HomeMy WebLinkAboutSWG2021-00672 - SWG As-Built - 7/6/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 20fii _ Q06 7 a Parcel it a aQQr- S- 3-o003o
Applicant Name T,-i 4«Key,by Subdivision (Name/Div/Block/Lot)
Applicant Address /Rso , ,e,,1,'//- 1 L.,kr ze,f.,X r/
City, State, Zip s Je/�,, 1,j A gysgy Installer Name Cp.,is. Nr.,, ,
Site Address 1gs7 c itX. /iiiiu L.s r c,,.p 6t/ Designer Name rt N,h,„/a„
INSTALLATION CHECKLIST
Bl'usi System Installation 0 Tank(s)Only 0 Orainfiuld Only ❑ Rcpoi; ❑fith:'
System Type PPss-r+.•L Prnlreritment Type Q,11i[S?JO ____
>5 ft. from foundation? • - - .. _ E.
Ni
WiA s no
>50 ft. from wells? - r- - - -= - 4' '12 ❑ El ❑
Z >50 ft. from surface water? - ' - = v ? [r ❑
• Cleanout between building and tank? • - -;- - dPl C t* i.b�$e� ' ['f ❑
U Tank baffles present? - - ��' - - - - Ef LI
n~ 24"access risers over each compartment?•Eiy - j [9/ ❑
tw Effluent filler installed?- y - - 0 0 Qr
3
Septic tank capacity(working) Soo gal Manufacturer,_445ee.,s.•?
o D-box water level and speed levelers used? - - - - - 3NrA ❑ YES ❑ NO
oO Manifold/D-box accessible fromsurface? " - - 0 El'
co Z Check valves Installed? • 0 [3 121.-/
t7 Q ,,
2 Transport line Size 2 Schedule/Class '•IO
Bedrooms installed(check one) 2 0 3 0 4 0 5 ❑6 0 CommerciatOther
>10 ft. from foundation? - - - - - - - - • 0 NIA ral.ES ❑ NO
>100 ft.from wells?- ❑ ❑
o
Li, >1 0n ft. from surface water? • - - - - - • ❑ Q,/ 0
LT. >1tl ft. from potable wafer lines?- - - - 0 _I- _ ❑
Z > 5 ft.from property lines and casements?- ❑ IS• . ❑
cc > 30 ft. from downgradient curtain/foundation drains?- " 0 E 7 ❑
Drainfield level and observations present - - - 0 [� ❑
0 Graveless chambers or Clean gravel used? (check one) �,/
Proper cover installed over drainfield?- - - - - - - -• - - - 0 L3" 0
Pump tank setbacks consistent w,th septic lank? - • ❑ NIA EVES 0 NO
Z• Pump tank capacity(flood) .1 e�U gal Manufacturer .'r !y.-.•i•+
Q 24" access riser(s)and accessible from surface?- - 0 Q" ❑
0. Alarm •or Control Panel installed? - - - - ' 0 Er ❑
,
2 Control Panel equipped with Timer/ETM/Counter- [mil/
0 ❑
t1 Pump installed in Bucket or ❑ On Block or ❑ Other
2 Pump Make/Model L, Je,.V Lg id D4oats or 0 Transducer
R. Tank draw down _p in/min Pump capacity e gpm Squirt Height in
R. �
Pump on time_ si 7 ,,, Pump oft lime 6__6_„__ Daily flow set at 1 '0 uN
Mason County OSS Installation Report pg. 2 Parcel aZ20 O 5 - S 3 00 3 v
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project', - - - - - - - - - - - - - ❑ YES ❑ NO
II yes, please describe.
Were MI components pumped out and property abandoned per WAC246-272A-0300? • - - - - - - - ❑ YES ❑ NO
RECORD DRAWING
i ale.e a permanent record and must be accurate and descriptive entwpir lu re-locale In IIUr nerd of rntnntenMCe activities and M1tfure development. I rviotr Retold
'Jtavenge!rssta.rr LVa:nnr4I A rnt^54Id nrlenteben d u.rR7t.SeG11UCwnttr'tvtM kK-Meer titian rn:tw .o.+arvn ursnrcld.a,.stotd..'.I V0P041/td t+J.IC.rhlt 10C1'.1.1..tl acts.widower.
w.rh.r4m.tvttfte parts cNence+te +✓eJ.*'n'mwntnntnce nC:e.'pool' Ifeximpmtn ttiooY 1 Dnwwtgs.nivi armed/6c3n1nf nrenr4.n Inal etunik>t.t.n.tpprrtv.til met relabel per‘;.
2 PC`?3'`
(.Record Orewtrig 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 cleated/approved by both
and Mason County Public Health and meet all Stale myself and Mason County Public Health and meal 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.
D -----] 1y`' 6-/.-;leY-
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i
Signature of installer rr,''O 'Lair
-i"t11)
Printed Mime of Sigr VI,
MASON COUNTY PUBLIC HEALTH \ oil IT:- i 4.1
The undersigned approves this installation Report and rf j- `)di
.
stoasas 'c�1
Record Drawing on behalf of Mason County Public �i �G,N MANE.HALVERSON-•
Health �' LICENSED DESIGNER It
k)-e\AD•V\VS� -7 J 6 ft DARES:09/1 ty'A
Sttplatu)19 of Enveonntentetl Health Specialist Dole t stamp, signature; and demo)
THE-:DORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE L"'r"'"a t"I''‘'"
RECORD DRAWING (continued)
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