HomeMy WebLinkAboutSWG2021-00338 - SWG As-Built - 7/3/2023 r 1
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT! PERMIT INFORMATION
Permit Number. SWG 2021-00338 Parcel # 32412-11-90104
Applicant Name LAT Ventures LLC Subdivision (Name/Div/Block/Lot)
Applicant Address 14901 80th St. E.
I City, State, Zip Puyallup, WA 98372 Installer Name T.J. Goos
Site Address N. Seagull Way, Lilliwaup Designer Name Dale L.Tahja
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only 0 Drainfield Only ❑ Repair 0 Other
System Type Gravity Trenches Pretreatment Type
>5 ft.from foundation? - - ❑ N/A ®YES ❑ NO
>50 ft. from wells? —�-r;�] ❑ ® 0
Z >50 ft.from surface water? - �1 - ❑ ® ❑
Q Cleanout between building and tank? - -- , - ❑ ® 0
i 1: JUN-I 5 202.3 -�
U Tank baffles present? - �� _g. - ---b 0 ® 0
a24" access risers over each compartment? B ❑ II El
W Effluent filter installed?- -- — 0 ® ❑
4 N
Septic tank capacity(working) 1.250 gal Manufacturer Hagerman
0 D-box water level and speed levelers used? - - ❑ N/A ®YES ❑ NO
oO Manifold/D-box accessible from surface?- - El II 0
4 co, Z Check valves installed? - - ® 0 ❑
CiQ
2 Transport Line Size 4 inch Schedule/Class 3034
Bedrooms installed (check one) 0 2 0 3 ❑4 0 5 0 6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A ® YES ❑ No
O >100 ft.from wells?- - ❑ ® 0
W >100 ft.from surface water? - - El II El
ti >10 ft. from potable water lines?- - 0 ® ❑
Z > 5 ft.from property lines and easements?- - El II
ii > 30 ft.from downgradient curtain/foundation drains? - - ❑ ® ❑
Drainfield level and observation ports present - - ❑ I ❑
® Graveless chambers or 0 Clean gravel used? (check one)
Proper cover installed over drainfield?- - 0 I 0
Pump tank setbacks consistent with septic tank?- - ❑ NIA ❑ YES ❑ NO
• Pump tank capacity(flood) gal Manufacturer
< 24" access riser(s)and accessible from surface?- - 0 0 0
H
a Alarm or Control Panel Installed? - - El ❑
2 Control Panel equipped with Timer/ETM /Counter- - 0 0 0
m
a- Pump installed in ❑ Bucket or 0 On Block or 0 Other
fZ• Pump Make/Model 0 Floats or 0 Transducer
a Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 8121/2018
Mason County OSS Installation Report pg.2 Parcel# ?�� \ -.\ en `C)
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - 0 YES MI NO
If yes, please describe: ❑
Were all components pumped out and property abandoned per WAC246-272A-0300? - - 0 NO
1 RECORD DRAWING
This is a permanent record and meet be accurate and descriptive enough to relocate in the treed of maintenance activities and future driaiopment. 7'yp
loid Record
Drawings contain: Drtntleld a manifold orientation&layout Septidpump tank location,North aaaw reserve dtakNdld,existing and proposed buNdtga,
localon of visas,mistrals,
wells,abeetvadoo ports,(Ammo.and other nmktMnana access points. Incomplete Record Drawings may create additional delays In Anal 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
hem have been deared/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 ra4e. form and attached Record Drawing is accurate.
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Signature of Installer Date ow,�, , !tV
Printed Name of Signee / s FA.'o yc ,,
MASON COUNTY PUBi.IC HEALTH '�+ �.' `:L."jA
The undersigned approves this Installation Report and
510021a
Record Drawing on behalf of Mason County Public al..14
DALE L. TAHJA 1s �I
LtCEWSEn n.SIGNER I
Health: �- _:-F, �.►ra a►tok�,, •
R;L-1SX6Thi If\
�J 1 EXi.- f-1: - -_.: -
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 (*Wad 8121@p18
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APPROVED
JUL032023
MASON COUNTY ENVIRONMENTAL HEALTD.
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