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Mason County OSS Installation Report pg. 1 • MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG r oc,7/ - 00 . �1 Parcel # �17 i 2� - /l/-C)c) d C>c)
Applicant Name Hon /tl- Subdivision (Name/Div/Block/Lot)
Applicant Address y/I v N f)% ,. -
City, State, Zip C c , , 4.,'; VY0(4") Installer Name c..4 V.i.e.✓.1/ S/2/)‘/.. /
Site Address 4/0
j W p/k i1 /t/r)/ RJ Designer Name �r�c4 JC f
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INSTALLATION CHECKLIST
ull System Installation ❑ Tank(s)Only ❑ Drainfield Only ❑ Repair ❑Other
System Type Pretreatment Type
>5 ft. from foundation? - - ❑ N/A 1414 YES ❑ NO
>50 ft. from wells? - - - - - ❑ $] ❑
Z >50 ft from surface water'? - A- ❑ El
H Cleanout between building and tank'? - IA )1-"Nk A� {�f i� - 0 ❑ ❑
Q Tank baffles present? - - ❑ [ ] 0
d24" access risers over each compartment?- -- - ❑ ® ❑
W Effluent filter installed?- i - ❑ ❑
N
Septic tank size Latb gal Manufacturer Ho (i-Se 8 stag,-{-j elt,t
0 D-box water level and speed levelers used? ❑ N/A g.YES ❑ NO
oO Manifold/D-box accessible from surface?- - ❑ ❑
,t, mZ Check valves installed? - - - - •- - - -- - ❑ [
o ii
Transport Line Size Schedule/Class ;0344
Bedrooms installed (check one) ❑ 2 Ne3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
I CI
>10 ft. from foundation?- ❑ N/A YES ❑ NO
>100 ft. from wells?- - ❑ ❑ -
W >100 ft from surface water? - ❑ ® ❑
Z >10 ft from potable water lines?- J� - � - - ❑ [] ❑
Q
> 5 ft from property lines and easements. 4. - - ❑ ® LI
Q > 30 ft. from downgradient curtain/foundation ins?- - - sr�- - -�6- [1] ❑
Drainfield level and observation ports present - - � - [� ❑ -
tGraveless chambers or ❑ Clean gravel used. heck on
Proper cover installed over drainfield?- - ❑ [i-i:1 ❑
Pump tank setbacks consistant with septic tank?- - ❑ N/A ❑ YES NO
Pump tank size gal Manufacturer
Q24"access riser(s)and accessible from surface?- $(-: -
a. Alarm or Control Panel Installed? - ❑ ❑ ❑
2 Control Panel equipped with Timer/ETM /Counter- - ❑ ❑ ❑
M
a Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
O. Pump Make/Model ❑ 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 gpd
Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - -- - ❑ YES ❑ 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-locale in the need of maintenance activities and future development. Typical Record
Drawings contain. Drainfield&manifold onentation&layout,Septic/pump tank location.North arrow.reserve drainfield,existing and proposed buildings.location of wells.waterlines.
wells.observation ports.cleariouts,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 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
1 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 Dry ing is accurate.
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Si na e of Install r Date i�,�
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Printed Name o Signee ;
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MASON COUNTY PUBLIC HEALTH '"d 004
E WAIT �t �
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The undersigned approves this Installation Report and r LICENSED DESIGN i
Record Drawing on behalf of Mason County Public EXRIRLS 05oOr
Health:
C(30 ( Z3
Signature of Environm ntat Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8Rtrzot8
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�, UCEN D DE s ER . / `
:.� .......0 ' �ib.��l, /•> 1. Existing
EXPIRES 05»0
2. Existing shop
3. 1200 gallon concrete septic tank
ry .. / ( b 4. Transport line
APp Ov E V' ;�' k 5. D-Box
f� ,,(� 6. Primary/reseve drainfield
SUN 3� 2023 r t` 7. Soil log #1(0-72" loamy sand)
Ty NVIRONMSNoAI. ����' . 8. Soil log #2(0-84" loamy sand)
MASON COON ! \,>' 9. Well
RET / 10. Waterline
/ 11. Clean out
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