HomeMy WebLinkAboutSWG2022-00429 - SWG As-Built - 6/30/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG ZQ ZZ- Q0�29 Parcel # p 7-7—°ZIA -zo -02)05Th
Applicant Name Atirpr ('c44Di Subdivision (Name/Div/Block/Lot)
Applicant Address az nlyy, c;p 1L 1 Sly
City, State. Zip , ei.V.Jujiab6,wpt ccggq Installer Name /-kiu5 fir ors
Site Address GI2_1 F Los-\ (ti ❑c - Designer Name 7-km 2.41(\(1y
INSTALLATION CHECKUST
rcll System Irstailatror. ❑Tank,,s;Drill; ❑ Dra;n`idb O^h/ ❑Repair ❑Other
System Type Pretreatment Type
>5 ft. from foundation? - -- ❑ N,A sr YES ❑ NO
>50 ft. from wells? - -- ❑ 0 ❑
• >50 ft. from surface water? - ❑ j ❑
Z
• Cleanout between building and tank? ❑ 0 ❑
U Tank baffles present? - ❑ IDin
d24' access risers over each compartment?- -- - - - - El ES
WEffluent filter installed?- -• 0 !il 0
Septic tank caoac.ty (working) `7_C_)0 gal Manufacturer I--ifb1)Ce_ NW Bc cs c -r -.
_o D-oox water level and speed levelers uses? - ❑ NIA p YES ❑ NO
X0 Manifold!D-box accessible from surface?. 0 0
QCheck valves installed? • - `R ❑ 0
5 Transoor. _ire Size L` .rrcyl Schedule.Class t0-)1/
Bedrooms installed(check one) ❑ 2 ❑3 vi-.4 ❑ 5 06 ❑Commercial/Other
>10 ft.from foundation?• 0 NIA "J YES ❑ No
>100 ft.from wells?- ❑ ❑
W >100 ft. from surface water?- - 0 0 0
u. >10 ft.from potable water lines?- . ❑ .- ❑
Z > 5 ft. from property lines and easements?- - ❑ tl. 0
Ct > 30 ft.from downgradrent curtain/foundation drains'? - 0 ❑
c
Drainfield level and observation ports present - 0 0
3,1 Graveless chambers or ❑ Clean gravel used? tci.eck one!
_Prooer cover installed over drainfield?- •- ❑ IA ❑
mot' ,r0 tank setbacKs consistent with septic tank? - - gN/A ❑ YES ❑ NO
Y Pumo tank c ity(flood) gal Manufacturer
< 24' access riserts)an cessible from surface?- - ❑ 0 ❑
1--
Alarm or Control Panel Installe . - ❑ ❑ ❑
a
2 Control Panel equipped with Timer i E . ,Counter- - ❑ 0 0
a Pump installed in 0 Bucket or 0 On Block ❑ Other
a• Pump Maxe?wlocel ❑ Floats or 0 TtansUucer
capacity Tank dray down in/min Pumpca acitpm Squirt Height 9 f:
Pump o- time Pump off time Daily flow set at gnd
Mason County OSS Installation Report pg. 2 Parcel# Zz O 2 y -2.0-O Z G5-0
I1 ABANDONMENT RECORD
If Were existing septle components abandoned as part of this project? - ❑ YES ❑ NO
If yes please describe'
1 Were all components Dumped out and properly abandoned pe• .'JAC24E-272A-O300? - - 0 YES ❑ NO
RECORD DRAWING
This is a permanent revere and must be accurate and descriptive enough to re-locate ro the need of maintenance activates and tuta.rc development. ,. c.d-4 ,
..,nv,aa ca.,- --f..to a-6....,4 k ^ta:on G 1.n out Septa a..'r7%+-‘1c;.dti0- Nei-a.'x •ese: _t:oa .4.evsung a^c pop'3.ed n-ddutr,•: Iaabon C' .toll..s ieerF•.
:wilt,anat.'avwlann.vr'a .-.1e.,••c.:a.uri tV•e'mewieh:an:e atctas u7`ta, t v7-4S e'e Re ur:::a,mys^tar vealc adelxsnei,a k s In t-rai cat•llw v'au7•u.d1 a^c: ',Wel ix'', r-
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CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER!ENGINEER
I certify that I installed tr+e 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 clearedapproved 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 furth certify that ail information contained on th;s I further certify that all information contained on this
for . an attached Recorq'Drawing is accurate. form and attached Record Drawing is accurate.
Ai-er..Y-6 2 -2 -5
Sign 're ci Instaile- at_
1T i 1�1
Printed Name of Sr ee ,%� •1
gr; 1/
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MASON COUNTY PUBUC HEALTH / ;':: ''"'s,�,./1
The undersigned approves this Installation Report and ; ° �• `�,11
1
Record Drawingbehalf of Mason County Public /o� , "Ni3m:ln,"
on oun y i 1 E,r.ED DESlGteER 1
Health: Ce•I w . . .. ,.
Expu l•:8/17/ i-3
fC(- a irL3
ISignan: o!c'r.:ircrrren aalth Sp�'cialist Date (stamp. signature and date)
T-11G PnPM MAY SF sr.ANNFI)Am-)A✓AI:Arts F FhR Pt 1P1 le.VIPW ON THE MASON riot INT V+/dFR CITE `
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I— 'I,� - I Q )UN 30 2023
1�n MASON COUNTY ENVIRONMENTAL HEALTH .4*
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