HomeMy WebLinkAboutSWG2023-00158 - SWG As-Built - 1/16/2024 Or ,
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG i U Z. 3 -OC I S Y� Parcel 4 22 3 j S/(>()QS'Z
Applicant Name (1\ -U .-, er'••., C.„ Subdivision (Name/Div/Block/Lot)
Applicant Address (1'C WSJ. (b,-`,)c:,,,..t.,-. L• vv.,t,.\ Coc)-C-- 4' y 7-- ¶ Z
City: State. Zip b,z-\ , ,,-.r- (,,.,ram cl (53ZY Installer Name (. \ (&,ALi f„`:,�u,k
Site Address ��� u`r ,�
�PV Yv� �r�.�r t L.� Designer Name S`�.-� ,,,,•11
INSTALLATION CHECKLIST
❑ Full System Installation ❑ Tank c Oniy )'aurf:aid OW v D Repay ❑Other
System Type &-r"c...._ \.- , V -t 6 > P:etreatment Type
>5 ft. from foundation? - -- IA• �� __
❑YES 0 NO
>50 ft. from .yells? - - a'- ❑ ❑
Z >50 ft. from surface water? Er
0 0
HCleanout between building and tank? Eir 0 ❑
U Tank baffles present? - gi ❑ ❑
a24' access risers over each compartment?- - - - - - 15 0 0
cW Effluent filter installed?- ID ❑
Septic tank capacity (working) y gal Manufacturer
CID-nox water level and speed levelers ;serf' • - - - - - - - - - - - - - • ❑ NIA ErYES 0 NO
DO Manifold/CI-box accessible from surfatie". -- - IDig- ❑
m z Check valves installed? - - - ' ❑ ❑
2 Transport Line Size 363LA LI Scheduie.Ctass • O3`-1 Bedrooms installed(check one) -2 ? ❑4 ❑ `- ❑b 0 Commercial/Other
>10 ft. from foundation? - - - ❑ N/A ❑ YES E'NO
>100 ft. from wells?• - ❑ Eit ❑
J .. `-, nn surface water? - - - ID El ID
c-o , potable water lines?- ❑ fig- D
Z > 5 ft. from property lines and easeme its?- - - - - - - - - - •- - - - • ❑ 0
a
Ce > 30 ft. from downgradtent curtarn!fourdation drams • - - - -. - - - - • ❑ Z ❑
ca
Drainfield level and observation ports present • •- - - - ❑ El ❑
"Graveless chambers or 0 G1ean gravel used' check one r
Proper cover installed over dratnfietd? - - - - - -- - - ❑ Iiir ❑
Pump tank setbacks consistent with septic tank . - - -- - - - • -- - - - • 42r-N,A ❑ YES ❑ NO
• Pump tank capacity(flood) ____ gat Manufacturer ____ --__--_--
Z 24 access riser( ,) and accessible front surface 0 0 0
a I-
Alarm or Control Panel Installed" - - ❑ ❑ 0
2 Control Panel equipped with Timer i E-M r Counter• . 0 0 ❑
n
n- Pump installed in 0 Bucket or C On Block or ❑ Other __________ _.___ _ ----
d• Pump Make-Model_ _-___.____ ___ _ __..__.. __.__._...._. CI Floats or ❑ Transducer
a.• Tank draw down in:min Pump capacity m Squirt Height _- __f'
P. on time Pomp off time ___._-__- ____ - Daily flow set at _. _ rf
Mason County OSS Installation Report pg. 2 Parcel z Z 3 cf-S qCx c. s
ABANDONMENT RECORD
Were 9,i t t •,r•ptic components abandoned a� part ri' !i :c;: - - - - YES EI- NO
If yes. please descnbe.
.
Were all components pumped out and propel, -: , • - . - YES NO
RECORD DRAWING
'h., ;4 permanent record and nn,st t:,: •,.:.:c.,.rt:• ar.<t u.•sc itptr..•c oo_ryh: ,o..,k• i:•tn. .n•ee rat m•untenance ac tivtetet and suture clevebpment.
•
iecord Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ ENGINEER
I comfy 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 deviatio is shown Mason County Public Health and that any deviations
here have been cleared/approved by both he designer show,. Isere have been cleared/approved by both
and Mason County Public Health and mee all State myself and Mason County Public Health and meet all
and Mason County Codes. State and Mason County Codes
I further h off r atioop cootau etl on this I further certify that all information contained on this
form .awing is accurate form and attached Record Drawing is accurate.
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Signature of Installer 0,3 e
j itte A NN �{ �
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n,:nn:r t..;nre of Signee t��. 4t�b
MASON COUNTY PUBLIC HEALTH � '
The undersigned approves this Installation Report and % ,,,, 45,4
'Of
Record Drawing on behalf of Mason County Public ' t GNER
Health. s :• �S�
(( —/ L(
Signature of Environmental Health Specialist D.ite (stamp. signature and date)
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