HomeMy WebLinkAboutSWG2020-00388 - SWG As-Built - 11/16/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT! PERMIT INFORMATION
Permit Number SWG 2020-00388 P; rcl # 31903-41-00050
Applicant Name KEITH COOK i :LIB v;ion (Name/Div/Block/Lot)
Applicant Address 2950 SE LYNCH RD
City State, Zip SHELTON, WA. 98584 Installer Name SELF INSTALL
Site Address SAME Designer Name/ CINDY WAITE
.X
INSTALLATION CHECKLIST
a Full System Installation ❑ Tank(s) Only ❑ flroinfieid Onl
Y ❑ Repan ❑ Other
System Type — GRAVITY r'entreatment Type
>5 ft from foundaton? . _ ____..___
>50 ft from wells" - - - - _ _ - _ L; N/A YES El NO
>50 ft. from surface water? - - _. - _ _ -J 0 ❑
Z _ _ . . _ - [rzr ID Cleanout between building and tank'>
V Tank baffles present? - - - _ _ _ _ 'l ❑
a24" access risers over each compartment? ❑ ❑
N La Effluent filter installed?. - _ _ - _ ❑ 0 ❑
i ❑ o ❑
Septic tank size 1S41�7 gal Manufacturer
\O D-box water level and speed levelers used' r
'O Manifold/D-box accessible from surface?- - L 1 N/A YES ❑ NO
EC Check valves installed? - - - - - _ - - ❑ ❑
Transport Cme Size 4 * ❑ ❑
Sr heaure (44-3 3034_ _
Bedrooms installed (check one) [I 2 ❑ ', CIn lit r n
❑ ❑Commercial/Other
>10 ft from foundation?
Ll NIA YES ❑ NO
0 >100 ft from wells?-
-/ >lo0 ft. from surface water? - - - [J 0 ElW C] r-LA ❑
Z >10 ft. from potable water lines>
> 5 ft from iin ❑ 0 ❑p'npprty ec and c�sr,�:e'-`jO - - - - ❑ 0 ❑
CE > 30 ft from downgradient curtain/founuation drains? _. 0
Drainfeld level and observation ports present ❑ ❑ ❑
ElGraveless chambers or ' Cleat u!!sal „ed7 I.
❑
R one,
Proper cover Installed over drainfield/ - - -
IJ f El
Pump tank setbacks consistant with septic tanb'r
❑ NiA _] YFS Q NO
'1 Pump tanK size
Z oat Manul/r, rn' _
< 24 access riser(s) and accessible from r e !face?- - - r-! El -- r
ci. Alarm or Control Panel Installed? -
2 Control Panel equipped with rimer'ETM Counter _ - - - ❑ ❑
0_ ❑
Pump installed in Bucket or { l Dr Blo i of I •„.-
1
❑
CL
Pump Make/Model
----- _- -. ❑ Flcats or ❑ Transducer
0_ Tank draw down In/min Pump capacity
_ — ypm Sou,rt Height ft
Pump on time Pump , tt time
__ _ _ DDail/y Flow set at gpd
- _ -
Mason County OSS Installation Report pg. I // 31903-41-00050
ABANDONMENT RECORD
Were existing septic components abandoned as pent of Ins sift m I
-
If yes, please describe. - YES ❑� NO
Were all components pumped out and properly alto idol e 1 p.o /, c 03002 - -
E.] YES n NO
RECORD DRAWING
This permanent record and must be accurate and descriptive - an I0 m l
nce:E.in Pie need, _ e ce activities arid r ture development 3ecom
we. aror:.Acne iar. s , docher ," q'w nn .mr,ee I r.ocI .eeiee'eee I
er rre ens. i - ,_ii i ..aee r .in. npe�ne,
Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ ENGINEER
I certify that I installed the system in accordance wrlli r cei bty that the system has been installed in accor the septic design stamped-APPROVED by Mason dance Lath the septic design stamped APPROVED by
County Public Health and that any deviations shotvrt Mason Snunty Public Health and that any deviations
hero have been cleated/approved by both the designer ;;Boer; Noe have been cleared/approved by both
and Mason County Public Health and freer all State myse/f and Mason County Public Health and meet all and Mason County Codes. „
n a. Courtly watch
I further certify that all information contained on this t(bathe, certify Mal all information contained on this
form att ed Recor swing is sect Irate
form and attar:lied Record Drawing is accurateer
rgnaN of Installer W ut ��—
I 'I DamCocic QP 9p
gots 4 MI.
Printed Name of Signer) ------ -- s y1' tAd?$t;m
I_ e]y11
gs
MASON COUNTY PUBLIC HEALTH c.?
The undersigned a ei
9 approves this Installation Report and o� LICENSED
e DWAITE
ESIGNER
Record Drawing on behalf or Mason County Public,
Health: a
P1 I 1 1I 6 73
Signature of Environmental Health Specialist Dnto
(stamp. signaNro and date)
THIS FORM MAY BE SCANNED AND AvAll AHi r rnl e font:
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