HomeMy WebLinkAboutSWG2023-00422 - SWG As-Built - 12/12/2023 Mason County OSS Installation Report pg. 1 MASON COUNTY UBI�I H
APPLICANT/ PERMIT INFORMATION R,cCr Ii
Permit Number SWG —2023 -- ()Q9-1Z.Z_ Parcel# Z2 )6-, S 3 C O ( 3 3
Applicant Name r),q1/,0 ,./ b(4 I Subdivision (Name/Div/Block/Lot)
Applicant Address A b60 x Z SD 6
City, State, Zip Au Is ba (1,►�- Q G 3"7 U Installer Name /?0y ,a /{/u s ce,71(c
Site Address &l/(/ Z,U///TE i-4.)Y L-/U Designer Name 4 DA 7i9 //r/,-7 7-,C,2
INSTALLATION CHECKLIST
❑ Full System Installation ank(s)Only ❑ Drainfield Only ❑ Repair ❑Other
System Type f2'l/ ik.&L /. T4NK Pretreatment Type /iO/UE
>5 ft. from foundation? - - ❑ N/A gyES ❑ NO
>50 ft. from wells? - - 0
0
>50 ft. from surface water? - ❑ ❑
Z
Cleanout between building and tank? - - 0 0
U Tank baffles present? - - 0 El 0
a24"access risers over each compartment?- - 0 ❑
LU Effluent filter installed?- ❑ ❑
CO
Septic tank size /2 S U gal Manufacturer i--/lifi /`1,4A F/tc451
s D-box water level and speed levelers used? - ❑ N/A ❑YES ❑ NO
gO Manifold/D-box accessible from surface?-- - - - - 7___-- & - - 0 ID
m,Z Check valves installed? -
- ❑
a 0 El
2 Transport Line Size Schedule/Class
Bedrooms installed (check one) ❑ 2 ❑3 ❑4 ❑ 5 ❑6 VCommercia ther)
>10 ft. from foundation?- - ❑ N/A ❑ YES ❑ NO
>100 ft. from wells?- - ❑ ❑
o0
—I >100 ft.from surface water? - 0 El ❑
w
u. >10 ft from potable water lines?-
- ❑ 0 ❑ CO o
z > 5 ft. from property -
-
lines and easements?- El El ❑ :<
> 30 ft. from downgradient curtain/foundation drains? - ❑ ❑ 0
0
Drainfield level and observation ports present - - ❑ ❑ 0
❑ Graveless chambers or ❑ Clean gravel used? (check one)
El 0 :,_r.,
Proper cover installed over drainfield?- ❑
Pump tank setbacks consistant with septic tank?- IN
0 N/A ❑ YES ❑INO �—=-1
ZPump tank size gal Manufacturer
< 24"access riser(s) and accessible from surface?- - 0 0 0
a Alarm or Control Panel Installed? - - ❑ 0
0
__ 0
Control Panel equipped with Timer/ ETM/C r- - 0 ❑ 0
a- Pump installed in 0 Bucket or ❑ On Block or ❑ Other
aPump Make/Model ❑ Floats or ❑ Transducer
EL Tank draw down in/min Pumpcapacity aci P ty qpm Squirt Height ft
Pump on time Pump off time Daily flow set at qpd
Updated 8212018
Mason County OSS Installation Report pg. 2 Parcel# 22 (7 S ' 133
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? — - ❑ YES [] No
if yes, please describe: v" 13
Were ail components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ YES ❑ 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: Drainfiel F.manifold orientation&layout,Septic/pump tank location.Nash arrow.reserve drainfield.existing and proposed buildings,location of wells,waterlines.
wells,observation ports,cieanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits,
t(A1N
N c 1-114,�
❑ 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
fo and a shed Record Drawing is accurate. form and attached Record Drawing ' accurate.
—Z3
natu of Installer Date
e- 6 6G
7.//j,e3I27
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Printed Name of Signee L
: w. ,•
MASON COUNTY PUBLIC HEALTH + 0
The undersigned approves this Installation Report and 5VU%1?Record Drawing on behalf of Mason County Publiccar.t J.tiuiaTFR
Health: •,:.i_;>"i1 I �-4
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 812112(318
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SCALE-1"=20'-0"
APPROVED
•
aa.arY OCT 16 2023
•
• YMSC�� l.'�uNt :+i1!SCWE T.L -IEAL'•..
Rur,�,,YfS�T ET
•
•
• ....PROPOSED 1200GAL.HOLDING TANK
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• `040
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' ••-•PROPOSED STU•GUT/CLEANOUT
• EXISTING DRIVE ', �' \ PROPOSED 4'TIGHT NE(2%SLOPE REQUIRED) `
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MASO ,VIN8 2023 `:l • •
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RET ``4TRL HE4t r t,m ,>:lt;S.L..i..~t.-LI•
24
-HIGH WATER ALARM(AUDIO AND VISUAL)REQUIRED JIM HUNTER & ASSOC.
-RISERS AND LIDS REQUIRED TO SURFACE P.O. BOX 162, OLY,WA 98507
-WATER-TIGHT FITTINGS 753-1226
-INSTALLATION BY CERTIFIED INSTALLER REQUIRED 1nANDASSOcumsfo 4OrMAk COM
HOLDING TANK SITE PLAN SITE ADDRESS/LEGAL
81 N WHITE WAY LN
OWNER• DAVID ALBERTI
LEGAL:
Prt Ft 0 $1,� ..:w �x; ,.:‘,.....,,v. .- . € r ~ `>va 42216-53 00133 LAKE CUSHMAN#16 TR 133
:MesCg m from 1 :�,:x.;,ENS
Printed