HomeMy WebLinkAboutSWG2022-00300 - SWG As-Built - 9/11/2023 CLEAR FORM
Mason County OSS Installation Report pg. 1 CC" MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number swG 2022-00300 Parcel # 220085000018
Applicant Name TBC Enterprises Subdivision (Name/Div/Block/Lot)
Applicant Address PO Box 2503 Timberlake#13 Tr 18
City, State, Zip Gig Harbor, WA98335 Installer Name Jack Johnson
Site Address 150 E Willipa, Shelton WA Designer Name Jim zimny
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only 0 Drainfield Only ❑Repair ❑Other
System Type Gravity Bed Pretreatment Type
>5 ft. from foundation? - - 0 N/A ®YES ❑ NO
>50 ft. from wells? - - ❑ NI ❑
Z >50 ft. from surface water? - - ❑ II El
H Cleanout between building and tank? - - Cl Ill
U Tank baffles present? - - ❑ ® ❑ co E' c":
a24"access risers over each compartment?- - 0 ® El "
W Effluent fitter installed?- - ❑ III`
Septic tank capacity (working) 1250 gal Manufacturer Hagerman z-
CID-box water level and speed levelers used? - - ❑ N/A In YES ❑ NO w
�O Manifold/D-box accessible from surface?- - El PI El
mz Check valves installed? - - I 0 0
OQ
Transport Line Size 4" Schedule/Class 3034
Bedrooms installed (check one) ❑ 2 ❑■ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A IIIYES ❑ NO
>100 ft. from wells? -P P--O--V E ® ❑
J >100 ft. from surface water? -- - - - 1 ® ❑
W
L.T. >10 ft. from potable water lines?- - - --SE--1-1-2023-- ■ ® ❑
Z > 5 ft. from property lines and ease „ I ❑ ® El
'Y' E�aly�6u'1VTY-Ef�V1F7MENTAL HEAL;
IIE > 30 ft. from downgradient curtain/foundation drains?- - ❑ ® ❑
Drainfield level and observation ports present - JB� - 0 ❑ ❑
❑ Graveless chambers or pi Clean gravel used? (check one)
Proper cover installed over drainfield?- - Cl II Cl
Pump tank setbacks consistent with septic tank? - - ❑ N/A ❑ YES ❑ NO
X Pump tank capacity(flood) gal Manufacturer
Q 24" access riser(s)and accessible from surface?- - ❑ ❑ ❑
1--
Alarm or Control Panel Installed? - - ❑ ❑ ❑
a
E Control Panel equipped with Timer/ETM/Counter- - El ❑ ❑
n
a- Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
--
a.• Pump Make/Model 0 Floats or ❑ Transducer
d
Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated amnoto
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Mason County OSS Installation Report pg. 2 Parcel#1Z O 0 A s_3 con/Ej_
ABANDONMENT RECORD
Were existing septic components abandon_ d as part of this project? - - El YES Or NO
If yes, please describe:
Were all components pumped out and property abandoned per VVAC246-272A-0300?- - 0 YES 0 No
RECORD DRAWING;
Thle a s permanent..cord and mot be monads and dsncafptlw.nough co eeloana fn Me need of roaintaranna activities and Nere d.v.lopw.nc Typical Record
Drawings contain: Dray Odd&dean atraee a byaA.BePerlpuee tint rota ran.WPM arrow.mrsam drattlafd.alkani and piosad Gatinps,holm orwas,"Oda".
wells.oNenefon ports.deanoub.and.Mh.r m.rr.,.r<e asshicompaelle Alcoa Drawings may ovate aodIorar daays in red e'at eaton approval and rer.#d Demts.
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; ,SON COUNTY ENVIRON
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MENTAL HEALTH
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Record Drawing Attached
I
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'appraved by both the designer shown here hate been cheated/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
1 further certify that all information contained on this I further certify that all information contained on this
fond is accurate. holm and attached Record Drawing is accurate.
Vd alt d Record Drawing, 4 - ,- 2,3
/
Si.,:, re of Installer Date
Printed Name of Signee = • I i
MASON COUNTY PUBUC HEALTH =%fir
The undersigned approves this Installation Report and ...,, -», e
Recorrawing on behalf of Mason County Public " "...• .........��,',
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&jnitu►e• ,y• lal Health Specialist Date (stew.signature and date)
( THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE L4'6°1°1211°re
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