HomeMy WebLinkAboutSWG2023-00121 - SWG As-Built Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATION
Permit Number SWG 2023 00121 Parcel # 22336-54-00062 &C y7
Applicant Name Antonio Marcus Subdivision (Name/Div/Blocld ) JUN 2 0 „-'?
Applicant Address PO box 3131 lynch cove Div 4 lot 62 BY_
City, State, Zip Belfair Wa 98528 Installer Name Shumaker Construction ---_
Site Address 20 Ne Katherine Ct Designer Name Frank Marcinko
INSTALLATION CHECKLIST
0 Full System Installation 0 Tank(s)Only II Drainfield Only 0 Repair 0 Other
System Type Gravity Pretreatment Type
>5 ft.from foundation? - •- ❑ N/A ■YES ❑ NO
>50 ft. from wells? 0 II 0
Z >50 ft.from surface water? - - 0 II
F Cleanout between building and tank? 0 III
ty Tank baffles present? - - 0 . 0
1 24"access risers over each compartment? ❑ III
y Effluent filter installed?- 0 ■ 0
Septic tank capacity(working) 1150 gal Manufacturer Existing
�0 D-box water level and speed levelers used? 0 N/A YES El NO
A 5 Manifold/D-box accessible from surface?- 0 e 0
0?2 Check valves Installed? - • 0 0
E Transport Line Size 4 Schedule/Class 3034
Bedrooms installed(check one) ❑ 2 ®3 ❑4 0 5 ❑6 ❑Commercial/Other
>10 ft.from foundation?- - ❑ N/A ■ YES 0 NO
O >100 ft.from wells? - 0 ■ 0
W >100 ft.from surface water? 0 Il 0
LT. >10 ft.from potable water lines?-
Za > 5 ft.from property lines and easements? ❑ • 0
2 >30 ft.from downgradient curtain/foundation drains? 0 I® 0
Drainfield level and observation ports present - . 0 e 0
0 Graveless chambers or r Clean gravel used? (check one)
Proper cover installed over drainfield? - 0 ■ 0
Pump tank setbacks consistent with septic tank? - 0 NIA 0 YES ❑ NO
Y Pump tank capacity(flood) gal Manufacturer
Z
< 24"access riser(s)and accessible from surface? 0 0 0
1 Alarm or Control Panel Installed? ❑ ❑ ❑
Control Panel equipped with Timer/ETM/Counter- - 0 0 0
a- Pump installed in 0 Bucket or 0 On Block or 0 Other
2 Pump Make/Model ❑ Floats or ❑ Transducer
0.• Tank draw down in/min Pumpcap
acity acil P y qpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
UpMIM 812112015
Mason County OSS Installation Report pg. 2 Parcel# 22336-54-00062
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? 0 YES Q NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? El YES 0 NO
RECORD DRAWING
This Is a permanent record and must es accurate end descriptive enough to relocate In the need of maintenance activities and Osten derelopmeM. Typical Record
Drawings mMsh. DrenteId&manifold orientation&layout.Septic/pump tank location.Not Snow,reserve Weinfeld.misting and prepmed baling.bcaliun d weup waterlines,
wa6,observation pats.deenab.and other maintenance access points. Incomplete Record Drawings may aeete additional Mays in final Installelm approval and related parts.
IN 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 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.
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Signature of Installer Date . I
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Pri fed Name of Signee , 4 w 1 n
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MASON COUNTY PUBLIC HEALTH iA sI : 5�d111
The undersigned approves this Installation Report and , yy 20t�09 FI11
Record Drawing on behalf of Mason County Public O' Frank A.Marcinkd
Health: % LICENSED DESIGNER 1
a 1,
Signature of Environmental Health Specialist Date (stamp, signature and date)
THIS FORM MAYBE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE VWatedarzv2me
NE Katherine Ct
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On-Site Septic ROC Name: Marcos Tax Parcel: 22336-54-00062
pLLIEQ Scale = I" = 20' Address: 20 NE Katherine Ct,Belfair
♦Selk 0 `to• This is net 2 survey all propertyInes/boundaries haw been demonstrated by the Ownerlslend/or theirAeenpsl.
On-Site Septic Design I Mlied Septic Design and Excavating