HomeMy WebLinkAboutSWG2021-00623 - SWG As-Built - 6/9/2023 Mason County OSS Installation Report pg. 1 C MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2021-00623 Parcel # 22003-50-00025
Applicant Name Ernie Goudreault Subdivision (Name/Div/Block/Lot)
Applicant Address 20 E. Cougar Lane
City, State, Zip Shelton,Wa 98584 Installer Name 5 yard line construction
Site Address Fox Lane Designer Name Bob Paysse
INSTALLATION CHECKLIST
Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type Standard Pressure Pretreatment Type N/A
>5 ft.from foundation? - - ❑ N/A ®YES 0 NO
>50 ft. from wells? - - ❑ IN ❑
Z >50 ft. from surface water? - - El II
H Cleanout between building and tank? - - 0 U 0
U Tank baffles present? - - ❑ 1111 0
d24"access risers over each compartment?- - 0 NI El
Cl)W Effluent filter installed?- - 0 PI El
Septic tank capacity (working) 1500 gal Manufacturer Infiltrator
in D-box water level and speed levelers used? - - ElN/A ❑ YES ❑ NO
DO Manifold/D-box accessible from surface?- - ElIt 0
mZ Check valves installed? - - 0 ® 0
oQ
E Transport Line Size 2" Schedule/Class 40
Bedrooms installed (check one) 0 2 ❑■ 3 0 4 0 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A ® YES ❑ NO
0 >100 ft. from wells?- - ❑ I ❑
u.1 >100 ft.from surface water? - - ElHI 0
CZ >10 ft. from potable water lines?- - 0 PI ❑
Z > 5 ft.from property lines and easements?- - 0 Q 0
> 30 ft. from downgradient curtain/foundation drains? - - 0 ❑ ❑
CI
Drainfield level and observation ports present - - ❑ UI 0
❑ Graveless chambers or I Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ It ❑
Pump tank setbacks consistent with septic tank? - - ❑ N/A II YES ❑ NO
• Pump tank capacity (flood) 1500 gal Manufacturer Infiltrator
Q 24" access riser(s) and accessible from surface?- - 0 UI 0
E-
a. Alarm or Control Panel Installed? - - ❑ UI 0
E Control Panel equipped with Timer/ETM /Counter- - ❑ IN 0
D
O. Pump installed in IN Bucket or ❑ On Block or 0 Other
O..• Pump Make/Model Zoeller 0 Floats or 0 Transducer
a
Tank draw down 2 in/min Pump capacity 30 gpm Squirt Height 48"+ ft
Pump on time 2 min Pump off time 4 hrs Daily flow set at 360 gpd
Updated 8/21/2018
Mason County OSS Installation Report pg. 2 Parcel# 22003-50-00025
IABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - E YES El NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? �■ 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. 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.
111 Record Drawing Attached
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 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 att hed Record Drawing is accurate. form and attached Record Drawing is accurate.
5-23-2023
Signature of Installer Date
fl.0 p r1') 12 — esi
Printed Name of Signee J ��((
MASON COUNTY PUBLIC HEALTH 11\ 1-`!,
The undersigned approves this Installation Report and y
Record Drawing on behalf of Mason County Public
Health:
AAA7 tp (c (- 3
Signature of Environmental Health Specialist Date (stamp, signature and date)
I
Updated 8R1 2078
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE
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AS3 17-9 RET EXPoRcS
CUSTOMER: ERNIE GOUDREAULT SC\LE:1:30 I F 1
PIONEER DIGGING, INC. PARCEL#:22003-50-00025
SEPTIC DESIGNS ADDRESS: 361E FOX LANE
3083 E.MASON BENS.ON RD. GRAPE\'IEW,WA 985.46 DESIGNER: ROBERT PAYSSE CRSCLAIMER TNIS IS NOT A SURVEY.REFERENCES INCLUDE APPLICANT/COUNTY PROV17ED
PUPS CR SURVEYS.FLLCOJVTY GIS DESIGN INTENDED FOR SEPTIC
PuR.OFFICE-360-4261803 FAX-360-127-2353 DEPARTMECSES GAY PROPOSED DEA DEVELOPMENT REST MAY OR SUBJECT TO DEER
DESIGN PAGE RECORD DRAWING SEPT COMPONENTS
REVIEW DESIGNER NOT RESVWLS 6AF FOR SETBACAS S UNRELATED TC
SEPTIC 00MVONEYTS