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HomeMy WebLinkAboutSWG2023-00386 - SWG As-Built - 11/15/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2023-00386 Parcel # 42329-50-00121 Applicant Name SHELLEY WHITE Subdivision (Name/Div/Block/Lot) Applicant Address 19017 4TH AVE NE City, State, Zip POULS8O, WA. 98370 "— Installer Name TRIPLE A • Site Address 20 N WYNOOCHEE DR Designer Name CINDY WAITE INSTALLATION CHECKLIST ❑ Full System Installation 0 Tank(s)Only Q Drainfeld Only ❑ Repair ❑Other_ System Type GRAVITY Pretreatment Type >5 ft. from foundation? - - -- >50 ft. from wells? - CI N/A I]YES ❑ No - MI Z >50 ft. from surface water? ❑ CIF Cleanout between building and tank? ❑ Ell Tank baffles present? - ❑ 0 El • R 24" access risers over each compartment?- CI © Q N Effluent filter installed?- rYifr.► ❑ ❑ Septic tank size 1000 gal Manufacturer ❑ IN D anufacturer NOT KNOWN EXISTING 0 0-box water level and speed levelers used? Ou.0 Manifold/D-box accessible from surface? ❑ N/A YES ❑j No Ca Check valves installed? ❑ Transport Line Size 4 ❑ ❑ ❑ Schedule/Class ASTM2729 , • Bedrooms installed (check one) ❑li 2 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft. from foundation? -p >100 ft. from wells?- 0 NrA YEs ❑ No J >100 ft. from surface water? . ❑ 0 ❑ Ill 0 2 >10 ftt from potable water lines?- ❑ sr >5 ft. from property lines and easements?- ❑ l] 0 > 30 ft. from downgradient curtain/foundation drains? - 0 ❑ Drainfeld level and observation ports present - NI ❑ ❑ ® Graveless chambers or ❑ Clean gravel used? (check one) CI fil ❑ Proper cover installed over drainfield? ❑ o ❑ Pump tank setbacks consistent with septic tank? . 2 Pump tank size_ ❑ N/A ❑ YES Q No gal Manufacturer < 24"access riser(s)and accessible from surface?. y Alarm or Control Panel Installed? ❑❑ ❑ CI 7 0 Bucket or ❑ On Block or ❑ Other \\1Control Panel equipped with Timer/ETM/Counter- El ❑ d Pump installed in ❑ ❑ El El f Pump Make/Model ❑ Floats or ❑ Transducer y Tank draw down in/min Pump capacity gpm Squirt Height ft Pump on time Pump off time Daily flow set at uodaLe Mason County OSS Installation Report pg. 2 Parcel# 42329-50-00121 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - ❑ YES 0 NO If yes, please describe: Were all components pumped out and properly abandoned per WAC246-272A.03007 D YES D NO RECORD DRAWING This la a permanent record and mutt be accurate and descriptive enough to re-locate In the need of maintenance activities and future development, Typical Record Drawings contain: Dreinlleld®manifold orientation 8 layout,6epticlpump tank location North arrow,reserve dlsnneld existing and proposed bwldings,location of wells,waterlines welts,observation pods,cleanouls.anddoother maintenance access points. Incomplete Record Drawings may oreale additional delays in final instellation appmeal and related perms ?_ vs �/rd 0 i PN Cif lqa/ ® 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 Countyson yodes Health and meet all and Mason County Codes. State and I further certify that all information contained on this further certify a that all information contained on this form an 1 c Record D wi g is accurate. form and attached Record Drawing is accurate. iG /j ial 73 . 1 Si attire of Installer Date r. 1' tedNameo Pllll rk' '9d,ea Printed Name of Signet i rdry 4,,c ; 1 ; N1 MASON COUNTY PUBLIC HEALTH - 1p11Y /p2)I7rJ The undersigned approves this Installation Report and I Dv e a ITF14 Record Drawing on behalf of Mason CountyPublic LICENsao oaslBrvBq )p ,�i�aa�a�w o<���1! Health: • UDINES dsn0r f A� Signature of Environmental ealth Specialist Date (stamp, signature and date) THIS FORM MAYBE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON'THE MASON COUNTY WEB SITE Uedeted F. came i11war 1 i N /�P Ty 3W3.w��•.ye' 111. ft co_s1or d /1 GIN, art it i91Yi 1 ._. __ _. ,Li' (. 'r ✓exjail 10dd $.. F s , j �f (...:,,. ,o. ... ( e } Tap xr . .e ,,., ,(J I � �' y 60 C.. /n4.4 n el' 1 co c(f i AD- I —lg. 4. 1, xV <1 i Trap.sT X1 PA +� (" )___SO s,,, l f .,a( ?a N IA1 1 NOG Chet pt., j! 4.a -Tani,- 1 1 !>,� TA dts `(2329-50- a) raj ( tll I_ 2a � 1 /u' 1 6o / "= 2v' APPROVED c2 ` Y 75\'1 NOV 15 21123 el J,,,r, _Ly_',-li_'HEALrr. - 920/4 n^� 0/re0 `/ iL\ A . 40Nr I / D leW 8 / 3e C% U blr ...,r f o,v fitjkl. 3/ 7' L o� i\ Q !o ' / "-" /o' -r„ — i e� rib % C" R— z" IUD la -*lie i sr 4 1 \ PP ROVr:[) "e E' n NOV 15 202: 1-1 e� % tit J, 1 41 FT A a. LICENSED DESIGNED ITE 11' \rya, .......S... IP w�.41ov EXPIRES 051101