HomeMy WebLinkAboutSWG2022-00367 - SWG As-Built - 8/15/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION _
Permit Number SWG 2022-00367 Parcel # 42216-52-00002
Applicant Name Carolyn Houston Carlson Subdivision (Name/Div/Block/Lot)
Applicant Address 5082 Westside Rd. Lake Cushman Div, 12 Lot 2
City, State, Zip Cle Elum,WA 98922 Installer Name Arrow Excavating
Site Address 80 N. Rainbow Circle Designer Name Dale L.Tahja
INSTALLATI011CHECKLIST
0 Full System Installation 0 Tank(s)Only 0 Grainfield Only ❑Repair 0 Other
System Type Pressure Trenches Pretreatment Type BNR 500 NuWater
>5 ft.from foundation? - - -1) 4-141- -1 N/A ®YES 0 NO
>50 ft. from wells? - 0 ❑
• >50 ft.from surface water? - AUG-03-2-0-23- D U El
Z - J 'J 0 0 0
• Cleanout between building and tank?
*J Tank baffles present? - -By - ❑ IN 0
F= 24"access risers over each compartment?- —.---❑ e 0
Q.
• Effluent filter installed?- •- III ❑ ❑
U)
Septic tank capacity(working) 500 gal Manufacturer Hagerman
c3 D-box water level and speed levelers used? - - in N/A 0 YES 0 NO
❑ II 0
0DO Manifold/D-box accessible from surface? ❑ 0 0
C E Check valves installed? -
❑Q
2 Transport Line Size 2 inch Schedule/Class Sch.40
Bedrooms installed (check one) 0 2 0 3 ❑4 0 5 0 6 0 Commercial/Other
>10 ft.from foundation?- - ❑ N/A El YES ❑ NO
O >100 ft.from wells?- - 0 U 0
W >100 ft.from surface water? - - 0 0 ❑
k >10 ft.from potable water lines?- - 0 ® 0
Z > 5 ft.from property lines and easements?- - ❑ III El
12 >30 ft.from downgradient curtain/foundation drains?- - e ❑ 0
Ci
Drainfield level and observation ports present - - ❑ 0 0
0 Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - 0 II 0
Pump tank setbacks consistent with septic tank?- - ❑ N/A ® YES 0 NO
3C Pump tank capacity(flood) 1.000 gal Manufacturer Hagerman
Z El 0 0
< 24"access riser(s)and accessible from surface?-
t~
a Alarm or Control Panel Installed? - - El U El
• Control Panel equipped with Timer I ETM/Counter- - 0 ® ❑
C. Pump installed in ❑LBucket or XOn Block or El Other
Ai Pump Make/Model i b P r t y a xD 0 Floats or 0 Transducer
0.
a Tank draw down / /2" in/min Pump capacity 16' qpm Squirt Height ! / Il ft
Pump on time 0 , 25 Pump off time S/j J. ' /7, ?it Daily flow set at Q Y G gpd
Updated 812t/2018
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Mason County OSS Installation Report pg. 2 Parcel# 42216-52-00002
. ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - El YES Q NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - El YES El 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 E.layout,Septic/pump tank location,North arrow,reserve drainfieid,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.
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` AUG 1 5 2023
MASON COtiNTY ENVIRONMENTAL HEALTH
JBW
a Record Drawing Attached
CERTIFICATION OF INSTALLATION
r
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
1 further certify that all information c fined on this 1 further certify that all information contained on this
form and atta ed Record wi is accurate. form and attached Record Drawing is accurate.
YLO3
Si ature of Installer Date
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-
John Gilliland
Printed Name of Signee / - of y (A,
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MASON COUNTY PUBLIC HEALTH r •j` a l s'f Z
The undersigned approves this Installation Report and I
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Record Drawing on behalf of Mason County Public - - �i
' DALE L. TAHJA
He • =� L' <NsF ) w^SIGNER
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Sig to vironmental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated W21/2018
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AUG 15 2023 0
MASON COUNTY ENVIRONMENTAL HEALTH
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