HomeMy WebLinkAboutSWG2023-00382 - SWG As-Built - 1/4/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
IPermit Number SWG 2023-00382 Parcel# 42216-50-00080
Applicant Name Katie Holmes Subdivision (Name/Div/Block/Lot)
Applicant Address P.O. Box 98093 Lake Cushman Div, 9 Lot 80
City, State, Zip Lakewood, WA 98496 Installer Name T,J, Goos
Site Address Kokanee Cove Way Designer Name Dale L.Tahja
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only 0 Drainfield Only 0 Repair 0 Other
System Type Sand Lined Pressure Bed Pretreatment Type Sand Lined
>5 ft.from foundation? - - ❑ N/A ®YES ❑ NO
>50 ft. from wells? - 114 'i!T14 I fl - ❑ ® ❑
Z >50 ft. from surface water? ❑ ® ❑
H Cleanout between building and tank? -- Ii -�Q3-2�21-U - 0 ® ❑
U Tank baffles present? - ----- ❑ ® 0
d 24"access risers over each compartment?4- - - • -- 0 El- 0
W Effluent filter installed?- .- ❑ ® ❑
N
Septic tank capacity(working) 1,250 gal Manufacturer Hagerman
0 D-box water level and speed levelers used? - - IN N/A ❑YES ❑ NO
OO Manifold/D-box accessible from surface?- -
El Ill
mZ Check valves installed? - - ❑ ® 0
GQ 2 Transport Line Size 2 inch Schedule/Class Sch.40
Bedrooms installed (check one) IN 2 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft.from foundation?- - ❑ N/A 1111 YES ❑ NO
0 >100 ft.from wells?- - ❑ IS ❑
W ® El>100 ft. from surface water? - - 0
u. >10 ft.from potable water lines?- - El ® 0
ZQQ > 5 ft.from property lines and easements?- - 0 NI 0
d > 30 ft.from downgradient curtain/foundation drains? - - ® 0 0
0 Drainfield level and observation ports present - - 0 ® 0
❑ Graveless chambers or li Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ It 0
Pump tank setbacks consistent with septic tank? - - ❑ N/A IN YES ❑ NO
Pump tank capacity(flood) 1.000 gal Manufacturer Hagerman
< 24" access riser(s)and accessible from surface?- - ❑ ® ❑
F-
a Alarm or Control Panel Installed? - 0 0 El
2 Control Panel equipped with Timer/ETM/Counter- - 0 ❑ ❑
D
Q- Pump installed in ❑ Bucket or ® On Block or ❑ Other
d Pump Make/Model Liberty 280 ❑ Floats or 0 Transducer
a.
a Tank draw down 2 inches in/min Pump capacity 44 gpm Squirt Height 6 ft
Pump on time 2.25 min. Pump off time 5 hrs.57.75 min Daily flow set at 180 gpd
Updated 8/212018
Mason County OSS Installation Report pg. 2 Parcel# .-SO-,C)
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? - - 0 YES [] NO
4
RECORD DRAWING
This is a permanent record and must be accurate and descriptive enough to re-locale in the need of maintenance activities and Mum development Typkal Record
Drawings contain: Drainfleld&manifold orientation&layout,Septic/pump tank location,North arrow,reserve drelnfiekl,existing and proposed buildings,location of vigils,waterlines,
wells,observation ports,cteenouts,and other maintenance access points. Inonmplete Record Drawings may create additional delays in final installation approval and 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 n attached Record Drawing is accurate. form and attached Record Drawing is accurate.
c...), ,C(.1*
ignature of Installer Date i ii:,
? *ov boos •/7 ,4/, •
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Printed Name of Signee ` Ors y of ` 4,.%1
MASON COUNTY PUBLIC HEALTH y il° •, .i t ,,,A IL
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The undersigned approves this Installation Report and "-,,:� `, ` 510021 t D` `,�t�,• :
Record Drawing on behalf of Mason County Public ,• 4"- SALE L. TAN jA • _?' ,f
Health: ,'� LIGENS D 0 SIGNER +1
I u / 73 EYE'"'. ; —I,
Signature of Environ ntal Health Specialist 1 I Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated8/212018
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APPROVED •
JAN 0 4 2023
\ MASON COUNTY ENVIRONMENTAL HEALTH
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