HomeMy WebLinkAboutSWG2020-00445 - SWG As-Built - 5/12/2023 iN•s.,
Mason County OSS Installation Report pg. 1 CX MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG Parcel#
t233 ors bovv.,
Applicant Name t3YLW1 y c J �.Z t e rz Subdivision (Name/Div/Block/Lot)
Applicant Address --At,q,-t Ai t=V►i-D14 sr SE
City, State, Zip pagy—prLcHladrD Ah4, q f 3ttCi installer Name - s - 1.40t,7-
Site Address si f ,oc- c.uI- ESS .N1941 Designer Name t4-014rYt PluitirEr2
INSTALLATION CHECKLIST
gi-Full System Installation ❑Tank(s)Only 0 Dralnfield Only ❑Repair ❑Other
System Type FLcxrr 64' X-C-53 4-'r2-C Pretreatment Type
>5 ft.from foundation? - - 0 N/A [ Es (] NO
>50 ft.from wells? - •- 0 Dv 0
Z >50 ft.from surface water? - - 0 ❑/ 0
1--
Cleanout between building and tank? - - 0 EV 0
✓ Tank baffles present? - - 0 Elk- 0
a24"access risers over each compartment?- - ❑ a
tW Effluent filter installed?- •- 0 [4l ❑
Septic tank size gal Manufacturer
9 D-box water level and speed levelers used? - --- - f !A ❑YES ❑ No
DO Manifold/D-box accessible from surface?- - 0 ❑
mZ Check valves Installed? - - E'` 0 0
inQ
2 Transport Line Size 2." - Schedule/Class 4-7/0
Bedrooms installed(check one) ❑ 2 . 3P. [ 0 5 ❑6 ❑Commercial/Other
>10 ft.from foundation?- - ❑ N/A s ❑ No
0 >100 ft.from wells?- - ❑ ❑- ❑
W >100 ft,from surface water? - - ❑ Et-- ❑
LL >10 ft.from potable water llnes?- - ❑ ❑i ❑
Z• >5 ft.from property linos and easements?- 0 ISI--- 0
d >30 ft.from downgradient curtain/foundation drains?- - ❑ 11— ❑
Dralnfield level and observation ports present - - ❑ 1- 0
El-Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover Installed over drainfield?- - 0 Er 0
Pump tank setbacks consistent with septic tank?- - 0 WA [` YES ❑ NO
• Pump tank size Mac) gal Manufacturer pvN 1, ?L _evtA.,an -
Z
< 24"access riser(s)and accessible from surface?- - 0 0- 0
dAlarm or Control Panel Installed? - - o- 0 0
• Control Panel equipped with Timer/ETM/Counter- - ❑ ❑
4. Pump Installed In ❑ Bucket or 0 On Block or ❑ Other J.1/Y
a.
E Pump Make/Modell/W l s>t \ V ErOcer
d Tank draw down /414- In/min Pump capacity_A04— gpm Squirt 1 Helght,•� L ft
Pump on time. 1i4 Pump off time_._. MAY Dz y` f set at gpd
MASON COUNTY ENVIRONMENTAL HEALT amee e12112
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Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - YES [t�tQo
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - YES 040
RECORD DRAWING
This is a permanent record end must be accurate and descriptive enough to re-Locate In the need of maintenance activities and future development Typical Record
Drawings contain: Dralnfield&manifold orientation&layout,Septic/pump tank location,North arrow,reserve drainfield.existing and proposed buildings,location of wells,waterlines,
walls,observation pods,cteanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays In final Installation approval and related permits.
[ Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNERI 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 attache. '_.ord 'rawin• is accurate. form and attached Record Drawing is accurate.
�► / 2 3 }�•uit.
��� • of lnst.:ll'- , " '{tom
Date N'rl
Printed Name of Signee LI r_, Atk/ PROVE
-,
MASON COUNTY PUBLIC HEALTH s
�`�""•��\ ��.�.� �. MAY 12 2023
The undersigned approves this Installation Report and ? �i 1 �:�
)4Z417
Record Dr g on behalf of Mason County Public '�:' `'''°"` %i'
OUNTY ENViR�Nif1ENTF L HEAL�F'
Ap�til:,! lIUNTEI?
. .
Health: ''1' 'I'ii:i',�1�I i`.�1, DJA
Sign re 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 Updated 8t21/2019
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