HomeMy WebLinkAboutSWG2022-00478 - SWG As-Built - 3/4/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2022-00478 Parcel# 221337800020
Applicant Name Elliott Mack&Linda Subdivision (Name/Div/Block/Lot)
Applicant Address 130 E Strong Road
City, State,Zip Shelton Wa.98584 Installer Name Shumaker Construction
Site Address 128 E Strong Road Shelton Designer Name Pioneer Digging Inc
INSTALLATION CHECKLIST
El Full System Installation 0 Tank(s)Only ❑ Drainfield Only ❑Repair 0 Other
System Type gravity Pretreatment Type
>5 ft.from foundation? - •- ❑N/A 1111 YES ❑ NO
>50 ft.from wells? - - 0 • ElY >50 ft.from surface water? - - ❑ ® ❑
Z
< Cleanout between building and tank? - - 0 a ❑
✓ Tank baffles present? - - El ■ ❑
a24"access risers over each compartment?- - 0 • El
tu N Effluent filter installed?- - El • ❑
Septic tank capacity(working) 1250 gal Manufacturer Hagermen's
9 D-box water level and speed levelers used? - - 0 N/A li YES ❑ NO
gO Manifold/D-box accessible from surface?- - ❑ • ❑
0 Q Check valves Installed? - - • El
2 Transport Line Size 4" Schedule/Class 3034
Bedrooms installed (check one) 0 2 ®3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft.from foundation?- ❑ N/A III YES ❑ NO
CI >100 ft.from wells?- . 0 ■ 0
W >100 ft.from surface water? - - ❑ ill0
Z >10 ft.from potable water tines?- . ❑ U El
z >5 ft.from property lines and easements?- - ❑ MI El
ale >30 ft.from downgradient curtain/foundation drains?- - ❑ ® ❑
o
Drainfield level and observation ports present - - ❑ ® ❑
0 Graveless chambers or lig Clean gravel used? (check one)
Proper cover installed over drainfield?- - 0 ® ❑
Pump tank setbacks consistent with septic tank?- - ❑ N/A 0 YES ❑ NO
ZPump tank capacity(flood) qal Manufacturer
H24"access riser(s)and accessible from surface?- - El El El
a Alarm or Control Panel Installed? - - ❑ ❑ ❑
Control Panel equipped with Timer/ETM/Counter- - ❑ ❑ ❑
d Pump installed in 0 Bucket or 0 On Block or ❑ Other
n"• Pump Make/Model 0 Floats or ❑Transducer
d Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at qpd
Updated 82112018
Mason County OSS Installation Report pg. 2 Parcel# 221337800020
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES 0 NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? • - 0 YES pi NO
RECORD DRAWING
Tide Is a permanent record end must be accurate end descriptive enough to re-locate In the need of maintenance activitles and future development. Typical Record
Drawings contain: DraiMkld&manifold orientation&layout,Septic/pump tank location,North arrow,reserve drainfield,existing and proposed buiIdlrgs,location of wells,waterlines,
wells,observetkur ports.cleanouts,and other maintenance access points. Incomplete Record Drawings may create additional dolays In final installation approval and related permits.
❑ 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
1 further certify that all information contained on this I further certify that all information contained on this
form and attach R cord Drawing Is accurate. form and attached Record Drawing is accurate.
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Signature of Installer dilate t
4t.4s'ait
Printed Name of Signee t
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MASON COUNTY PUBLIC HEALTH •
The undersigned approves this Installation Report and LE ' ROBE Hpgy65E =�
Record Drawing on behalf of Mason County Public ! �•'.• .:e,_ ,
Health: EXPIRES
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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 8n1/418
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CUSTOMER LINDA ELLIOT TEST HOLES PER SWG2006-00995
PIONEER DIGGING, INC. PARCEL# 22133-78-00020
SEPTIC DESIGNS ADDRESS: XXX E STRONG RD
3083 E MASON BENSON R.D. GRAPEVIEW,WA 98546 DESIGNER: ROBERT H.PAYSSE u7SORSURVEY SNOTT SURVEY. EFERENCESINC GDSE.DAE6GNNTENT OU FopsOO€D
OFFICE 3604261803 FAX 360 427 2353 DEPUPARTMENT/AGENCY
ONLY. PROPOSED DEVELOPMENT REP MAYL BE SUBJECT R TED TO
SHEET: ASBUILT SCALE I"=30' SEPTIC ES ONLY
REVIEW PROPOSED
OMEN NOT RESPONSIBLE FOR SETBACKS UNTO ATEOTO
SEPTIC COMPONENTS.