HomeMy WebLinkAboutSWG2023-00233 - SWG As-Built - 9/11/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG .'.. (Y.X3 - Cv' 3 Parcel # 4 c?�V - cD 1- b(-}DC(p
Applicant Name )QV'\C(1 0 C'C. Subdivision (Name/Div/Block/Lot)
Applicant Address Po PJ
13-, .,
City, State, Zip Vh()C Sccx v `'1CV.5' Installer Name Aoya.\ ' -\ .s�\
Site Address �� ;►Js CAS ' U t Designer Name A.) J A
INSTALLATION CHECKLIST
El Full System Installation PI Tank(s)Only ❑ Drainfield Only El Repair El Other
System Type Pretreatment Type
>5 ft from foundation? - (V-T - - ElN/A 'YES ElNO
>50 ft from wells? - - -- - EI ❑ ❑
>50 ft. from surface wate .\ -{4,l4C+ 1.-�� ;ma' ❑ El CI
MtIMIIIIA
HCleanout between building : tank? .-t-- - - _0-. - CI tir CIU Tank baffles present? - - - T1,--__">-,_-- _----____ - ❑ ❑
a 24"access risers over each compartment?- - ❑ Vi ❑
W Effluent filter installed?- - ❑ iEr ❑
N
Septic tank size \ -D,c)C gal Manufacturer 0\e-ArW O.VA
13 D-box water level and speed levelers used? - - ❑ N/A ❑ YES El NO
gO Manifold/D-box accessible from surface?- ) - CI 0
mZ Check valves installed? - - ❑ ❑ ❑
caQ
2 Transport Line Size Schedule/Class
Bedrooms installed (check one) ❑ 2 ❑3 ❑4 ❑ 5 El 6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A ❑ YES ❑ NO
0 >100 ft. from wells?- - 0 0 ❑
J >100 ft. from surface water? - 0 0 CIW -�
LL >10 ft. from potable water lines?- - -- - - ❑ ❑ ❑
Z >5 ft. from property lines and easements?- CI CI CI
tE > 30 ft.from downgradient curtain/foundation drains?- - ❑ ❑ ❑
o
Drainfield level and observation ports present - - ❑ ❑ ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ ❑ ❑
Pump tank setbacks consistant with septic tank?- - El N/A El YES ❑ NO
Pump tank size gal Manufacturer
Q24"access riser(s)and accessible from surface?- - El ❑ ❑
aAlarm or Control Panel Installed? - - - - ElCI❑
2 Control Panel equipped with Timer/ETM/Counter- - - - - ) - - El ❑ ❑
M
d Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
a. Pump Make/Model El Floats or ❑ 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 821/20/8
ri:
Mason County OSS Installation Report pg. 2
ABANDONMENT RECORD
b`tCX�tt
Were existing septic components abandoned 'as part of this project? - - T. YES NO
If yes, please describe: L�V`' +\E T(t`n� \r'Q iN\ e ilIl
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - "YES D 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: Drainfieki&manifold orientation&layout,Septic/pump tank location,North arrow,reserve drainfield,existing and proposed buildings,location of wells,waterlines,
wells,observation pods,cleanouts.and other maintenance access points- Incomplete Record Drawings may create additional delays in final installation approval and related permits-
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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
4 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
I further certify that all information contained on this I further certify that all information contained on this
form d tt rd Drawing is accurate. form and attached Record Drawing is accurate.
Sig t re Installer Date
7)Li / 6 ,R04. I '
Printed$$ame of Signee ( '
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
H:. •
AL ;OA
S'•na Ire Environmental 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)
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