HomeMy WebLinkAboutSWG2020-00259 - SWG As-Built - 10/16/2023 rr
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Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC I.EALTH
APPLICANT/ PERMIT INFORMATIONi.
I Permit Number SWG Or A-c J-�jtb - OO cj Parcel# '];tOtL -rO-9' 0gvie
Applicant Name S C O�C x Subdivision (Name/Div/Block/Lot)
Applicant Address �6 rg \91 lilt
City, State, Zip PP'��11 sr�)J kS ntt]k1.1Q- �'l5N Installer Name m A =
Site Address t.0 O E. IV tC1(1Y11^,—fa Designer Name 1
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only 0 Drainfield Only ❑Repair 0 Other
System Type WAN) Pretreatment Type
>5 ft.from foundation? - - ® N/A ❑YES ❑ NO
>50 ft. from wells? - - ❑ El ❑
Z >50 ft. from surface water? - El❑
f
Cleanout between building and tank? - z+:-y -*t j n' -- - -- 0 ® ❑
ra Tank baffles present? - ❑ V. ❑
F 24"access risers over each compartment?,..,a - =-'-'. -1- --- 0 lid ❑
0.
W Effluent filter installed?- - 0 ® 0
W
Septic tank capacity (working) VATS eel Manufacurer 1250
o D-box water level and speed levelers used? - - ❑ N/A ® YES ❑ NO
00 Manifold/D-box accessible from surface?- - ❑ ® El
mZ Check valves installed? - - ❑ 0 N
af Transport Line Size q Schedule/Class 30-3q Swv ?-.PC
Bedrooms installed (check one) ❑ 2 C73 [9)4 ❑ 5 06 ❑Commercial/Other
>10 ft. from foundation? - - ® WA ❑ YES ❑ NO
a >100 ft. from wells?- - 0 El 0
W El El El>100 ft. from surface water? - -
it >10 ft. from potable water lines?- -- ❑ ® ❑
Z > 5 ft. from property lines and easements?- - 0 NI IDa ❑ ® ❑
G >30 ft. from downgradientcurtain/foundation drains? -
Drainfield level and observation ports present - 0 04 ❑
® Graveless chambers or ❑ Clean gravel used? (check one) •
Proper cover installed over drainfield?- -- ❑ IA ❑
Pump tank setbacks consistent with septic tank? - ® N/A ❑ YES 0 No
• Pump tank ca (flood
)it gal Manufacturer
Q24"access riser(s)and access'I�TSYrome ce? - ❑ ❑
a.
a Alarm or Control Panel Installed? - - - - - - -- ❑ ❑ 0
P Control Panel equipped with Timer/ETM/Counter- ❑ ❑ ❑
7
C Pump installed in 0 Bucket or 0 ock or ❑ Other
a• Pump Make/Model aEl Floats or 0 Transduccq
I • Tank draw down in/min Pump capacityqpm Squirt Height ft
Pump on time Pump off time Daily flow set at qpd
Mason County OSS Installation Report pg. 2 Parcel#
❑
tABANDONMENT RECORD
Were existing septic components abandonedas pan of this project? -
YES
❑ NO
If yes. please describe' - ❑ NO
Were all components pumped out and propedy abandoned per WAC246272A-0300? - ❑ YES
RECORD DRAWING
This is a permanent record anti must be accurate and descriptive enough to relocate in the need of maintenance activities and Mure development.lam E a cna. c�a"raH& c I &layout sees open WADI,.aim reserve dnnheameting and proposedo ug s Ior3M its.n .emnes'rc al Record
..etlsmaw-yawnun co es.xanu"...and cre,maintenance access mode Incomplete SmoteDrawings may wear additional delays rOng' mate.or aporoal am r sib ed vete Is.
.
0 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"APPRO/ED"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 bo h
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.
amw� �/I.S D27
Sign tare oure ollnstaller Date
Sew 44o.,� 0 ,elite( r-3
Printed Name of Signea
ti
MASON COUNTY PUBLIC HEALTH * a ; �,!�
The undersigned approves this Installation Report and f ''r
Record Drawing on behalf of Mason County Public norr IILNi ER
i r4 I
Health: .1Tt-CCc :X,_Ss >:.'� t
RJIN\QAA
Signature of Environment Health Specialist Date (stamp, signature and date)
THIS FORM MAY RF SCANNFn AN/1 AVAII ARI F FOR PI IRI IC.VIFW ON THE MASON COUNTY WFR SITF Added e2112d+e
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