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Home My WebLink AboutSWG2021-00583 - SWG As-Built - 7/6/2023 DocuSign Envelope ID:C7D35F9B-2940-4B78-B7F5-0968CDFD3C2E Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2021-00583 Parcel # 22112-77-00070 Applicant Name Benjamin &Amanda Tibbs Subdivision (Name/Div/Block/Lot) Applicant Address 240 E WHEELWRIGHT ST City, State, Zip Allyn, Wa 98524 Installer Name Richard Moore Site Address 711 E Dawn Dr Designer Name Micah Halverson INSTALLATION CHECKLIST 0 Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair ❑Other System Type Pressure Trenchs Pretreatment Type Attenuation Zone >5 ft. from foundation? - ❑ N/A 0 YES ❑ NO >50 ft. from wells? - I .4 4 -lrJ- if ❑ 0 ❑ Z• >50 ft. from surface water? - I El0 ❑ FQ- Cleanout between building and tank? - - - - 'id -.iLLN. 2-3-1023- -I ❑ 0 ❑ U Tank baffles present? - Q L - ❑ 00 P. 24" access risers over each compartment?- - ❑ 0 ❑ W Effluent filter installed?- •- ❑ El ❑ N Septic tank size 1 250 gal Manufacturer Hagerman `0 D-box water level and speed levelers used? - - El N/A El YES ❑ NO DO Manifold/D-box accessible from surface?- - ❑ 0 ❑ u. 002 Check valves installed? - - ❑ x❑ ❑ thQ E Transport Line Size 2" Schedule/Class 40 Bedrooms installed (check one) LI 2 ❑ 3 x❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft. from foundation?- - ❑ N/A El YES ❑ NO >100 ft. from wells?- - ❑ x❑ ❑ W >100 ft. from surface water? - - ❑ El El LL >10 ft. from potable water lines?- - ❑ El ❑ Z > 5 ft. from property lines and easements?- - ❑ 0 ❑ Q l& > 30 ft. from downgradient curtain/foundation drains? - - ❑ 0 ❑ C1 Drainfield level and observation ports present - - ❑ El ❑ ❑ Graveless chambers or ® Clean gravel used? (check one) Proper cover installed over drainfield?- - ❑ N] ❑ Pump tank setbacks consistant with septic tank? - - ❑ N/A x❑ YES ❑ NO • Pump tank size 1500 gal Manufacturer Hagerman < 24" access riser(s)and accessible from surface?- - ❑ El ❑ 0- Alarm or Control Panel Installed? - - El El 2 Control Panel equipped with Timer/ ETM /Counter- - ❑ El ❑ CI- Pump installed in ® Bucket or ❑ On Block or ❑ Other 2 Pump Make/Model Liberty 290 ❑ Floats or ❑ Transducer CL a Tank draw down 1.5 in/min Pump capacity 55 gpm Squirt Height 6 ft Pump on time 1 min Pump off time 3hrs Daily flow set at 440 gpd Updated 8t21/2018 t gnat DocuSign Envelope ID:C7D35F9B-2940-4B78-B7F5-0968CDFD3C2E Mason County OSS Installation Report pg. 2 Parcel# 22112-77-00070 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - YES El NO If yes, please describe: I'm so Were all components pumped out and properly abandoned per WAC246-272A-0300? - - 0 YES 0 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. see Also: Approved Design Record drawing Attached: 1 Page 0 Record Drawing Attached CERTIFICATION OF INSTALLATION INSTALLER DESIGNER/ENGINEER 1 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 I further certify that all information contained on this I further certify that all information contained on this ,A0ched Record Drawing is accurate. form and attached Record Drawing is accurate. !WW1, M.eevt, 06m9/7073 14HC,Al,l,C45 Iu45 Signature of installer Date xao t• i, Richard Mnnre �t• 1� Printed Name of Signee (o �1 / 1� MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report and Record Drawing on behalf of Mason County Public rk ar► uvEr rt , LICENSED DESIGNER 1+ Health:)k41,,d\npsNoir) VeJ23 EXPIRES:09118! Signature of Envirotlmental Health Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 821/2D18 . 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