HomeMy WebLinkAboutSWG2023-00126 - SWG As-Built - 6/28/2023 idlason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2023-00126 Parcel # 220305000012
Applicant Name Lawrence Thomas Subdivision (Name/Div/Block/Lot)
Applicant Address 111 SE Earsley Lane euzz,9i' 3 i9}/ 7R. /z
City, State, Zip Shelton, WA 98584 Installer Name Bo Russell
Site Address 111 SE Earsley Lane Designer Name Chris Elstrott
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair ❑ Other
System Type Pressure trench Pretreatment Type NuWater
>5 ft. from foundation? - - ❑ N/A x❑ YES ❑ NO
>50 ft. from wells? - •- ❑ 0 ❑
Z >50 ft. from surface water? - - ❑ 0 ❑
HCleanout between building and tank? - - ❑ 0 ❑
V Tank baffles present? - - ❑ 0 ❑
F- 24"access risers over each compartment?- - ❑ ® ❑
a
W Effluent filter installed?- '- 0 ❑ ❑
u) Infiltrator
Septic tank capacity (working) 1094 gal Manufacturer
❑ D-box water level and speed levelers used? - - ❑x N/A ❑ YES Li NO
J
o � ❑O Manifold/D-box accessible from surface?- - X ❑
u.
OOz Check valves installed? - - ❑ ❑ 0
❑Q Schedule/Class sch 40
2 Transport Line Size 2 inch
Bedrooms installed (check one) ❑x 2 ❑ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A 0 YES ❑ NO
>100 ft. from wells?- ' ❑ 0 ❑
W >100 ft. from surface water? - - ❑ 0 ❑
LL >10 ft. from potable water lines?- - ❑ 0 ❑
Z > 5 ft. from property lines and easements?- - ❑ x❑ ❑
DE > 30 ft.from downgradient curtain/foundation drains? - - ❑ 0 ❑
in
Drainfield level and observation ports present ❑ 0 ❑
X❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ 0 ❑
Pump tank setbacks consistent with septic tank? - - Li N/A ❑X YES ❑ NO
Pump tank capacity (flood) 1094 gal Manufacturer Infiltrator
< 24" access riser(s) and accessible from surface?- - ❑ 0 ❑
~ Alarm or Control Panel Installed? - - ❑ x❑ ❑
0-
2 Control Panel equipped with Timer/ ETM / Counter- - ❑ ® ❑
m
n- Pump installed in ❑ Bucket or ❑X On Block or ❑ Other
d Pump Make/Model Zoeller N152 ❑X Floats or ❑ Transducer
D.
a Tank draw down 1.6 in/min Pump capacity VS gpm Squirt Height 5 ft
Pump on time /• 9 n+';1 • Pump off time 8 Daily flow set at 240 gpd
Updated 8/21/2018
Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - YES El NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - YES /t/y C3 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,deanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
s � 47T/4 :4t D
2a ,v'2 9w /iv6
ecord 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 I further certify that all information contained on this
form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
•
�o- sseEG 5/31/23 •:`rV� 44
� WAS � ,
Signature of Installer Date �., d
Bo Russell �'n
Printed Name of Signee
•
MASON COUNTY PUBLIC HEALTH • 0.0 45 8a
The undersigned approves this Installation Report and �.ONAL ‘
Record Drawing on behalf of Mason County Public
Health:
01\ l (Vb I .0
Signature of Environmental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8121l2018
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