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HomeMy WebLinkAboutSWG2022-00059 - SWG As-Built - 5/10/2023 CLEAR FORM Mason County OSS Installation Report pg. 1 C ,t MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2022-00059 Parcel# 322147501400 Applicant Name David Cooper Subdivision (Name/Div/Block/Lot) Applicant Address 4826 Sleepy Hollow Ct City, State, Zip Port Orchard WA 98366 installer Name Jack Johnson Site Address 50 NECady Ln,Tahuya Designer Name Jim Zmny INSTALLATION CHECKLIST 10 Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other System Type Gravity trenches Pretreatment Type >5 ft.from foundation? - - ❑N/A ■YES ❑ NO >50 ft.from wells? - - 0 ® El Z >50 ft. from surface water? - - El ® El H Cleanout between building and tank? - - El NI El U Tank baffles present? - - 0 IN ❑ a 24"access risers over each compartment?- - ❑ III El LW Effluent filter installed?- - 0 NI Septic tank capacity (working) 1200 gal Manufacturer Hagaerman 0 D-box water level and speed levelers used? - - ❑ NIA IN YES ❑ NO (1O Manifold/D-box accessible from surface?- - ❑ U ❑ QQCheck valves installed? - - 0 0 U d_ 2 Transport Line Size 4" Schedule/Class 3034 03 3 ' g Bedrooms installed (check one) ❑ 2 ©3 El 4 ❑ 5 ❑6 ❑Commercial/Other >10 ft.from foundation?- - ❑ NIA ® YES i] NO CI >100 ft.from wells?- - 0 ® d -1 -1 >100 ft.from surface water? - - ❑ I <r W cc >10 ft. from potable water lines?- - 0 Z ❑ III > 5 ft. from property lines and easements?- - >30 ft. from downgradient curtain/foundation drains? ❑ IN 0 in Drainfield level and observation ports present - - 0 IN ❑ I ❑ Graveless chambers or ® Clean gravel used? (check one) Proper cover installed over drainfield?- - 0 ® 0 Pump tank setbacks consistent with septic tank?- - Iii N/A 0 YES 0 No Pump tank capacity (flood) gal Manufacturer Q24" access riser(s) and accessible from surface?- - 0 0 0 I-a Alarm or Control Panel Installed? - - CI CI E Control Panel equipped with Timer/ETM I Counter- - ❑ ❑ ❑ m a- Pump installed in El Bucket or 0 On Block or ❑ Other d Pump Make/Model 0 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 Upd t 8/21/2018 I Mason County OSS Installation Report pg. 2 Parcel tf 3 L.7 ( ' -7 5-6 I "I v b ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - El YES a 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 and must be accurate and descriptive enough to re-locate in the need of maintenance activities and future development. Tit Record Drawings contain. Orainfeld&nna told oeentamon E Isyota.Septic pump t rk lc:Mon.Nock afros-tcserre dcast.c c,curse}ard utecosed tr,nn-mis.Keaton of nets.matedrie-. wells.observation ports.ckz.roc lc.and other maden.-rce access porn!; Ina ninlvte Record Ora-AIMS may create additional decay:in final i-slae4t en approval and n3d+t1 p`roal. 2-Record Drawing Attached ii 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 MasonCounty Public Health and meet all and Mason County Codes_ myself and Mason County Codes I further certify that all information contained on this i further certify that all information contained on this form.nd all bed Record Drawing is accurate. form and attached Record Drawing is accurate. 2 - Il - 2_Uz3. pure of Installer Date r+l J�(AC_ .Jv k ii'c n-,� I .:re- ...I Printed Name of Signee ' / C .i•/ar t i ,., iris i', MASON COUNTY PUBLIC HEALTH Se 3-• ++ ?l zat t,t+ The undersigned approves this installation Report and o ; .t.nSea ZIn.:ry f ENSEIY EStGNER Record Drawing on behalf of Mason County Public.•. .... .. . .....+. Expires:71/17/ yV Health: CLLfj' \IR -INQi 9V1 C707- S ) - i Signature of Environmental Health Specialist Date (stamp,signature and elate) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE ut'''-.1 8 ul•Aold "'ter i -4 A r �\ taadoad au ` . rn rn 1 Water & Utilitiips i .).") + rn :.: oo > cr I O o I rV N . iti a) CD V. S' ` PPR®VED o MAY 1 U N MASON COUNTYEN3 N VIRONMENTAL HEALTH RET ►— N N N = O < �_ i & OJO 05 v+ ? I,\0`\\ (�D i 0 U /Ia 1� B D