HomeMy WebLinkAboutSWG2023-00210 - SWG As-Built - 11/2/2023 [
11 ocon County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT!PERMIT INFORMATION
er SWG 2023-00210 Parcel It 123201201160
me Mike Roperis Sul/ ivlsion (Name/Div/Block/Lop
'-t+=t-.:dress 1540 Old Belfarr HWy
SIlu Sip BCIWir wa 9852B Installer Name Mike Roberts
lice 1iiress 1540 Old SeltairHWy Designer Name Jim Lmny
I . INSTALLATION CHECKLIST
—I __ _ _ -_ rl r 1'1.,
_ .._,,. ,��,.,.,.._.., �„ ,,:y U�,e,.uem July SneMn ❑Ciher
)yaem Type cravat. Pretreatment Type
5 'I Thy'foundation, ❑N.A EYES 0 NO
SU0 hnmw OHS' - _ . _ _ _ __ __ .- ❑ 11 0
Z5rh tr...-m surface water, -- - 0 . 0
i • bet. een building rein
!= anJ' - LI ® LI
U Ta lk baffles present, - 0 I ❑
d24 access risers over each compartment' - --- 0 II 0
w EH Jell' titter Installed,- .. - 0 III 0
va
or rank capacity(working) 1200 gal Manufacturer _ Fred Hill
O D-box water level and speed levelers used', - 0 NIA 111YES 0 No
QO Mandrel D-box accessible from surface, ❑ ® 0
W 2 Check valves installed, I 0 ❑
I ranspnrt Line Size 4" Schedule/Class J0014
Bed'ooms installed (check one)� ❑ 2 RI3 ❑4 05 ❑6 ❑Commercial/Other
410 ft fmin foundation? ❑ NIA II YES ❑ No
O >100 f1 hum wells? - 0 ■ 0
W >100 tt from surface water' El 1. 0
u. >10 0 from potable water lines, - 0 ® 0
Z > Sit from property lines and easements'- - 0 I. 0
Q
IY > SO It from downgradient curtaiNfoundatinn drains,- 0 II 0
Di einfeld level and observahon pods present - - 0 IN 0
r Graveless chambers or 0 Clean gravel used, (check one)
Pr cover installed over drainfield? 0 NO 0
Pump lank setbacks ednsistent with Septic tank, ® NIA 0 YES ❑ NO
Y Pump Tank capacity(f100d)_ gal Manufacturer
ex24- access rlser(s)and accessible from surface,- - 0 0 0
2 Alarm or Control Panel Installed, - 0 0 0
• Control Panel equipped with Timer/ETM/Counter 0 0 0
Cl- Pump installed in ❑ Bucket or 0 On Block or ❑ Other
2 7 Pump Make/Model ❑ Floats or 7 Transducer
O.
a Tank draw down in/min Pump capacity gpm Squid Height ft
Pump on time Pump Ott time Dan S ffi g
NOV 0 2 21123
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JBW
EN
Mason County OSS Installation Report pg. 2 Parcel k 123201201160
ABANDONMENT RECORD
here existmg septa components abandoned as part or this polled.' Q YES 0 NO
'I yes. please describe old Dreamed
Were all components pumped out and properly abandoned per WAC246272A-033O'+ IN YES EI NO
RECORD DRAWING
This r,a permanent,.KO and mut Ire accurate anddescriptor*.Snevgli to r....,t•m a.need...,A /Re actem n at future ae.a r _..,
APPRQVE
NOV0p2023
aso COUITyrti✓I�u+,,,E, •TitithI
JB� ® Record Drawing At!ached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that I installed the system in accordance with I cerhfy that the system has been installed in accor-
the septic design stamped"APPROVED"by Mason dance with the septic design stamped APPRQVED by
County Public Health and that any deviations shown Mason County Public Health and that any deviations
here have been oleareceapproved by both the designer shown here have been cleared/approved by both
and Mason County Public Health and meet all Stale myself and Mason County Public Health and meet elf
and Mason County Codes. State and Mason County Codes
I further certify that all information contained on this I further certify Mat all information contained on this
form anji attached Record Drawing is scour to form and attached Record Drawing rs accurate.
/V,_,_ LAB /0I0la3
Signature of Installer Ha
A CI
Mike Roberts _
Pooled Name of Signee ,�
f f/
MASON COUNTY PUBLIC HEALTH
The undersigned approves This Installation Report and n ,d
Record Drawing on behalf of Mason County Public fl !L
HeC �?l, II-2-2-3
Sign ur nvwOnmenraf Health Sneraafsr care (stamp.signature and date)
'His FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY SITE '�i0"'T1
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