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HomeMy WebLinkAboutSWG2023-00393 - SWG As-Built - 1/29/2024 DocuSign Envelope ID: D8E2E243-AF0A-46A9-9124-D85A733BBE59 r Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2023-00393 Parcel # 22005-51-00080 Applicant Name Ronald H Belisle Subdivision (Name/Div/Block/Lot) Applicant Address j200 E Fillips Lake Loop Rd Phillips Lake Div, 2 Tr 80 City, State, Zip Shelton Wa 98584 Installer Name Jamie Workman i Site Address 907 E Phillips Lake Loop Rd Designer Name Micah Halverson INSTALLATION CHECKLIST J Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair ❑ Other System Type ATU to Pressure Trenchs Pretreatment Type NuWater BNR-500 >5 ft. from foundation? - - ❑ N/A ❑ YES ❑ NO >50 ft. from wells? g_ _ _)E11.144- ❑ El ❑ • >50 ft. from surface water? - -4 - - -� -- - ❑ x❑ ❑ z -20-24 11',f-FQ- Cleanout between building and tank? - - Li i- - x❑ ❑ ❑ ✓ Tank baffles present? - By _--_� CI El El a24" access risers over each compartmen 7- - - - ------- J- - ❑ El W Effluent filter installed?- - x❑ ❑ ❑ N Septic tank size 500+ NiiwatPr gal Manufacturer Sound Placement 0 D-box water level and speed levelers used? - - EN/A ❑ YES ❑ NO DJ O Manifold/D-box accessible from surface?- - ❑ x❑ ❑ 032 Check valves installed? - - x❑ ❑ ❑ OQ 2 Transport Line Size 2" Schedule/Class 40 Bedrooms installed (check one) ❑ 2 ❑ 3 x❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft. from foundation? - - - ❑x N/A ❑ YES ❑ NO C) >100 ft. from wells? - -,-• -A t� rj x❑ ❑ W >100 ft. from surface water? ■ x❑ ❑ E. >10 ft. from potable water lines?- - -�-E� -1-O-40k ] ❑ ❑ Q > 5 ft. from property lines and easements?- '')NCaUNT-yE ❑ El > 30 ft. from downgradient curtain/foundation drains? - - - - -JB - HEALTH ❑ ❑ CD Drainfield level and observation ports present - - ❑ ® ❑ ❑ Graveless chambers or ® Clean gravel used? (check one) Proper cover installed over drainfield?- - ❑ x❑ ❑ Pump tank setbacks consistant with septic tank? - - ❑ N/A Q YES ❑ NO • Pump tank size 1223 gal Manufacturer Sound Placement < 24" access riser(s)and accessible from surface?- - ❑ E ❑ H- a Alarm or Control Panel Installed? - - ❑ El 2 Control Panel equipped with Timer/ ETM /Counter- - ❑ ® ❑ D a Pump installed in ® Bucket or ❑ On Block or ❑ Other a'• Pump Make/Model Liberty 280 0 Floats or ❑ Transducer a Tank draw down 2 in/min Pump capacity 45 gpm Squirt Height 4 ft Pump on time 1 min Pump off time 3 hrs Daily flow set at 360 gpd Updated 8/21/2018 .., DocuSign Envelope ID:D8E2E243-AF0A-46A9-9124-D85A733BBE59 i Mason County OSS Installation Report pg. 2 Parcel# 22005-51-00080 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - ❑ YES X❑ NO If yes, please describe: Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ YES ❑ NO RECORD DRAWING This is a permanent record and must be accurate and descriptive enough to relocate In the need 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. " +.( I(,,,, pr-e%k^4wt Cd4, ti AP-- iS •, l Sys�c.►� iS wr.-c _ PpRp202 �4F �v, EB2° � , ,,ONcoUNr �NViRO MENr Jew k„,„ „,,,,,,._ 0 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 frwg,g4Atloched Record Drawing is accurate. form and attached Record Drawing is accurate. 9/26/2024 -Ztvrnrj.sravxr+l.t.. .� Signature of Installer Date 1 i- lI .12miP Workman 2 v. Printed Name of Signee l ell MASON COUNTY PUBLIC HEALTH 1 i y'tj 11 The undersigned approves this Installation Report and �,�I� Record Drin ing on behalf of Mason County Public 0 WIN' 1 MINIM DESIGNER IHealt . . b1 1 itvi _Th .-)_�i_y EXPIRES:owe/ _j Signs re .f.,' onmental Health Specialist Date (stamp, signature and date) • IS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8/2t/20t8 0 - o 0 c ("Da) F3* 30 -t m CO 7 ,Cr} (<D ila N N 901 T al •Q CD 3 z N 3 _ N (bill a' r O Vm • N_ D : ry (D lb ( -r (D (1 � r _Q III C ( n, -, vh O O (b (C U1 N Tv 3 N m O N a El- 3 n)-a A ( (D S < n it• �_ d — Ci1 • S '"� El_ N-r 3 N -- -n \ / _ N D cp CD ill (D N N Q 73 QCO \ / / D • N o coo 3m -3 a t o �, / / 0 T (.7. i Q I ► 0 3 E. ID 0 O mNC- / \ A .73 F:, „7. ik x. 5 -K:, =,T.,, cip 1 i ,,,,,:,, ../.„.. -7 1 N 3 p \ • co �' / e. ' ,. I \ • AX x k D. \ / a $ \ / _ I, Iv N / r r- • m 0 � �01`0 — (n • o q 1 FT; 1 o •1 $ r il l,`t%411 • -8 • 1 us foky,NS e, <— . e/ 11 i Moi let ` T Zl 1 u I�� • R .. IM Mb • k' l 1 1 (II t d f9 , l� 4cf4to ` r e </‘ 4, : , s w / ib S/ qh • CD sovmcn � CA) N.) -• `\ // ``` (n071 � 13 (� Z (nA JO '� 0 "E' -- CCCO W �� O`�` (D (D (CD n < (n ••= \ 0 p m .A rn co �CD Reserve ► © .\ 0 _ci 0 (5D (D O D Cn (D (/) A'o, R m , c> > vcn 99, 00 50co L_________________ 0 Reserve P s n- o w 10 54 1--------------______J .\ o 0 ,\\a 6 (D o so / 0 C M.Halverson Design LLC Applicant/Owner. Ronald H. Belisle Site Into BELISLE FAMILY LLC SHEET NUMBER PO Box 1519 Shelton Wa 98584 Mailing: 1200 E Phillips Lake Loop Rd 907 E PHILLIPS LAKE LOOP RDII Shelton Wa 98584 HalversondesignlIc@outlook.com Parcel#22005-51-00080 REVISION N:1