HomeMy WebLinkAboutSWG2021-00069 - SWG As-Built - 10/9/2023 •
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Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION / '
Permit Number SWG 2U21 -C�Ohq Parcel # ,?7II)q(D 660 O LV`-1
Applicant Name -?Ca . I 01 ti AS\ 4 Subdivision (Name/Div/Block/Lot)
Applicant Address S7/ /LJJ }3 Roe I
City, State, Zip Jurnmr, wry 9F390 Installer Name oaf &JlOFilira (.IrLLA.
Site Address £ Utrci(\to Cocci- Designer Name 4i('a ei Sml]h
INSTALLATION CHECKLIST
fA-Full System Installation 0 Tank(s)Only 0 Drainfield Only
�� 0 Repair 0 Other
System Type N\TA/rt-- pt%L € lry CPPretreatment Type
>5 ft. from foundation? - ❑ N/A le9JYES 0 NO
>50 ft.from wells? - p( ❑
Z >50 ft. from surface water? - - ❑ � 1 0
HCleanout between building and tank? - ❑ L ID
U Tank baffles present? - - 0 '� El
a24"access risers over each compartment?- - ❑ 0
W Effluent filter installed?- - ❑ 0
u) Septic tank capacity(working) (a200 gal Manufacturer Du W(i*c.(�ie$oi Ina(
5 D-box water level and speed levelers used? - mi/A ❑YES ❑ NO
Ou Manifold/D-box accessible from surface? El El
tn— Check valves installed? - - El 0
o< r•
2 Transport Line Size L Schedule/Class CL s Id D
Bedrooms installed (check one) 14.2 1:13 04 05 06 ❑CommerciaVOther
>10 ft. from foundation? - - ❑ 94E N/A ' 5 0 NO
0 >100 ft. from wells?- LS7/ ❑ ❑
11.1 >100 ft. from surface water? - ❑ �/ 0
tLL >10 ft.from potable water lines?- - ElL/J ❑
Z �-
> 5 ft. from property lines and easements?- - 0 ❑
> 30 ft. from downgradient curtain/foundation drains? ,` 0 'G/ 0
Dr field level and observation ports present - - El 0
1444 Graveless chambers or 0 Clean gravel used? (check one)
Proper cover installed over drainfield?- 0 rgi 0
Pump tank setbacks consistent with septic lank? - 0 N/A EY ElES NO
Pump tank capacity(flood) lap gal Manufacturer HCJSL. O,IOS
< 24" access riser(s)and accessible from surface?- - ❑ g' ❑
~
a Alarm or Control Panel Installed? - - 0 El 0
2 Control Panel equipped with Timer/ETMJ,/Counter - 0 EN ❑
a Pump installed in ❑ Bucket or On Block or ❑ Other ,_/
a Pump Make/Model Zoe LoC 153 gA Floats or ❑ Transducerra
y Tank draw down 2. in/min Pump Capacity yg gpm Squirt Height ft
Pump on time )•25 m•e u}eS Pump off time 3 6ov( Daily flow set at ZMO qpd
Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
Were existing septic components abandoned as pad of this project? - ❑ YES 0 NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? ❑ YES ❑ NO
RECORD DRAWING
This Is a permanent record and must be accurate and descriptive enough to re-locate In the need of maintenance activities and future development Typical Record
Drawings contain Draingeld&manifold orientation&layout,Sepbtlpump tank location,North arrow.reserve drainf'eld,existing and proposed buildings location of wells waterlines.
wells.observation ports,cleanouls,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
0 Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNERI ENGINEER
I certify that 1 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
yattached Record Drawingis accurate.
Sign lure of Ins Iler Date i r,og S obit:)C! 4
f,
f-
,De- 0 _ Q V/Min h
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Printed Na e of Signee f' '
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and , ;5 1 {,
Record Drawing on behalf of Mason County Public
Health:
,0 , t d4 (23
Signature of Environmental L lealth Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE updated mztame
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