HomeMy WebLinkAboutSWG2018-00454 - SWG As-Built - 10/17/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2018-00454 Parcel # 22202-42-90020
Applicant Name Bruce Giese west Subdivision (Name/Div/Block'Lot)
Applicant Address 4171 NE Northshore Rd
City. State. Zip 98528 Installer Name Arrow Excavating
Site Address same Designer Name NA
INSTALLATION CHECKLIST
❑ Full system iri to lauon ®Threes)Only ❑ P alnneld only ❑Renee ❑Other
System Type .__. Grinder for garge Pretreatment Type
>5 fL f'on foundation 2 - - - — ❑ NIA ®YES ❑ NO
>50 N. from ,Nell - - .. . . - - - . - - - - - . ❑ e ❑
Z >50 tt from surface water? ❑ it ❑
4 Cleanout hatwoen budding and tank' -- - - - ❑ II ❑
f.
O Tank baffles present? ® ❑ ❑
P 24 access risers over each compaMrent^ . - -- --- ❑ in ❑
a
W Effluent filter installed' - 0 ❑ ❑
m
Septic tank capacity (working) gal Manufacturer barnes ecotran oqp grinder
Cr D-box waer level nrd speed levelers used' - - - - - - - Q N:A ❑ YES ❑ NO
J
*O Manifold.D--bax accessible `ram surface?- II ❑ ❑
c, 2 Crick salves installed' . - ® ❑ ❑
04
2 Transport 1_ina Size 1 1/4 Schedule/Class 250 psypoly_
Bedrooms Installed tcheck one1 02 03 04 ❑❑ ❑CoimnercialvOther
10fI. 'rcm bu ldaticn' - - - - - - -- NiNrA El ❑ NO
O >100 ft Irom we Is, _ - _ _ _ - - _ ® ❑ ❑
W >100 ft from surface water? - - - - - ' ' ® El
LT >10 ft_ Irom potable wafer lines'. .- ® ❑ ❑
Z > 5 ft. from property lines easements?- - - - - PI ❑ ❑
4 NI ❑ ❑
re > 30 ft. from dower ' ten[ cudain in i(oundalion drams' - - - - - - - -
Dr amfield rev and observation ports present Q ❑ ❑
❑ Gr ess cnamcers or ❑ Clean gravel usen' tcheck one,
('.roper cpverinstalied over di ainfield2 ilil A. ❑ ❑
Pump ' shacks consistent with septic tank' - - - - - - - - - - ❑ YES ❑ NO
X Pump tank capacity (flop , _ gal Manufacture
<• 24 access riserts) and accessible ro . . - e?- - - - - ® ❑ ❑
a
Alarm or Control Panel Installed' -- - -- - El ❑ ❑
• Control Panel equipped with Timer/ ETM l '• miter - IN ❑ ❑
0
a Pump rest lr .aIn ❑ Bw Het • Int On Bin k or ❑ Other _
4'• Purl„ Make Model _ _ ❑ Floats or Transducer
aTank draw d in/min Pump rapacity pm Squirt Height_ fi
P en he Pump off tim __. Daily flow set at_. __� gpd
Mason County OSS Installation Report pg. 2 Parcel u
ABANDONMENT RECORD
Were exisunq ceptic components abandoned as port of th prnjert% -- - - - YES S(NO
If yes please describe
'here all components pumped nu;a d properly abandoned per WAC?4h-272A-O300 YES pit Q NO
RECORD DRAWING
♦ie,ie etreocanew record and,nua,be accurate arid a snarl. er eu '.to,o iomN ni,ln need of maintenance act vme era future de, Ionem„i tom!' k,
m PLO 1ch
\. ' G5� At \� Ir L623 .
Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ ENGINEER
I certify that I installed the system rn accordance with I certify that the system has been installed in actor-
the septic design stamped 'APPROVED by Mason dunce with the septic design stamped "APPROVED'by
Calory Public Health and that any deviations shown Mason County Public Health and that nay deviations
honIe have hnr,I1 cleated appry,N1 by nosh , ilesipnoi <hcwn here have er em c.!ea _ if pprvved by both
mid Mason County Public Health and meet all State myself and Mason Coufny Public Health and meet all
and Masi)!i County Codes Slate oat/Mason County Codes
forthet certify that all information rail ed on this I fir^her ref fllyrr 0t all adorn-ration contained on this
f r ur'a aid Ricca/ r 'accu ate c un end aNa hr Rc nr,f flawing is as orate.
/6/r/
natwe of lnsl:r'lu Date
� ohr� (Jru /Flr2% �
Footed Homo of Signce
MASON COUNTY PUBLIC HEALTH
Thu under srgned appnmos This /m;!rillolrufi Rupod and
Record Drawing on behalf of Mason County Public
llrnth
101I7IZ3
gdurenEm Ebb Him!Healr .iais. Odle (stamp, signature and date(
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TH6 FORMMA+ `� SCANNeU AN AA'A'e401- F(JR PUBLIC uli.at.C N -I�L M0.5G6 U Jir ALB S
RECORD DRAWING (continued)
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