HomeMy WebLinkAboutSWG2020-00529 - SWG As-Built - 11/21/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2020-00529 Parcel# 12207-75-90022
Applicant Name Lynda&Jeffrey Jacobs Subdivision (Name/Div/Block/Lot)
Applicant Address PO Box 3029
City, State. Zip Belfair,WA 98528 Installer Name Neil Triebenbach Services
Site Address 644 E Alderwood Rd, Belfair Designer Name Arrow Septic Designs, Inc
INSTALLATION CHECKLIST
• Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair • Other so Geier Prerrealreem
System Type Shallow Pressure Pretreatment Type NuWater
>5 ft.from foundation? ❑ WA Q YES ❑ NO
>50 ft. from wells? ❑ ® ❑
>50 ft.from surface water? - ❑ • ❑
fCleanout between building and tank? ❑ 0 ❑
0 Tank baffles present? - 0 IN 0
F- 24"access risers over each compartment? ❑ ❑� ❑
W Effluent filter installed?- � S>� - ❑I• ❑ ❑
Septic tank capacity (working) NuWater gal Manufacturer Infiltrator
a D-box water level and speed levelers used? 0N/A ❑ YES ❑ NO
DmO Manifold/D-box accessible from surface? - ❑ II ❑
Z Check valves installed? 4}- 1 ❑ El ❑
04
f Transport Line Size 2" Schedule/Class 40
Bedrooms installed (check one) ❑ 2 0 3 ❑4 0 5 ❑6 ❑Commercial/Other
>10 ft from foundation?- - ❑ N/A Q YES ❑ NO
0 >100 ft.from wells? Se- LL50- r ❑ D ID
W >100 ft. from surface water? - ❑ ❑l ❑
u. >10 ft. from potable water lines? . ❑ C3 ❑
QZ > 5 ft from property lines and easements?- ❑ . ❑
d > 30 ft.from downgradient curtain/foundation drains? ME ❑ ❑
0 Drainfield level and observation ports present - - - - ❑ ER ❑
❑ Graveless chambers or Q Clean gravel used? (check one)
Proper cover installed over drainfield? ❑ ❑� ❑
Pump tank setbacks consistent with septic tank? ❑ N/A ® YES ❑ NO
Pump tank capacity(flood) 1282 gal Manufacturer Infiltrator ix' L�-. _-L
< 24" access riser(s) and accessible from surface? El 0 7
~a Alarm or Control Panel Installed? ❑ El ti
P l
Control Panel equipped with Timer/ ETM /Counter- ❑ El
o C,-
Pump installed in ® Bucket or ❑ On Block or ❑ Other I r.i
d
I
f Pump Make/Model Liberty 280 ❑� Floats or ❑ Transducer i <J
1
a Tank draw down 2" in/min Pump capacity 50 gpm Squirt Height 5 1 ft f���IL
Pump on time 1.8 min Pump off time 6 hr Daily flow set at 360 qpd' '
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Mason County OSS Installation Report pg. 2 Parcel# 111UT"15"R0022-
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - 0 YES ■ NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ YES D NO
RECORD DRAWING
This is a permanent record and must be accurate and descriptive enough to re-locate in the need of maintenance activities end future development. Typical Reosd
Drawings contain. Drainfielda manifold odentation a' v :A Septic/pump N location,North arrow.reserve crainfieio.exisbng 311C proposed '.d 5 .location of wess,waterlines.
wells,observation ports.deanwG,and other ienance access portS. ;scampi ete Remrd Draangs may ceate adevo z delays ir finalnslsllavon approval ad 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 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.
,1J A L `)-8-23
Signature of Installer Date '(1
ALE:_ 70t.=aFunur:-t aria
t off,
Printed Name of Signee r-�Srti %A/�.
MASON COUNTY PUBLIC HEALTH ' ((
C: 11-1.
The undersigned approves this Installation Report and
Record Drawingon behalf of Mason CountyPublic ,�b�� �+ut:,_ .;
Health: ti b�
( ( (Rho >, �sst
Signal re of Envimnmen I Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE urdalec ti2+12Ota
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