HomeMy WebLinkAboutSWG2022-00188 - SWG As-Built - 1/9/2024 Mason County OSS Installation Report pg. 'I
MASON COUNTY PUBLIC HEALTH
APPL%CANTI PERMIT INFORMATION o Ga 6
Permit Number SWG 202 L -DO S
Parcel## s/ o - rL-ai o
i7- Subdivision (Name/Div/Block/Lot)
Applicant Name TA- o'"Z' s i3i�. z iv t6 �//
Applicant Address fo GaS-f- L/c d/e O'-' Lo s�G'E k/i 7�
City, State, Zip SA c/j w y8s"'
installer Name /z ti Ss Go4-.r��4 —
Site Address <a Goct z/< J4 ' 40/` Designer Name GAf-/s /y/sf�a74}-
INSTALLATION CHECKLIST
Drainfietd Only 0 Repair 0 Other____________—_�i ull System installation 0 Tank(s)Only0 Pretreatment Type� `L'_ ��K �P
System Type �GSu
- 0 NIA YES El No
>5 ft.from foundation? - El 0
>50 ft.from wells? - - 0 ❑
>50 ft.from surface water? - 0 ❑
Z
Cleanout between building and tank? - 0
0
C.) Tank baffles present? -a 0 ❑
24"access risers over each compartment?- ❑ ❑ 0
ta,i Effluent filter installed?- n'
to �7V gal Manufacturer G '
•
Septic tank capacity(working) � NIA El YES ❑ NO
O D-box water level and speed levelers used? - El 0 0
O Manifold/D-box accessible from surface?-a? ❑ f4 ❑2 Check valves installed? - r�
pQ �� Schedule/Class 7a a
2 Transport Line Size y=-----
n ❑CommercialIOther p
Bedrooms installed (check one) 2 pp OV- ❑ N/A Co YEs ❑ NO S
>10 ft.from foundation?- ❑ ❑
>100ft-from wells? - - - ---- JAN O 5 202�L-_ ❑ ❑
O ------
J >1 00 ft from surface water] ----- - ❑ 0
CC >10 ft from potable water lines? vNaLCCANTX•Ek}''lthJ1�'`"�'�1TFL -- - ❑ 0
Z > 5 ft.from property lines and easements?---a�w - ❑
Q ID ❑ i
> 30 ft.from downgradient curtainlfoundation drains? ❑
Drainfield level and observation ports present
01 Graveless chambers or ❑ Clean gravel used? (check one) ❑ `L ❑
Proper cover installed over drainfield?-
❑ NIA YES 0 N°
x Pump tank setbacks consistent with septic tank? !
Manufacturer / � ❑ 6
Pump tank capacity(flood) gal ❑
Q 24"access riser(s)and accessible from surface? -- - - - - ❑ ❑
1 ~ Alarm or Control Panel Installed? - - - -- - ❑ ❑
a edwithTimerIETMICounter- --------
� Control Panel equipped
On Block or ❑ Other
�- Pump installed in ❑ Bucket or �✓ �Floats or
` 0 Transducer
�' Pump Make/Model ✓ ft
� pm Squirt Height 2•�
Tank draw down---tnlmin Pump capacity -g pd
a. h� Daily flow set at 3- tG�g
�umpontime 3 y�iw
Pump off time Updated 8)21/2018
Mason County OSS Installation Report pg. 2
Parcel#
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? -- --- -- -
- -- 0 YES X j NO
if yes, please describe: ---
___ ❑ YES NO
Were all components pumped out and properly abandoned per WAC246-272A-0300.
RECORD DRAWING . ._.
Typical Record
reserve t ainte ante aandpes anddutu de,locationnt. T Reced
This is a permanent record and must be accurate and descriptiveenough�uo�INorth arrrox,e need of maintenance activities and future development
points. incomplete Record Drawings may create additional delays in final Installation approva+and related permits.
Drawings conteln: Ordin9eld&manifold orientation&layout,Sep p
wells.observation pops,dea"outs,and other maintenance access
ecord Drawing Attached
CERTIFICATION OF INSTALLATION
.. DESIGNER/ENGINEER
INSTALLER I certify that l installed the system in accorda I certify that the system has been installed in accor-
the septic design stamped"APPROVED"by Masonh dance with the septic design stamped"APPROVED"by
Mason County Public Health and that any deviations
County Public Health and that any deviations shown roved by both
here have been cleared/approved by both the designer shown here have been cleared app
and Mason County Public Health and meet all State myself and Mason County Public Health and meet allState and Mason County Codes
and Mason County Codes. I further certify That all information contained on this
I further certify that all information contained on this
and attached Record Drawing is accurate.
form and attached Record Drawing is accurate. form �
Date VJA,Syy l�'
Signature of Installer •
• � 'A�'•`
•
Panted Name of Signee . - + -or;' W
• �. 28508, •. f'
MASON COUNTY PUBLIC HEALTH - ,p
The undersigned approves this Installation Report and , ,,....
Record Dr.wing on behalf of Mason County Public OMA
%.2..3 �v3
Hea : ( --2— °�
//a --•
- (stamp, signature and date)
1•, Date
Sign Hea SPe� • -" updated a+z+no+a
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE
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