HomeMy WebLinkAboutSWG2022-00295 - SWG As-Built - 1/16/2024 LEM
JAN Q @ 2024
Mason County OSS Installation Report pg. 1 WAN col l TY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2022-00295 Parcel# 22133-12-60020
Applicant Name Mason County Fire Dist#5 Subdivision (Name/Div/Block/Lot)
Applicant Address P.O. Box 1910 TR 2 OF NW NE
City, State, Zip Shelton,WA 98584 Installer Name Mason County Excavating
Site Address 1741 E Pickering Rd, Shelton Designer Name Arrow Septic Designs
INSTALLATION CHECKLIST
❑ Full System Installation ❑ Tank(s)Only ❑ Drainfield Only ❑ Repair ® Other (2)500 gallon
System Type Shallow Pressure Pretreatment Type NuWater BNR-500
>5 ft. from foundation? - - 0 N/A ❑■ YES ❑ NO
>50 ft. from wells? - - ❑ ® ❑
Z >50 ft. from surface water? - - ❑ ❑■ ❑
< Cleanout between building and tank? - - ❑ ❑■ ❑
U Tank baffles present? - - ❑ ❑■ ❑
1:: 24" access risers over each compartment?- - ❑ ® ❑
`W Effluent filter installed?- —5'OL7' Q.5707 ❑ El El
Septic tank capacity(working) NuWater BNR gal Manufacturer Hagerman
0 D-box water level and speed levelers used? - - '- - - - - ❑ N/A ❑ YES ® NO
><O Manifold/D-box accessible from surface?- di;., El II
co Z Check valves installed? - t u..v -6.—,"k. At - ❑ III ❑
6Q
2 Transport Line Size 2 inch Schedule/Class 40
Bedrooms installed (check one) ❑ 2 ❑ 3 ❑4 ❑ 5 ❑6 ■❑Commercial/Other 480 &PD
>10 ft. from foundation?- - ❑ N/A Q YES ❑ NO
O >100 ft. from wells?- - ❑ U] ❑
w >100 ft. from surface water? - - ❑ ❑■ ❑
ti >10 ft. from potable water lines?- - ❑ 0 ❑
Q Z > 5 ft. from property lines and easements?- - ❑ ❑■ ❑
Ce > 30 ft.from downgradient curtain/foundation drains?- - ❑ in ❑
Drainfield level and observation ports present - - 0 PI ❑
❑ Graveless chambers or 0 Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ It 0
Pump tank setbacks consistent with septic tank?- - ❑ N/A ® YES ❑ NO
• Pump tank capacity(flood) 1,250 gal Manufacturer Hagerman
< 24" access riser(s) and accessible from surface?- - ❑ 0 ❑
~
d Alarm or Control Panel Installed? - - ❑ 0 ❑
E Control Panel equipped with Timer/ETM /Counter- - ❑ IR ❑
n
a• Pump installed in ❑ Bucket or U] On Block or ❑ Other
a.
2 Pump Make/Model Liberty 290 21: IcRs RO Vzit Ea r
• Tank draw down 3 in/min Pump capacity 66 ,'. /pm Squirt Height ft
a JAIb 410
Pump on time 1.8 minutes Pump off time 6 ho., r a/y ow set 480 gpd
.v11 S{JN CUUN I Y ENVIKUNMEM AL HEALTh1iated 8'21,2Ct8
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Parcel# _
Mason County OSS Installation Report Z l33- 12 Co 2-a
ABANDONMENT RECORD
YES 0 NO
Were existing septic components abandoned part of .'sfprolQ q44 O 1,
If yes, please describe: 1 D. e u h 'f�Zt YES ❑ NO
Were all components pumped out and properly abandoned per WAC246-272A-0300? `t3'
RECORD DRAWING
This is c
ennanent record and must be accurate and descriptive enough to relocate in the need of maintenance activities and future development Typical Record •
p
Di Dngs contain: Dra rtfield&manifold orientation&layout,Sep dpump tank location.No arrow.reserve drairfield,exis ng and proposed buildings,location of wells,waterlines,
wells,observacon ports.deanot.Ts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
ppROVE
,, 1 JAN 1 6 2024
Record Drawing Attached
10t snni cntlNTY FNUIRONNIENTAL HEALTH
CERTIFICATIM 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 and atta ed Record Drawing is accurate. form and attached Record Drawing is accurate.
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Signal of installer 6 6Date / _q.1}�
Pc\A GAY`, r� 4.-. �r
Prnted Name of Signee y�At. ul : . i,
t/31 '� • t,
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MASON COUNTY PUBLIC HEALTH ` ;\ •,.
The undersigned approves this Installation Report and ,:;i stcua4e .• t)
Record Drawing on behalf of Mason County Public .Y fa' PAULA JOY JOHNSON
6:_ ltC f$E r$:fONE'ft:.
He th
sS'�w,�s rid �`
•nmentalh Specialist Date (stamp, signature and date)
Sign to/i/i
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THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated e21rzc1e
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