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Home My WebLink AboutABANDONMENT RECORD - SWG As-Built - 11/20/2023 M 4N � N 3oO Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION ) Permit Number SWG Parcel# `� t H I '0 O DO C) Name Stz.r LocrA-Sc_ker Subdivision (Name/Div/Block/Lot) Applicant Address 1 332,0 W. el0`,ft?,gin City, State, Zip f/w^ a_ ga I Installer Name / Site Address S..v ---C Designer Name INSTALLATION CHECKLIST ❑ Full System Installation ❑Tank(s)Only A El nrainfield Only ❑ Repair VI Other Rbv,�JOInwuzh, System Type Q V(A/V 1---ki Pretreatment Type >5 ft. from foundation? ❑ N/A ❑YES ❑ NO >50 ft. from wells? - - ❑ ❑ ❑ >50 ft.from surface water? - ❑ ❑ ❑ 6 Cleanout between building and tank? - - ❑ 0 ❑ 1— ✓ Tank baffles present? - ❑ ❑ ❑ F 24" access risers over each compartment?- ❑ ❑ ❑ W Effluent filter installed? ❑ 0 ❑ N Septic tank capacity (working) gal Manufacturer O D-box water level and speed levelers used? ❑ N/A ❑ YES ❑ No oO Manifold/D-box accessible from surface?- ❑ ❑ ❑ u. m Check valves installed? ❑ 0 El O Z Q Schedule/Class 2 Transport Line Size Bedrooms installed (check one) El 2 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft.from foundation? - El N/A ❑ YES ❑ NO p >100 ft. from wells?- ❑ ❑ ❑ W >100 ft. from surface water? ❑ ❑ ❑ LL >10 ft.from potable water lines?- - ❑ ❑ ❑ QZ > 5 ft.from property lines and easements? ❑ ❑ ❑ LL > 30 ft. from downgradient curtain/foundation drains? ❑ ❑ ❑ ▪ Drainfield level and observation ports present - ❑ ❑ ❑ ❑ Graveless chambers or El Clean gravel used? (check one) Proper cover installed over drainfield?- ❑ ❑ ❑ Pump tank setbacks consistent with septic tank? ❑ N/A ❑ YES El NO Y Pump tank capacity (flood) gal Manufacturer < 24"access riser(s) and accessible from surface? ❑ ❑ ❑ F a Alarm or Control Panel Installed? - ❑ ❑ ❑ Control Panel equipped with Timer/ETM/Counter- - ❑ ❑ LI a Pump installed in ❑ Bucket or ❑ On Block or ❑ Other 2 Pump Make/Model ❑ Floats or ❑ Transducer 0_ a Tank draw down in/min Pump capacity gpm Squirt Height ft Pump on time Pump off time Daily flow set at gpd Updated B/21R010 Mason County OSS Installation Report pg. 2 Parcel# ABANDONMENT RECORD Were existing septic components abandonedT as partof this proj ct? - ISC YES 0 NO If yes, please describe: . bC I�H K t-i W I lea r Je Y'� Were all components pumped out and properly abandoned per WAC246-272A-0300? v YES ❑ NO RECORD DRAWING F'` This is a permanent record and must be accurate and descriptive enough to relocate In the need of maintenance activities and future development. rypial Record Drawings contain oramneld&manilord orientation&layout,Septcipump tank location,North arrow.reserve drainneld,existing and proposed buildings,location of wells,waterlines, wells,observation ports,cleanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays In final installation approval and related permits. ❑ 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 hem 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 the'all information contained on this I further certify that all information contained on this form an. - Record Drawing is accurate. form and attached Record Drawing is accurate. Ali _ ) (/l z3 Sign due y/nstaller Date i?RL, steceri Punted Name of Signee MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report and Record Drawing on behalf of Mason County Public Health: / , � ' �,,. �. COI (If7,6/7_) Signature of Environmental Health Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY VVEB SITE Updated8mrzgte 1g <---z 13r -5.a. 1 : % \ ' 44, a 1 Si ° i1 M LS:\ 14411,..! I S NY Qom. iI t F° o a $ , t . r . 3 T N x w ' � ,* RS t rv. - - :1 r, ` \ y II" 1 4 444400441 My .s>J I s 4 1 W , � D M A p . • ROVe I ‘ vN o 1 Va° N. a � TM 0 "" pc � ( ' Nap Mr nted From Mason County DMS gated Iron :Mason Comity Ott/5 .0wes; like `2�' ' L V a