.reserve dranfield.existing and proposed stal are os location
ca ionl arceils b'aterl net
..ells.)t)servauon ec^s olea^.c..ts.and other maintenance access pr.nts. Incomplete Record Drawings may create additional delays
in fIrtal s.
E 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 a*or-
the septic design stamped -APPROVED"by Mason dance with the septic design stamped 'APPROVED"by
County Public Health and that any deviations shown ri
Mason County Public Health and that any deviatons
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 roger all
and Mason County Codes. State and Mason County Codes later
1 further certify that all information contained on this l further certify that all information contained on this
form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
f-c 7��� �I/ z3 •..
Signatur of installer Date k {• fr,•
i lit '
1 I I
t
Printed Name of Signee e. ' ' ,v„ '
MASON COUNTY PUBLIC HEALTH �� {= ` ' r)'
The undersigned approves this Installation Report and if— }„y f/
�' I•
Record Drawing on behalf of Mason County PublicHealth: ° ADAUL J.1ML11il4lER 1I,i� A° �»;�
tE +�`i I
aNudi t.Jr.r:tS w l
Signature of Environtental Health Specialist Date (stamp. signature and date)
'HIS FORM MAY RF SC'ANNFII ANr)AVAII ARI F FOR PI MI IC.VIEW ON THE MASON not INTY ViFR SITF ".4+448/2t`2'°'9
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