HomeMy WebLinkAboutSWG2023-00295 - SWG As-Built - 1/12/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG ��� Da�g'� Parcel # (� 7� �Q11�rr�
Applicant Name 4-ii61-o„k, G-4, Subdivision (Name/Div/Block/Lot)
Applicant Address gift e. VI NC'j4+( Cyr rig,
City, State, Zip 6a;U (,[4�- , Installer Name `/
Site Address Designer Name "7 ? .tf.( 3),yvt gefest
INSTALLATION CHECKLIST
❑ Full System Installation ❑Tank(s)Only ❑ Drainfield Only pair ❑ Other
System Type as doi,i Pretreatment Type
>5 ft. from foundation? - ❑ N/A I YES ❑ NO
>50 ft. from wells? - 0
0
z >50 ft. from surface water? - 0
❑
• Cleanout between building and tank? - El 0
U Tank baffles present? - ❑ ❑
a24"access risers over each compartment?- _ El Effluent filter installed?- ❑
�j El
Septic tank size Lx d,5l IOW gal Manufacturer l ivi itufg,
0 D-box water level and speed levelers used? -
❑ N/A 0 YES Nd
Q O Manifold/D-box accessible from surface? El ❑
mZ Check valves installed? - ❑
2 Transport Line Size Schedule/Class 5�h ,L.jo
Bedrooms installed (check one) 0 2 2?k......0 4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation? ❑ N/A 1 YES ❑ NO
>100 ft. from wells?- R ��� __ ❑ ❑
—� >100 ft. from surface water? - -- - -f '(.e (-7i€ --L -; ❑ i-I Ne4v W "'� ❑
ti >10 ft. from potable water lines?- ❑
Z ❑ _
De > 5 ft. from property lines and easements?- - 0 r El 30 ft.from downgradient curtain/foundation drains? 0 0
Drainfield level and observation ports present - - 0 0
0 Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield? - 0 ❑
Pump tank setbacks consistent with septic tank? - _ 0 N/A YES ❑ NO
• Pump tank size gal Manufacturer
Z
< 24"access riser(s)and accessible from surface?- ❑ Q
a. Alarm or Control Panel Installed? - - El ❑
2 Control Panel equipped with Timer/ETM/Counter- - El ID
- Pump installed in ❑ Bucket or XOn Block or El Other
2bn" Pump Make/Model
❑ Floats or Transducer
Tank draw down .v`
�. in/min Pump capacity kelm Squirt Height ft
Pump on time Pump off time Daily flow set at .3(?D qpd
Updated 8/21/2018
r 1
Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD /
Were existing septic components abandoned as part of this project? - - YES No
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - YES p 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: Drainfleld&manifold orientation&layout,Septic/pump tank location,North arrow,reserve drainfield,existing and proposed buildings,location of wolls,waterlines,
was,observation ports,cieanouts,and other maintenance access points. incomplete Record Drawings may create additional delays In final installation approval and related permits.
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3tecord Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ 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 Maso ounty Public Health and meet all State myself and Mason County Public Health and meet all
and Mas n County Codes State and Mason County Codes
I further rtify that all 1 • lion contained on this I further certify that all information contained on this
form an ttached R d awing is a curate. form and attached Record Drawing is accurate.
Signa of taller Date
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
.--1-1'\.--if\t\locW ( c 17r1-7)-1
Signature of Environmental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 812112018
RECORD DRAWING (continued)
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