HomeMy WebLinkAboutSWG2021-00543 - SWG As-Built - 6/9/2023 i
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Mason County OSS Installation Report pg. 1 C.C. I MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2021-00543 Parcel # 319032290020
Applicant Name Sean Parker Subdivision (Name/Div/Block/Lot)
Applicant Address 471 SE Ellis Rd
City, State, Zip Shelton, WA 98584 Installer Name Vernon Miler
Site Address 471 SE Ellis Rd Shelton WA 98584 Designer Name Dale Tahia
INSTALLATION CHECKLIST
- • Full System Installation ❑Tank(s)Only El Drainfield Only ❑ Repair ❑ Other
System Type Pressure Distribution Pretreatment Type
>5 ft.from foundation? - �- g Ill N/A ItYES ❑ NO
� t'>50 ft. from wells? - -- III ® ❑
Z >50 ft.from surface water? Jyy y-(►-'j-9o-29 - ' 111 ❑
Cleanout between building and tank? - g1�--- -- -- --- ■ ® ❑
V Tank baffles present? - - -- - _ ■ ® ❑
la: 24" access risers over each compartment? - - - By - • e ❑
LW Effluent filter installed?- -- 0 MI ❑
Septic tank capacity (working) 1200 gal Manufacturer Hagerman Precast
CD-box water level and speed levelers used? - - ❑ N/A ❑ YES ® NO
p0 Manifold/D-box accessible from surface?- - El ® ❑
u.
mZ Check valves installed? - - ❑ ® ❑
oQ
g Transport Line Size 2" SchedulelClass 40
Bedrooms installed (check one) ❑ 2 ❑ 3 0 4 ❑ 5 El 6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A ® YES ❑ NO
O >100 ft. from wells?- - ❑ II ❑
W >100 ft. from surface water? - - ❑ MI CI
LL >10 ft. from potable water lines?- - ❑ IN ❑
Z > 5 ft. from property lines and easements?- - ❑ NI ❑
a
Q > 30 ft.from downgradient curtain/foundation drains? - - ❑ II
Drainfield level and observation ports present - - El U] ❑
❑ Graveless chambers or U] 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 Hagerman Precast
< 24" access riser(s)and accessible from surface?- - ❑ U ❑
I`
O. Alarm or Control Panel Installed? - - CIMI 0
2 Control Panel equipped with Timer/ETM /Counter- - 0 II ❑
D
a- Pump installed in ❑ Bucket or 0 On Block or ❑ Other
1
n'• Pump Make/Model Liberty 290 ® Floats or ❑ Transducer
d ' Tank draw down 2.25 in/min Pump capacity 56.25 gpm Squirt Height 7 ft
Pump on time 1 m 36sec Pump off time 6hr Daily flow set at 360 gpd
Updated&21/2018
Mason County OSS Installation Report pg. 2 Parcel# 319032290020
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES Ei NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ YES ❑■ 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,deanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
Record Drawing Attached
CITIAOCTION 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 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.
6/6/2023 �}
Signature of Installer Date c
Vern Miller
i
Printed Name of Signee
� 1'
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and ,= ;� 5 .:14�\ks`r�,�.v
Record Drawing on behalf of Mason County Public J D: •HJA 17
Health: ' 'SIGNER
\ -(\td\f‘(\ocor\Signature of Environmentl Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8/21/2018
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