HomeMy WebLinkAboutSWG2023-00527 - SWG As-Built - 3/5/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2023-00527 Parcel # 123315100119
Applicant Name Gaspar Antonio Subdivision (Name/Div/Block/Lot)
Applicant Address PO box 3131
City, State, Zip Belfair Wa 98528 Installer Name Shumaker Construction
Site Address Designer Name Allied Design
INSTALLATION CHECKLIST
0 Full System Installation ❑Tank(s)Only ❑ Drainfield Only NI Repair 0 Other
System Type bed new 15x40 bed Pretreatment Type
>5 ft.from foundation? - •- ❑ N/A .YES ❑ NO
>50 ft. from wells? - - 0 III 0
Z >50 ft. from surface water? - - 0 II
Cleanout between building and tank? - - ❑ ■ 0
V Tank baffles present? - - 0 . 0
d24"access risers over each compartment?- - 0 U 0
`W Effluent filter installed?- - ❑ 0 0
Septic tank capacity(working) 1200 gal Manufacturer existing
0 D-box water level and speed levelers used? - - El N/A 0 YES El NO
oO Manifold/D-box accessible from surface?- - 0 0 El
m— Check valves installed? - II 0
GQ -
2 Transport Line Size 4" Schedule/Class 3034 i
Bedrooms installed (check one) ❑ 2 0 3 ❑4 0 5 ❑6 ❑Commercial/Other
>10 ft.from foundation?- N/A ill YES ❑ NO
0 >l00 ft. from wells? _ WM . ❑
W >100 ft. from surface water? - - 0 0
Z >10 ft. from potable water lines?- -L 0 t}_'. - ® 0
> 5 ft. from property lines and easements?- - ❑ MI ❑
> 30 ft.from downgradient curtain/foundation drakiN------ -.fl ® ❑
ca
Drainfield level and observation ports present -
0 Graveless chambers or Clean gravel used? (check one) 0 0 IN
Proper cover installed over drainfield?- - 0 ■ ❑
Pump tank setbacks consistent with septic tank?- - ❑ N/A ❑ YES ❑ NO
4 Y Pump tank capacity(flood) gal Manufacturer
Z
< 24" access riser(s) and accessible from surface?- - ❑ 0 0
a. Alarm or Control Panel Installed? - - 0 0 ❑
2 Control Panel equipped with Timer/ETM/Counter 0 0 0
m
d Pump installed in 0 Bucket or ❑ On Block or 0 Other
a.
2 Pump Make/Model
❑ Floats or 0 Transducer
D. Tank draw down in/min Pumpcapacity aci P tY gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 8/21/2018
•
Mason County OSS Installation Report pg. 2 Parcel# 123315100119
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project?
- Q YES El NO
If yes, please describe:existing drainfied
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 need of maintenance activities and future development. Typical Record
Drawings contain' Drainfield&manifold orientation&layout,Septic/pump tank location,North arrow,reserve drainrield,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.
® 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
form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
Signature
A4��o1lf Installer Date t /t
Printed Name of Signee �i��l
i
Orw? 117
MASON COUNTY PUBLIC HEALTH / '7 L`
The undersigned approves this Installation Report and 5100333
ie THOMAS E.WEAVER'•.
Record Drawing on behalf of Mason County Public •, Ks b.f.) NER"'
Health: Ex•.�........Int25/ ...
—StS&Ci � ntr2s/ /2-4
Signature of Environment Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8121/2018
13
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