HomeMy WebLinkAboutSWG2023-00289 - SWG As-Built - 9/27/2023 ai
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rMason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2.o2 -00 2-9J° Parcel # Z ZZo6—5 2 - GUD y0
Applicant Name gidetz, (o.S 3 ae c.(tee,( Subdivision (Name/Div/Block/Lot)
Applicant Address 2-0 �� olioid coy Pa.
City, State, Zip Ypr Yft- LJ' - q 41$ iN Installer Name f-tliptp 13 Ain A*
Site Address 5'OM Designer Name C_V.,i i) 4./4- -
INSTALLATION CHECKLIST
❑ Full System Installation ❑Tank(s)Only ❑ Drainfield Only Repair ❑Other
System Type Pi', (rt S75 1.,--.4-1 Pretreatment Type /1/ttc
>5 ft. from foundation? - / - ❑ N/A ,BYES ❑ NO
>50 ft. from wells? - - ❑ El ❑
Z >50 ft. from surface water? - - ❑ El CI
H CI
between building and tank? - - ❑ 10
V Tank baffles present? - - ❑ El ❑
Q~.. CI
access risers over each compartment?- - ❑ CS
W Effluent filter installed?- t51iNhA - El E4 ❑
co
Septic tank capacity (working) (Z.,Op gal Manufacturer I-D441- C-04
0 D-box water level and speed levelers used? - - lSI N/A ❑ YES El NO
0O Manifold/D-box accessible from surface?- - ❑ (k] ❑
mz Check valves installed? - - ❑ R. ❑
0< �c
2 Transport Line Size 2- Schedule/Class 110 —
Bedrooms installed (check one) El 2 El 3 C21.4 ❑ 5 ❑6 El Commercial/Other
>10 ft. from foundation? - - ❑ N/A yi YES ❑ NO
0 >100 ft. from wells? - - ❑ ® ❑
W >100 ft. from surface water? - ff�i E ri `❑ l Clu. >10 ft. from potable water lines?- iUr �s- ❑ ❑ ❑
> 5 ft. from property lines and easements?- - - - - s€p
> 30 ft. from downgradient curtain/foundation dr ❑,, 121 ❑
in
Drainfield level and observation portspresent
gy - - - - - - - El V ❑
❑ Graveless chambers or Tgl,Clean gravel u .
Proper cover installed over drainfield?• - ❑ DI Cl
Pump tank setbacks consistent with septic tank? - - El N/A YES El NO
Pump tank capacity (flood) /?` - I gal Manufacturer t' -_ ,,r f-r ,- A-✓Le---
Q24"access riser(s) and accessible from surface? - - - ❑ W ❑
H
a Alarm or Control Panel Installed? - ❑ [ ] ❑
2 Control Panel equipped with Timer/ ETM / Counter- - - - - -- - - - - - ❑ lil ❑
D
0_ Pump installed in 0 Bucket or Cg-On Block or ❑ Other _
2 Pump Make/Model • ge-L 7€.& 4,1 (5"Z Floats or ❑ Transducer 1\i,
d Tank draw down ,J in/min Pump capacity- ,e _gpm Squirt Height 5 ft _\
Pump on time /, / M%n Pump off time of Daily flow set at -Z4 _gpd
Updated 13,21 i20 1r.
MIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIr
Mason County OSS Installation Report pg. 2 Parcel # L2�� -�Z p0��-f b
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? - - 4 YES 0 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 Recoro
Drawings contain Dramlield&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.
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Ef 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
l further certify that all information contained on this I further certify that all information contained on this
form and attar d Record Drawing is ac urate. form and attached Record Drawing is accurate.
Sigre of ns , y� Date ��� ��
----TiY L .�y 1 , v
•
gc YlCsti 'FA
Name of Sfgnee 4? A n J 0
MASON COUNTY PUBLIC HEALTH 510 is
The undersigned approves this Installation Report and o CINDY E WAITE` S'
LICENSED DESIGNER
Record Drawing on behalf of Mason County Public
Health: ExpiREs osoo,
W) 9 f7-717-3
Signature of Environmental Health Specialist Date (stamp, signature and date) �1q
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8r2t/2018
RECORD DRAWING (continued)
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