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Mason County OSS Installation Report pg. 1 C MASON COUNTY PUBLIC HEALTI
APPLICANT! PERMIT INFORMATION
Permit Number SWG L(91 — C 3-‘3 Parcel # SZ071-4 tl- a3 O
Applicant Name Cedarland & CO LLC Subdivisiapn (Name/Div/Block/Lot)
Applicant Address PO Box 2269 Allynmore Ridge lot 4
City, State, Zip Gig Harbor WA 98335 Installer Name J&J development
Site Address 931 SE Mil(Crk Rd Shelton 98584 Designer Name Peninsula Septic Designs
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair ❑ Other
System Type pressure distrubution Pretreatment Type •
>5 ft. from foundation? - - ❑ N/A ® YES ❑ NO
>50 ft. from wells? - - ❑ Pi ❑
Z >50 ft. from surface water? - - ❑ 0 ❑
Fd- Cleanout between building and tank? - - ❑ 0 El
V Tank baffles present? - - ❑ El ❑
a24" access risers over each compartment?- - ❑ NE ❑
W Effluent filter installed?- - ❑ ® ❑
N
Septic tank capacity (working) 1250 gal Manufacturer Hagqerman Precast
0 D-box water level and speed levelers used? - - In NIA ❑ YES El NO
0O Manifold/D-box accessible from surface?- - ❑ WI El
L . mz Check valves installed? - •
- ❑ ® ❑
oa
2 Transport Line Size 2" Schedule/Class 40 .
V.
y CI Bedrooms installed (check one) ❑ 2 0 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
vo
hf\ >10 ft. from foundation?- - ❑ N/A in YES ❑ NO
I.1 >100 ft. from wells? - - ❑ 0 ❑
• "`" >100 ft. from surface water? - - El WI ElJ
lam. >10 ft. from potable water lines?- - ❑ 0 ❑
> 5 ft. from property lines and easements?- _ ❑ II ❑
12 > 30 ft. from downgradient curtain/foundation drains? ❑ IR ❑
Drainfield level and observation ports present - - ❑ 0 ❑
❑ Graveless chambers or Nu Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ ❑ ❑
Pump tank setbacks consistent with septic tank? - - ❑ NIA ® YES ❑ NO
• Pump tank capacity (flood) 1250 gal Manufacturer Haggerman precast
Q : 24" access riser(s) and accessible from surface?- - ❑ ® ❑
I—
a. `Alarm or Control Panel Installed? - - El 0 ❑
a
2 Control Panel equipped with Timer/ ETM /Counter- - ❑ 0 ❑
M
a Pump installed in ❑ Bucket or 0 On Block or ❑ Other
C.• Pump Make/Model liberty ® Floats or ❑ Transducer
p=„ Tank draw down 1.875 in/min Pump capacity 43.125 gpm Squirt Height 6 ft
Pump on time 84 sec Pump off time ' 4hrs Daily flow set at 360 gpd
Updated 8!21!2018
. Mason County OSS Installation Report pg. 2 Parcel# 32029 44 00000
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES Q NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A20300? - - ❑ 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.
•
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
i further certify that all information contained on this 1 further certify that all information contained on this
form and attache e ord Drawing is accurate. form and attached Record Drawing is accurate.
12/5/21 i'l
Si ature o In alter Date o 41
Kenneth Jones '' •°��1+)
Printed Name of Signee _v'�y+= +:
,- LT'l -, .Vii.
OVSV
MASON COUNTY PUBLIC HEALTH �•••IIWYY,,,F : ,
The undersigned approves this Installation Report and o,• EtGO:?9 VITA x�
if :BRADr RD B V..n 1 7: k?,
Record Drawing on behalf of Mason County Public i '•"i.iUti Wti_'L--$if- ' '
Health! Expr s J,ZZ-2J%
(0 PA iv� � _
i .. .. .
Signal re of�ivi�nmental 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
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