HomeMy WebLinkAboutSWG2020-00430 - SWG As-Built - 5/16/2023•
Mason County OSS Installation Report pg. 1 CdC MASON COUNTY PUBLIC HEALTH
AP,ICANT/PERMIT INFORMATION
Permit Number SWG 2020-00430 Parcel# 42125-77-90012
Applicant Name �g_e-.---Vrt- Subdivision (Name/Div/Block/Lot)
Applicant Address (50C CC'.•6Vso\ Vp,`,lr.
City, State, Zip q , 1\ ' Installer Name Johnson &Maddox Const.
Site Address .0\ E.. .\-..e- - , Designer Name Dale Tahja
INST ' . 'CHECKLIST --
• ® Full System Installation ❑Tank(s)Only ❑ Drainfield Only
0 Repair ❑Other
System Type Pressue Pretreatment Type
>5 ft.from foundation? .i-57 �'�;- A ®YES ❑ No
>50 ft. from wells? - TE2 ■ ® 0
1 ` 14 >50 ft. from surface water? - ® ❑
Fa- Cleanout between building and tank? - AY b$ 2023 fl ® 0
✓ Tank baffles present? - - 0 ■ 0
a24"access risers over each compartment?--- _!-BY . MI 0
U)
Effluent filter installed?- . - CI NI ❑
Septic tank capacity(working) 1200 gal Manufacturer Miles
9 D-box water level and speed levelers used? - - ® N/A ❑YES 0 NO
p0 Manifold/D-box accessible from surface?- - IN 0
aQCheck valves installed? - - 0 ill
2 Transport Line Size 1 112" Schedule/Class Sch 40
Bedrooms installed(check one) 0 2 11.3 ❑4 0 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ NIA ® YES ❑ NO
0 >100 ft. from wells?- - ❑ ® • >:
- >100 ft.from surface water? - - ❑. .
it >10 ft. from potable water lines?- - (] ® ❑
Z >5 ft. from property lines and easements?
ok >30 ft.from downgradient curtain/foundation drains?- - 0 0
a- ;Drainfield level and observation ports present - - . 0 . MI 0
:,'in Graveless chambers or 0 Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ ® ❑
Pump tank setbacks consistent with septic tank?- - ❑ N/A ® YES ❑ NO
• Pump tank capacity (flood) 1200 gal Manufacturer Miles
<• 24"access riser(s) and accessible from surface?- - 0 IC
aAlarm or Control Panel Installed? - - 0 ® 0
• Control Panel equipped with Timer/ETM/Counter- - 0 ® 0
a Pump installed in 0 Bucket or ® On Block or 0 Other
a' Pump Make/Model Liberty/280
g ® Floats or 0 Transducer
per, Tank draw down 1 in/min Pump capacity 25 gpm Squirt Height 63" ft
:Pump on time 3.6 minutes Pump off time 8 hours Daily flow set at 360 gpd
Updated 8/212018
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Mason County OSS Installation Report pg. 2 Parcel# 42125-77-90012
ABANDC, IIAENT RECORD
Were existing septic components abandoned as part of this project? - - 0 YES 0 NO
If yes, please describe:_
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - 0 YES NO
.; ORDDRAWING
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: Drsotteid&manifold orientation&layout,Septic/pump tank location,North arrow,reserve drainhleld,existing and proposed buildings,location of wens,waterlines,
wells,observation ports,cteanouts,and other maintenance ac m ss points incomplete Record Drawings may create additional delays in final Installation approval and related permits.
® Record Drawing Attached
INSTALLER • DESIGNER!ENGINEER
1 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 hem 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 Drawing is accurate. form and attached Record Drawing is accurate.
iS" ----- 3---1--..zp... .3
ignature of Installer Date
I.. 'A 4....e2.1 P
Printed Nam of Signee f.
§ ''
MASON COUNTY PUBLIC HEALTH / �'� ¢• ,`
The undersigned approves this Installation Report and '` ; \ •' •v
-rf 5:. °i4 ��
Record Drawing on behalf of Mason County Public -�;`_, DAL L. TA A -
. 1
Health: I'-" :.SIGNER
IcIkRilAV)(101/1 —ig iz- 3 Eix.,?.,. .„,
Signature of Environmental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE • :CIpOMltldtl D18
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APPROVED
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MAY 1 6 2023
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MASON COUNTY ENV1RONMENTA_HEALTH
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