HomeMy WebLinkAboutSWG2023-00128 - SWG As-Built - 6/7/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG U23`' Do I? Parcel # 2 2 3 3 I -S0 - o 00 C7 3
Applicant Name �12-1}9 DA-v.1612..o,J Subdivision (Name/Div/Block/Lot)
Applicant Address `.i2 O ' oX S (a LrN 5 LK D/'v / La E-' ,3
City, State, Zip :Xe.A: ir/ 61'65 Installer Name jmL1 _ S`Pv"
Site Address 671 NE C/ i<vi t/ Ptewej Designer Name ve3 5q)ii-L , lz14?-£- -
INSTALLATION CHECKLIST
❑ Full System Installation DI Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type A, 'T (I, To hzeS.Cv0c= Pretreatment Type N AM-ky_ ,t3A -$100
>5 ft. from foundation? - - zi N/A ❑ YES ❑ No
>50 ft. from wells? - {E {�1i T- T_ ❑ ❑
>50 ft. from surface water? - L� L ❑ ❑
Z
Cleanout between building and tank? - -0 S 12.3--. vs El ❑
V Tank baffles present? - LL-� - - - rA ❑ ❑
E. 24" access risers over each compartment?tis - (6 ❑ ❑
Y — -` - [ 1 ❑ ❑
fW Effluent filter installed?- -
Septic tank capacity(working) gal Manufacturer
5 D-box water level and speed levelers used? - - N/A ❑ YES ❑ NO
0 �O Manifold/D-box accessible from surface?- - ❑ ❑
012 Check valves installed? - ❑ ❑
, -
thQ
2 Transport Line Size Schedule/Class
Bedrooms installed (check one) r 2 ❑ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - [ )N/A El YES ❑ NO
CI >100 ft. from wells?- - ❑ ❑
W >100 ft. from surface water? - - (21 ❑ El
L >10 ft. from potable water lines?- - ❑ ❑
> 5 ft. from property lines and easements?- - ❑ ❑ ElaE > 30 ft. from downgradient curtain/foundation drains? - - ® ❑ ❑
Drainfield level and observation ports present - - D3 ❑ ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - In ❑ ❑
Pump tank setbacks consistent with septic tank? - - N/A gr YES ❑ NO
Pump tank capacity (flood) 1Z50 gal Manufacturer 6l�A)h-r-i i'I-i,r5i
Z
< 24" access riser(s)and accessible from surface?- - ❑ ,E] ❑
d Alarm or Control Panel Installed? - - El ❑
2 Control Panel equipped with Timer/ ETM /Counter- - El Idlid ❑
o. Pump installed in 0Bucket or El On Block or ❑ Other
n' PumpMake/Model Ctrs�i,, al Floats or q / ❑ Transducer
d Tank draw down 2 " in/min Pump capacity `'�� / gpm Squirt Height n�r ft
Pump on time �a Sec. ., Pump off time 2 -/?)L'/=5 Daily flow set at .?y0 gpd
Updated 8r21120,8
r
Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - YES EI NO
If yes, please describe: 1.� (-.1rf/2 % ear f%Nfir7/ i
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ErYES 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 tank location,North arrow.reserve drainfield 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.
[ Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ ENGINEER
I certify that I installed the system in accordance with 1 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
fo an atta ed cord rowing is accurate. form and attached Record Drawing is accurate.
Signature of Installer Date
s3ctw I e n1�cy
Printed Name of Signee
.,k
MASON COUNTY PUBLIC HEALTH e`4
o-- N.z,,
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health: e(PIRES tents;
c2:umvw Gyv\ �712-� 6/,/z 6,7L) -
)
Signature of Environments Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE updated tB 21/2018
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