HomeMy WebLinkAboutSWG2023-00369 - SWG As-Built - 10/20/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 21023-00Sot Parcel # 22623 • y/-70030
Applicant Name rl'�'" lorSc Subdivision (Name/Div/Sleek/Lot)
Applicant Address i e f{yytc 4u.
City, State, Zip 'Kwtr«Aup WA 913-1 I Installer Name / ,,t1, p J
Site Address 57 ((.2 E. vhaR'r S le pp Designer Name y able.
INSTALLATION CHECKLIST
❑ Full System Installation IN_Tanfk(s)Only ❑ Drainrieid Only ❑ Repair El Other
System Type 9 A4LJdfy Pretreatment Type
>5 ft.from foundation`?? • ❑ WA YES ❑ NO
>50 ft. from wells? - ❑ P ❑
Z >50 ft. from surface water? - ❑ 121. El
I—
(.) Cleanout between building and tank? ❑ ❑
Tank baffles present? - ❑ Et ❑
H 24"access risers over each compartment? ❑ ❑
a
W Effluent filter installed? - - - - - - - - - ❑ A 2 ❑
te p
Septic tank capacity (working) /?DO gal Manufacturer �(,�// o) J/cct-sc-rG, I _____
C D-box water level and speed levelers used? • - - - A N/A ❑ YES ❑ NO
J
DO Manifold/D-box accessible from surface?-- - -- - - % El El
mZ Check valves installed? - - b ❑ ❑
04
2 Transport Line Size _ - Schedule/Class
Bedrooms installed (check one) S,2 ❑3 ❑4 ❑ 5 ❑6 0 Commercial/Other
>10 ft. from foundation?- - - - ❑ NIA ,,,.,/,/YES ❑ NO
ra >100 ft. from wells? • ❑ X ❑
W >100 ft. fromsurface water? • - ❑ ❑
LL >10 ft. from potable water lines? - - ---- -- ❑ ❑
Q �,/Z > 5 ft. from property lines and easements?- - - ❑ +lam ❑
d > 30 ft. from downgradient curtain/foundation drains? • - ❑ IX 0,y
• Drainfleld level and observation ports present - - ❑ ❑ 'LT
❑ Graveless chambers or ❑ Clean gravel used? (check one)Proper cover installed over drainfield? - ❑ X ❑
Pump tank setbacks consists I with septic tank? • - ❑ wA YES ❑ NO
• Pump tank capacity(flood) _ ____ al Manufacturer __,
< 24'access riser(s)and accessible from su ?- ❑ ❑
~ Alarm or Control Panel Installed? • - 0 ❑ ❑
a
s Control Panel equipped with Timer/ ETM 1 Counter - - ❑ ❑ ❑
m
d. Pump installed in ❑ Bucket or ❑ On BI ' or ❑ Other
n'C- Pump Make/Model __. ❑ Floats r ❑ Transducer
0_
C Tank draw down in/min Pump capacity _gprn Squirt Height ft
Pump on lime Pump off time Daily flow set at gpd
Mason County OSS Installation Report pg. 2 Parcel# 22t423-9i 90:30
ABANDONMENT RECORD
Were existing septic components abandoned as pad of this projeste itc YES 0 NO
If yes, please describe TJ(3_rnY11L—j •
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - - YES NO
RECORD DRAWING
Iris is a permanent record and must be accurate and descriptive enough to re-locate In the need of maintenance activities and lu u•e development. Iyw al Recto
irawi contain Dra.ntleld A Iranllo,Orientation&layout,Seplitlpump lank mreeon North Brow.reserve dralmlud.costing and proposed buamngs.lncallon o'webs waterlines
wails.obsen2uon pods.clesnouls.nod Other mmMenance access pomis in ommele Record Drawings may create additonal delays in mai installation approval and relumd pormi6
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
I lurther certify that all information contained on this I further certify that all information contained On this
form and at ch d Record Drawing is accurate. form and attached Record Drawing is accurate.
IO1St23
Signature of Installer Owe
7 �
Printed Name of Signed
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Healtthhi,
Signature of Environment I Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE nmated d.I.nra
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APPROVE ne?
OCT 20 2023 - —^
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