HomeMy WebLinkAboutSWG2023-00258 - SWG As-Built - 6/30/2023 i
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT! PERMIT INFORMATION
Permit Number SWG2.623-0025% Parcel # 322,18-LI2-02)030
Applicant Name 2 g,Sha rat eyeth Jn Subdivision (Name/Div/Block/Lot)
Applicant Address I 1 I► Northll iff Rd•Unit-A
City, State, Zip sheltDrl,vJA qx.g-gq Installer Name maples 6xCc watir1 j
Site Address Ills WOri-hCItff Rd. UnitA Designer Name
INSTALLATION CHECKLIST
0 Full System Installation ❑ Tank(s)Only ❑ Drainfield Only ❑ Repair [v"Other Li f f &ta h on
System Type )ravi tvi Pretreatment Type
>5 ft.from foundation? - - ❑ N/A ❑ YES ❑ NO
>50 ft. from wells? - •- El ❑ ❑
Z >50 ft. from surface water? - - El El El
HCleanout between building and tank? - - ❑ El
U Tank baffles present? - - El El El
I:: El El El
access risers over each compartment?- -
W Effluent filter installed?- •- El El ❑
U)
Septic tank capacity (working) gal Manufacturer
_9 D-box water level and speed levelers used? - - Li N/A El YES ❑ NO
�O Manifold/D-box accessible from surface?- - ❑ El
El
I 5,12 Check valves installed? - - ElEl2 Transport Line Size Schedule/Class
Bedrooms installed (check one) ❑ 2 [ 3 El 4 El 5 ❑6 ❑Commercial/Other
>10 ft.from foundation?- - ❑ N/A ❑ YES ❑ NO
>100 ft. from wells?- - 0 ❑ ❑
>100 ft. from surface water? - -_ - Tit
❑ ❑
u., >10 ft.from potable water lines?- -�I[EP-- �- ❑ El
5 _ .,
> and easements?- - - ❑ CI- !I
aZ ft. from property lines easemenJUN- 023 .•.
ce > 30 ft.from downgradient curtain/foundation dr - - IA ❑ ❑
rn
Drainfield level and observation ports present - - El 0 DI
-
❑ Graveless chambers or ❑ Clean gravel used? (check one) -)
Proper cover installed over drainfield?- - El ❑ ❑
Pump tank setbacks consistent with septic tank? - - El N/A 'YES ❑ NO
X Pump tank capacity (flood) gal Manufacturer Z-QCIIor
< 24" access riser(s) and accessible from surface?- - ❑ ,E El
a Alarm or Control Panel Installed? - - ElL2d El
2 Control Panel equipped with Timer/ETM /Counter- - Ei ❑ El
m
- Pump installed in ❑ Bucket or [ "On Block or ❑ Other ,_,/
LA" Make/Model 7 11 e( Bt4 2IP'4- Floats or ❑ Transducer
0.
a Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 8'2112018
Mason County OSS Installation Report pg. 2 Parcel# ")2411I R' d'- 00030
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - El YES EZ 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,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 1 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
form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
(1I2$IZ6
Signature of Installer Date
Shane Maples
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
lcdpe f /a/Z3
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
RECORD DRAWING (continued)
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APPROVED
J U N 3 0 2023
A
�( MASON COUNTY ENVIRONMENTAL HEALTH
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