HomeMy WebLinkAboutSWG2021-00299 - SWG As-Built - 2/14/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION )
Permit Number SWG 2021 -- 9 Zgc1 Parcel # 21 q 1 1 U(v to
Applicant Name { chOk- Subdivision (Name/Div/Block/Lot)
Applicant Address grit U66,('.J14 ,ckyt
City, State, Zip JSK m, ,,,s qP6-Ft4 Installer Name mv, 6rAk,r
Site Address 2.k..t,t <S £ LEA C\('j,1 i11, Designer Name e&VYt HQV -r r
INSTALLATION CHECKLIST
g Full System Installation rfank(s)Only 0 Drainfield Only 0 Repair ❑Other
System Type 9(A,v A Pretreatment Type
>5 ft.from foundation? - - 0 N/A ®YES ❑ NO
>50 ft. from wells? - 0 71 0
Z >50 ft.from surface water? - - 0 ® - 0
H Cleanout between building and tank? - - 0 EA
V Tank baffles present? - `e - 0 ® 0
d24"access risers over each compartment?- - El 0
W Effluent filter installed?- j,L�rf�S'`� ❑ U ❑
C/
Septic tank capacity(working) 15j 4C) gal Manufacturer Rrs
9 D-box water level and speed levelers used? - - ❑ N/A YES ❑ NO
0 O Manifold/D-box accessible from surface?- - ❑ a El
u.
CQ Check valves installed? - - ❑ ❑
►' tJ
2 Transport Line Size 1 Schedule/Class 3 0-3 q
Bedrooms installed (check one) ❑ 23 30,4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A ® YES ❑ NO
>100 ft. from wells?- - 0 1St ❑
W >100 ft. from surface water? - - El IN
LT. >10 ft. from potable water lines?- - ❑ ® ❑
Z > 5 ft.from property lines and easements?- - ❑ ® 0
PE > 30 ft.from downgradient curtain/foundation drains? - - ❑ ❑
CI
Drainfield level and observation ports present - - ❑ ® 0
2 Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - 0 ® 0
Pump tank setbacks consistent with septic tank? - - 0 N/A 2 YES 0 NO
,,---1 £ 2‘-I-o •,`i
Pump tank capacity (flood) 12.5 0 gal Manufacturer }}4
< 24"access riser(s) and accessible from surface?- - 0 [Sit 0
f-
a Alarm or Control Panel Installed? - - ElEl
2 Control Panel equipped with Timer/ ETM/Counter- - ❑ 2 0
m
CI- Pump installed in IS/ Bucket or ❑ On Block or 0 Other
a Pump Make/Model
�2c io c IS3 El Floats or 0 Transducern
0. Tank draw down /� �- in/min Pump capacity gpm Squirt Height N�- ft
Pump on time Pump off time' 'VA' Daily flow set at . !r gpd
Updated 8r21r2018
Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES ® NO
If yes, please describe: Oa. SO-ten (rrt+/Trt1'Ct)1/4 fa- USG On C4CCC,C 1 h4U1R—
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ YES NO
RECORD DRAWING
This is a permanent record and must he accurate and descriptive enough to re-locate In the need of maintenance activities and future development. Typical Record
Drawings contain: Drainfield&manifold orientation&layout,Septiclpump 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.
❑ 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 wing is accurate.
h'cIVfrH
Si ature of Installer Date p
Printed Name of Signee •
1 /
MASON COUNTY PUBLIC HEALTH 4 �<': •�
c : 510W12
The approves undersigned this Installation Report and �'`• ADAM J.HUNTEfa
gp ,'
Record Drawing on behalf of Mason County Public
Health: •
ALA. (Z'i
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 8/21/2018
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