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SWG2023-00020 - SWG As-Built - 9/11/2023
um Mason County OSS Installation Report pg. 1 CC, MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2023-00020 Parcel # 32127-53-00175 Applicant Name Jollie Beans Espresso & Ice Cream Subdivision (Name/Div/Block/Lot) Applicant Address 2100 E Mason Lake Rd Lake Limerick Div 4 Lot 175 City, State, Zip Shelton, WA 98584 Installer Name Maples Excavating Site Address same Designer Name Arrow Septic Designs, Inc INSTALLATION CHECKLIST ❑ Full System Installation ©Tank(s)Only ❑ Drainfield Only ❑ Repair ❑ Other System Type Commercial Holding Tank Pretreatment Type >5 ft. from foundation? - - ❑ N/A ❑i YES ❑ NO >50 ft. from wells? - - 0 ❑ CI Z >50 ft. from surface water? - R - �- y - '-s i_l❑ ❑ Cleanout between building and tank? - 11 - ❑ II ❑ U Tank baffles present? - ' - - -}-g - - - ❑ 0 ❑ I— 24" access risers over each compartment? L ❑ 0 ❑ O. W Effluent filter installed?- -By - 0 ❑ u Septic tank capacity (working) 1,250 gal Manufacturer Hagerman El D-box w_ - - - -id seed levelers used? - - ❑ N/A MI - ❑ NO 3J 0 Manifold/D-box accessible from s - . - ■ ❑ CI mZ Check valves installed? - - ■ ❑ ❑ ❑Q 2 Tra ize Schedule/Class oms installed (check one) ❑ 2 p p (�5 6 ❑Commercial/Other >10 ft. f dation?- - r�,j� ■',,;„ . ❑ NO CI >100 ft. from wells? - - - �1 a ❑ ❑ >100 ft. from surface water? - - - SEP 1 1 11 ' V ❑ ❑ ❑ ❑ LL >10 ft. from potable water lines?- �'C0 ' MIENTAL Fi ❑ ❑ z > 5 ft. from property lines and easements?- - - - - - - - TN a ❑ El� > 30 ft. from downgradient curtai ation drains? - - Drainfield level and ob ion ports present - - ❑ ❑ ❑ ❑ Gravel ambers or ❑ Clean gravel used? (check one) er cover installed over drainfield?- - ❑ ❑ Pump tank setbacks consistent with septic tank? - - ❑ N/A ❑ YES ❑ NO Y Pump tank capacity (flood) qal Manufacturer < 24" access riser(s) and accessible from surface?- - ❑ ❑ ❑ aAlarm or Control Panel Installed? - -1 k-` --Qu`-�` - - - ❑ • ❑ 2 Control Panel equipped with Timer/ ETM /Counter- - ❑ ❑ D a Pump installed in ❑ Bucket or ❑ On Block or ❑ Other d Pump Make/Model ❑ Floats or ❑ Transducer 2 o_ a Tank draw down in/min Pump capacity gpm Squirt Height ft Pump on time Pump off time Daily flow set at gpd Urcatea F.2-,2C'a Mason County OSS Installation Report pg. 2 Parcel# S t 1- S3 -ooC-ls ABANDONMENT RECORD - E YES ■ NO Were existing septic components abandoned as part of this project? If yes, please describe: El YES NO Were all components pumped out and properly abandoned per WAC246-272A-0300? - 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 Recorc Drawings contain: Dranfield&manrfold orientation&layout.Septic/pump tank location.North arrow.reserve crainfieid,existing and proposed builcirgs,location of wets,wated'ines, wells.observation ports,cleanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in trial instataton approval and related permits. SEN 1 1 2023 , MASON COUNTY ENVIR(' • 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 ail 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. u- /G - -3- Z3 gature of Installer Date A clt,eit 5 ,i0.':V? sp Printed Name of Signee ram' `1 4t),• ��. h MASON COUNTY PUBLIC HEALTH �p*.IP �. . g ..t,`1; The undersigned approves this Installation Report and Cn:•v '7• •� -`��`1; yr„.... .PAULA /'• 51tiC34g ����) Record Drawing on behalf of Mason County Public JOY JOHNSON .;`4 I NSEtitdESiGNEq.. i.He37ih: � 5 �r .�Z;�j. Li(( l II 0—(t Z ENIREel� " l`N� AULI 1 n LULL Si:n11. 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 eC '2078 s 1 1t: 1Ln� S S i M • �T • 420 oL� �P V 4�/� i :c z(\, ,41_^�0-22"GS.. sQo075,ZZ_z�• ® ..P 7 �/ • l _ So / 1 i - � o 2S 5D ?S to` eQ IS , 9b' "Tr h eg. . N 1 (Sr { pw e' \ o-strc�L / a' 00 max ' 8 41 i. m `s Fes^pc8` , . • C 11 •• ug LY' Shop 1 , �`Icape \ 0 Audio-Visual Alarm Z3 Cleanout O 1200 Gallon Septic Tank Sso 2-Compartment with © , 4e) J � Effluent Filter b7® /� ' �sG ' / O Esrre-saoS}a..4.- New C,,,,r,r.-...Q-r-" \ A -vr)y'- - 12.S 0 GvN•w( T• .1.1\ p p min, , ,4. ..„,,,,,, i . , .-...0, , • , . 4 � , z ; 1 1 r w;•$ N. t t ,tea`, :Oki ENUIRONMEN rAl NEAL'- 10•: PAULA JOY JOHNSON - , K SEtlp 3iGNtt` l JBW AUG 1 6 2023