HomeMy WebLinkAboutSWG2021-00636 - SWG As-Built - 6/23/2022 CLEAR FORM
Mason County OSS Installation Report pg. 1 C..Q. MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2202-00636 Parcel # 123305200035
Applicant Name r n s \— U U{'3 6 Subdivision (Name/Div/Bloc grZ211727
Applicant Address 2315 NE Wyoming St Lynch Cove, Div 5, Lot 35 J JUN 1 4 2f121 '%
City, State, Zip Bremerton WA 98312 Installer Name Jack Johnsggy
Site Address 50 NE Schooner Ct Designer Name Jimzlmny [77 -
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only ❑ Drainfield Only El Repair ❑Other
System Type Gravity Bed Pretreatment Type
>5 ft. from foundation? - - ❑N/A ®YES ❑ NO
>50 ft. from wells? - - ❑ IN ❑
>50 ft. from surface water? - - ❑ ® 0
Z
HCleanout between building and tank? - - 0 ® 0
U Tank baffles present? - - 0 IN 0
d24"access risers over each compartment?- - 0 IN
`W Effluent fitter installed?- - 0 ® 0
o
Septic tank capacity (working) 1000 gal Manufacturer Infiltrator
5 D-box water level and speed levelers used? - - 0 N/A ® YES ❑ NO
00 Manifold/D-box accessible from surface?- - ❑ III El
CO2 Check valves installed? - - ® 0 0
oQ
2 Transport Line Size 16' Schedule/Class 3034
Bedrooms installed (check one) ❑ 2 ❑3 0 4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - 0 N/A ® YES ❑ NO
O >100 ft. from wells?- - ❑ ® 0
W >100 ft. from surface water? - - ❑ II ❑
LL >10 ft. from potable water lines?- - 0 ® 0
e.g. > 5 ft. from property lines and easements?- - El El El
d > 30 ft. from downgradient curtain/foundation drains? - - 0 ® 0
Drainfield level and observation ports present - - 0 ® 0
❑ Graveless chambers or mi Clean gravel used? (check one)
I Proper cover installed over drainfield?- - 0 ® 0
Pump tank setbacks consistent with septic tank? - - ❑ N/A 0 YES 0 NO
• PumAPc R oo E D gal Manufacturer
Q 24" access riser(s)and accessible from surface?- - 0 0 0
~4 a. Alarm or Core d r332en?I talled? 0 ❑ ❑
Con tr P OUNTm NVIROm3AL-I y.,ETM/Counter- - ❑ 0 0
a Pump installed in DE Bucket or 0 On Block or ❑ Other
a• Pump Make/Model El Floats or ❑ Transducer
a=. Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at glad
updated 812?/2018
Mason County OSS Installation Report pg. 2 Parcel# Z 3 �SZ�-'vo S
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - D YES Q NO
It yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - El 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 Drainteld&manifold orientation&layout.Septic/pump lank location.North arrow.reserve drainfietd existing and proposed buildings.location of wells.waterlines.
wells.observation ports.cleanOuts.and other maintenance access points incomplete Record Dra ags may aeale additional delays in final instatiatwn approval and related permits.
II Record Drawing Attached
CERTIFICATION OF INSTALLATION
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 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
to d attaji?- Record Drawing is accurate. form and attached Record Drawing is accurate.
Si.'iof J2 i 7- ZOZ2
re of Installer Date
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Printed Name of Signee S¢ .
MASON COUNTY PUBLIC HEALTH :,it• +,, ,fit
The undersigned approves this Installation Report and r 4, = i'
Record rawing on behalf of Mason County Public ;AY /.23033 ��►�
- o :ter,Zlrn:,y
Healt f LIC ED DESIGNER
t\. l=xpires:6/17/Z '
Signature of Environmental Health Speci st DE ftJ 'o (stamp, signature and date)
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THIS FORM MAY BE SCANNED AND AitrAl LIC VIEW ON THE MASON COUNTY WEB SITE r 'atel e121i.Ot3
MASON COUNTY ENVIRONMENTAL HEALTH
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Change of Designer Request
Building Site Address: 0 N E tcchao y^ QCl{-Lir Wh
Parcel Number: i�-330 — 52 — 00035
Previous Designer/Engineer: Po on V I i" LA-C' / Fr ift..n V-I I n 'J C-) i-N k
New Design Information: Jim Zimny—Advantage Perc& Design
36Q-516-7287
7178 Windflower PI NW
Se.ibeck,WA 98380
By signing below, I understand that the original designer/engineer of record is being replaced by the above-
identified designer/engineer.
John Cunningham Jahu C 1ta w9tatu
01-19-2023
PRINT NAME SIGNATURI DATE
Tyler Jones n qi9Y Jo? e.c01-24-2023
APPROVED
JUN 3 2 2023
MASON COUNTY ENVIRONMENTAL HEALTH
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Signer Tlmestamp Skinaiture
John Cunningham
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John auutix#alt4
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Recipient Verification: 1P 6606r4.1 136 100 17 56 .v.
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42,02-4-13 -0032D 62.„_6
OAudio-Visual Alarm APPROVED
Cleanout
JUN222023 A4..A1050 Gallon Septic Tank MASON COUNTY ENVIRONMENTAL HEALT
2-Compartment with
Effluent Filter RET
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0 „so Gallon Pump Chamber ;• f
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O Valve Control Box ,„ s, `•a
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.th: PAULA JOY JOHNSON .5.1.
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