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HomeMy WebLinkAboutSWG2021-00438 - SWG As-Built - 2/8/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2021-00438 Parcel # 32021-50-01005 Applicant Name DON POGREBA Subdivision (Name/Div/Block/Lot) Applicant Address 2018 SE WALKER PARK RD City, State, Zip SHELTON, WA. 98584 Installer Name MAPLES EXCAVATING Site Address SAME Designer Name CINDY WAITE INSTALLATION CHECKLIST © Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair ❑Other System Type PRESSURE Pretreatment Type >5 ft. from foundation? - N/A ❑ YES ❑ NO >50 ft. from wells? ❑ f ❑ Z >50 ft. from surface water? - ❑ ❑ ❑ • Cleanout between building and tank? - ❑ ❑ O Tank baffles present? ❑ ❑ ❑ d24" access risers over each compartment?- ❑ W Effluent filter installed?- ❑ ❑ 0 ❑ Septic tank size I c U 0 gal Manufacturer ROTH `� D box water level and speed levelers used? - -. - - - _. _. _ _ _ _ ._ _ .. _ N/A X0 Manifold/D-box accessible from surface? ❑ ❑ YES El NO ❑ 0 ❑ m- Check valves installed? - ❑ UI ❑ 0< 2 Transport Line Size 2 Schedule/Class SCHEDULE 40 Bedrooms installed (check one) ❑ 2 0 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft. from foundation? - ❑ NIA Q YES El NO - - - - - - - - - - 0 >100 ft. from wells?- _ ❑ ❑ ❑ --I >100 ft. from surface water? - - - - - w - - 0 0 ❑ u. >10 ft. from potable water lines?- - -- ❑ z I=7 0 Q > 5 ft. from property lines and easements? _ _ _ CI pg ❑ ce > 30 ft. from downgradient curtain/foundation drains? - -- - -- 0 ❑ ❑ Drainfield level and observation ports present _ _ _ _ ._ _ _ •❑ X ❑ ❑ Graveless chambers or © Clean gravel used? (check one) Proper cover installed over drainfield? ❑ 0 ❑ Pump tank setbacks consistent with septic tank?- - - - - .. _ ff--1t LJ N/A ❑ YES O NO Pump tank size I 0 LO gal Manufacturer ROTH z • 24" access riser(s) and accessible from surface?- - - - -- _ _ _ ❑ n ❑ a Alarm or Control Panel Installed? ❑ 0 ❑ E Control Panel equipped with Timer/ETM /Counter- - - - - -- - - ❑ 0 ❑ a Pump installed in El Bucket or gJ On Block or ❑ Othera. 5 Pump Make/Model tt6 Floats or ❑ Transducer Tank draw down �I . p a. cin/min Pump capacity_ gpm Squirt Height ft Pump on time Pump off time Daily flow set at d —9p Updated it/21/2018 Mason County OSS Installation Report pg. 2 Parcel # 32021-50-01005 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - -- - - - 0 YES El NO If yes, please describe: Were all components pumped out and properly abandoned per WAC246-272A-0300? - - 0■ YES NO RECORD DRAWING This is a permanent record and must be accurate and descriptive enough to re-locate in the treed of maintenance activities and future development. -Typical Record Drawings contain: Drainfield&manifold orientation&layout.Septic/pump tank location.North arrow,reserve drainfield,existing and proposed buildings,location of wells,waterlines, wells,observation ports.cleanouts.and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits. AThh eJ a S Fes- 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 codify that all information contained on this form and attached Record Drawing is accurate. form and attached Record Drawing is accurate. Signature of Installer Date >U\Ub1e) 04(.lL ' 44, �-a Printed Name of Signee - a v� MASON COUNTY PUBLIC HEALTH e 00 The undersigned approves this Installation Report and o� oY E.WAITM Record Drawing on behalf of Mason County Prlblic ` LICENSED DESIGNER • Health: t.Xi>IRIS 05,10, ro (-\u/y\r\30)71 Signature of Environmental Health Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON TI iE MASON COUNTY WEB SITE upda!ed 8/21/2018 Pa41,_____________1_4_:___.-15 -4-64'ittik5 _ . D ? 41 ) - AP• o v E ski tkt FE0082024 s ata �� �TA1 uEA`�� O= IN E.WAITE �' EltONME 1 Pl.S� LICENSED DESIGNER SON COUNSV ET .�. i Ln�'i�tLS gib tOt 20(6 5-.E. Wa4k e. rask J 3 aO a-1,50- c,1ear l .0 0 ie a f 6, 7TQ,.je_19.fi C . ---- 1' 0 eXt 54i ill We51.9(€.#102_, 1 (P" 1 0 14 a I/ii 77 1't 4 p vvy-tr • j G� Q oaf Is s Voi a'iQYr'► , 1 s -4 svo [ ",e- :: r- ' _ i „,/.. , I I° r2819‘9° bicAci4eid a. () So, / /cJii 0 -.6 '` L,.. 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