HomeMy WebLinkAboutSWG2023-00213 - SWG As-Built - 6/28/2023 County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT! PERMIT INFORMATION
:rmit Number SWG 2023_ 0=7213 Parcel # 120 ig"5-3 ^avolli'
Applicant Name IJAlrE O12 SAD Subdivision (Name/Div/Block/Lot)
Applicant Address to £ t' u.1
City, State, Zip 511L 1 f (Ai& ohlsgq Installer Name S L efortai
Site Address SPIrn0 Designer Name
INSTALLATION CHECKLIST
❑ Full System Installation Tank(s)Only ❑ Drainfield Only ❑ Repair ❑Other
System Type Pretreatment Type —•
>5 ft. from foundation? =miry rc 1 N/A YES ❑ NO
>50 ft. from wells? - 'Ill ❑
RI
>50 ft. from surface water? -- - VI CI.Ivrr r � zo�-
Cleanout between building and tank? - - ❑ ❑
Tank baffles present? - $Y: - 13 ,�4 ❑
24" access risers over each compart ntt? - - la --at
C}� p ❑ 12/li El
`fluent filter installed?- " ❑ El
Septic tank capacity (working) gal Manufacturer LDS ( 4s.i 1; 0
' o D-box water level and speed levelers used? - - ' J N/A ❑ YES El NO
>—.-.(
—IO MCl Ellanifold/D-box accessible from surface?- - ❑
mZ Check valves installed? - ? - CI CI CIo a t.�p
E Transport Line Size 2- Schedule/Class
Bedrooms installed (check one) ❑ 2 `Ar3 ❑4 El 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A 0 YES ❑ NO
C1 >100 ft. from wells?- - ❑ CI
W >100 ft. from surface water? - - CI El
>10 ft. from potable water lines?- - ❑ 4K ❑
Z > 5 ft. from property lines and easements? - ❑ ❑
Q > 30 ft. from downgradient curtain/foundation drains? - ❑ g ❑
!II Drainfield level and observation ports present - - CI El
chambers or Clean gravel used? (check one)
Proper cover installed over drainfield?- - CI CI
tank setbacks consistent with septic tank? E) N/A YES El NO
Manufacturer
-ump tank capacity (flood) 12^75 gal �� �
▪ 24" access riser(s)and accessible from surface?- - ❑ CI~
a Alarm or Control Panel Installed? ClCl
E Control Panel equipped with Timer/ ETM/Counter- - ❑ ❑
m
Q. Pump installed in ❑ Bucket or [ On Block or ❑ Other
a'• Pump Make/Model Floats or ❑ Transducer
Tank draw down 2,6 in/min Pump capacity 4P47•S gpm Squirt Height - ft
Pump on time I .5 Pump off time ( N'>- Daily flow set at 3 tP gpd
Updated 8,21/2018
Mason County OSS Installation Report pg. 2 Parcel# I2)°lEr—g0 — 600/41
ABANDONMENT RECORD
existing septic components abandoned as part of this project? - - YES ❑ NO
111 s. please describe:
.re all components pumped out and properly abandoned per WAC246-272A-0300? - YES ❑ NO
RECORD DRAWING
I .!permanent record and must be accurate and descriptive enough to re-locate in the need of maintenance activities and future development. Typical Record
. •.,;.Ings contain: Drainfield&manifold orientation&layout,Septicipump tank location.North arrow.reserve drainfield.existing and proposed buildings,location of wells,waterlines.
.ells.observation ports,cleanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installat on approval and related permits.
/ .e, pf5. pyeitta
pl. ❑ Record Drawing Attached
CERTIFICATION OF INSTALLATION
,airLER DESIGNER! ENGINEER
certify that 1 installed the system in accordance with I certify that the system has been installed in accor-
9 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..(erd Drawing is accurate. form and attached Record Drawing is accurate.
toH173
Signature of Installer a`Y �D Date
Printed Name of Signee
• ..ASON COUNTY PUBLIC HEALTH
.e undersigned approves this Installation Report and
ocord Drawing on behalf of Mason County Public
1111. qcon G (2_g a 3
RI—NU
1 ; Signature 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 8/21/2018
AS-BUILT FORM - PAGE TWO Revised 12/14/94
II r' tt } PARCEL IDENTIFICATION ;
II Applicant's Name 4t1S bn t�(CCDt,0o.}lrt� Faf N4s}e �Ouu`S+-.' 1 II
11; Permit Number SkG9 � T I Subdivision cb ( S .4- 1?
ame iTii T oc L,o
Installer's Name t}twS *o✓•i Caw�t'r' Assessor's Parcel No. IZQl gC7OO/ 3 I
•rp1er's Name �Jtn••14i ��
l
'• I itors CTweive-v1git Number) j
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AS-BUILT DRAWING I
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T o 'p.CVl(�` °I' 101 1 ' o
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1S' MASON COUNTY ENVIRONMENTAL HEALTF
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CAUTION, :fluor edjwteente to wept-lc tank locatico end dralnflela orientation mode In the held try that installer are genar�lly ac-
ceptable to both the department and the designer, but could in certain cases co prise the viability of the system. It is the
installer's responsibility to obtain prior written approval from either the health department or the designer before salting any
deviations from the design that affect system viability. Any deviations from the Approved design oust be show above.
it i
II AS-BUILT CHECKLIST I
I`
N 1-1 Drainfield orientation rl Observation port location Undisturbed native soil
and layout between trenches
Cleanout location t ,�
Trench/bed dimensions and rn L�J North arrow
critical distances within Manifold placement
layout Scale of drawing shown I
Orifice placement on scale bar U
ti1D-Box/"T"/"L" location Q
'kLateral placement, with Additignal Mound Information
Septic tank/pump chamber distances to edge of bed
location LEndslope width
U Location of wells, roads
Location of. Y:u Ldi
'Pngs �.: Overall fill dimensions
ri me u i- o m I ,,,,'!1 .,'`. with tik s' u . ty D u e s
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