HomeMy WebLinkAboutSWG2023-00318 - SWG As-Built - 8/18/2023Am
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2023-00318 Parcel # 519085300030
Applicant Name Proper Global Subdivision (Name/Div/Block/Lot)
Applicant Address 10024 138th Ave NE
City, State, Zip Kirkland, WA 98033 Installer Name Bo Russell
Site Address 981 Star Lake Drive Designer Name Jim Henry
INSTALLATION CHECKLIST
❑ Full System Installation ❑ Tank(s)Only Q Drainfield Only N1 Repair ❑ Other
System Type Glendon Pretreatment Type
>5 ft. from foundation? - - ❑■ N/A ❑ YES ❑ NO
>50 ft. from wells? - - ❑■ ❑ ❑
Z• >50 ft. from surface water? - - ❑■ ❑ ❑
H Cleanout between building and tank? - - ❑■ ❑ ❑
U Tank baffles present? - - ❑■ ❑ ❑
a 24" access risers over each compartment?- - ❑■ ❑ ❑
cW Effluent filter installed?-....1 - ❑� ❑ ❑
Septic tank capacity (working) 1200 gal Manufacturer Sound Placement
ca D box water level and speed levelers used? 0 N/A El YES ❑ NO
0O Manifold/D-box accessible from surface? - ❑ 0 ❑
m Z Check valves installed? - - ❑■ ❑ ❑
6Q
2 Transport Line Size 1" Schedule/Class Sch 40
Bedrooms installed (check one) ❑■ 2 ❑ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A is YES ❑ NO
C1 >100 ft. from wells?- - ❑ ❑� ❑
J >100 ft. from surface water? - - ❑ 0 ❑
W
ti >10 ft. from potable water lines?- - ❑ ❑■ ❑
Z > 5 ft. from property lines and easements?- - ❑ ❑� ❑
Q
0 > 30 ft. from downgradient curtain/foundation drains? - - ❑ ■❑ ❑
Drainfield level and observation ports present - - II ❑ ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ ■❑ ❑
Pump tank setbacks consistent with septic tank? - - ❑ N/A ❑ YES ❑ NO
• Pump tank capacity (flood) 1,000 gal Manufacturer Sound Placement
< 24"access riser(s)and accessible from surface?- - ❑ I ❑
F-
a Alarm or Control Panel Installed? - - ❑ • ❑
E Control Panel equipped with Timer/ETM /Counter- - ❑ 0 ❑
D
n- Pump installed in ❑ Bucket or ❑l On Block or ❑ Other
d• Pump Make/Model Goulds 20AE0511 ❑ Floats or I Transducer
a.
a Tank draw down Glendon in/min Pump capacity Glendon gpm Squirt Height Glendon ft
Pump on time Glendon Pump off time Glendon Daily flow set at 240 gpd
Mason County OSS Installation Report pg. 2 Parcel# 519085300030
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES ❑■ NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ YES ❑■ 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.cleanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
Removed C-33 sand off of existing Glendon mounds, replaced with new C-33 sand.
El 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 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
form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
44-ssei 8/16/23
Signature of Installer Date
Bo Russell
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
17/1,-
Signature f nvironmental Health Specialist Date (stamp. signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE updated 8/21/2018
RECORD DRAWING (continued)
I