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Home My WebLink AboutSWG2023-00235 - SWG As-Built - 10/17/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG202.3-002 5 Parcel #4?PH - 41-000(10 Applicant Name Ri nard & E;p ra.i, tiauar4 Subdivision (Name/Div/Block/Lot) Applicant Address PO(BOX 406.41 it N of ELZ A Tctg 1 t 1 - D City, State, Zip Cparlawas. WA ggAIR Installer Name Ma.plris &GAWifih9 Site Address 21510 M. ttwy tel Designer Name INSTALLATION CHECKLIST IDFull System Installation iTank(s)Only 0 Drainfield Only ❑ Repair ❑Other System Type C1y 4v iiv) Pretreatment Type >5 ft. from foundation? - - ❑ N/A BYES ❑ NO >50 ft.from wells? - _ -- ❑ Cl ❑ H.>50 ft.from surface water? - ll " /)i 1 - ❑ ❑ 2 F Cleanout between building and tank? ❑ [� ❑ o Tank baffles present? - ❑ EY ❑ a 24" access risers over each compartment?- ❑ [� ❑ N Effluent filter installed?- IOW - ❑ a Septic tank capacity(working) IOW gal Manufacturer Roth a D-box water level and speed levelers used? - - ❑ N/A ❑ YES ❑ NO OLL Manifold/D-box accessible from surface? ❑ ❑ ❑ 92 Check valves installed? - - ❑ ❑ ❑ 0< f Transport Line Size Schedule/Class Bedrooms installed (check one) VI 2 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft.from foundation?- - ❑ N/A ❑ YES ❑ NO G >100 ft.from wells?- ❑ ❑ ❑ W >100 ft. from surface water? - ❑ ❑ ❑ L >10 ft.from potable water lines?- ❑ ❑ ❑ ct > 5 ft.from property lines and easements?- - El El C > 30 ft.from downgradient curtain/foundation drains? . ❑ ❑ ❑ Drainfield level and observation ports present - ❑ 0 ❑ • ❑ Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?- ❑ El ❑ Pump tank setbacks consistent with septic tank?- - ❑ N/A ❑ YES ❑ NO 2 Pump tank capacity(flood) gal anufacturer < 24" access riser(s) and accessible from su ce? !7/ ❑ 0 ❑ F- a Alarm or Control Panel Installed? - ❑ ❑ ❑ f Control Panel equipped with Timer/ETM /Coun r. - ❑ ❑ ❑ 3 a Pump installed in ❑ Bucket or ❑ On Block r ❑ Other a f Pump Make/Model ❑ Floats or ❑ Transducer A. Tank draw down in/min Pump capacity gpm Squirt Height ft Pump on time /ump off time Daily flow set at qpd Updated em n010 Mason County OSS Installation Report pg. 2 Parcel# Llaal4-ill- 00040 ABANDONMENT RECORD �.�( Were existing septic components abandoned as part of this project? - L� YES NO If yes, please describe'. r Were all components pumped out and properly abandoned per WAC246-272A-0300? - - 12 YES Ei NO RECORD DRAWING This is a permanent record and must be accurate and descriptive enough to relocate in the need or maintenance activities and future development. Typical Record Drawings contain Drainfield&manifold orientation a layout,Septic/pump tank lncauon.North arrow,reserve dralnneld,existing and proposed buildings.location of wets.waterlines, wells.ober,ation ports,cleanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final erstallat on approval and related permits. dRecord 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 1 further certify that all information contained on this form and attached Record Drawing is accurate. form and attached Record Drawing is accurate. Sew — 4812mla3 Signature of Installer Date Shvfe Maples Printed Name of Signee MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report and Record Drawing on behalf of Mason County Public Health.' --11\-AlIADL6Y14 0Ic7 t2jTh Signature of Environ ental Health Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE updated 8..11/2018 RECORD DRAWING (continued) - Hood Cana1 lZ 0 m 1 L Q HOUgt h r aio, c -tJt;W loot alai ion Roth (A +tuaJ lei POW # 42aiU -III-000x10