HomeMy WebLinkAboutSWG2023-00530 - SWG As-Built - 2/14/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG a(jX?) - C.)0 3CO Parcel # 3-..'-mil -- 3`--k_ ap\3CO
Applicant Name 3-e irfir Lifc.Itc-ev, co 0 r Subdivision (Name/Div/Block/Lot)
Applicant Address 2.-7'7 a/I 0 N N w r /01 'NV
City, State, Zip /-/ocp,5Poft7- v.w. 9 5 'f6 Installer Name Ayed 4211 . J-yLc_
Site Address a-la-\b tJ VAS t-\vv f ti I.U\ 4 Designer Name ,;+ m , ' j fi-,5 C. -
INSTALLATION CHECKLIST
A-full System Installation ❑Tank(s)Only ❑ Drainfield Only 66 epair ❑Other
System Type F076 1 Le 55 5 ZAUO 6 T pretreatment Type OtNXA
>5 ft. from foundation? - - ❑ NIA .3YES ❑ NO
>50 ft from wells? - - ❑ iflk,, ❑
Z >50 ft. from surface water? - - El ❑
< Cleanout between building and tank? - C --
-
- 0
0 Tank baffles present? - 7t71--T_ _ _ _ - 0 Et 0
d24" access risers over each compartment?- _ 0 El
CA
Effluent filter installed?- SI
- ID
Septic tank size /2_56' gal Manufacturer , .4cE f i,i A''-le c;;)s
0 D-box water level and speed levelers used? - - ❑ N/A ❑YES ❑ NO
OO Manifold/D-box accessible from surface?- /LL.11---
-_ ❑ El
mZ Check valves installed? - - ❑ ❑ ❑
0<
2 Transport Line Size Schedule/Class
-
Bedrooms installed (check one) ❑ 2 p 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ NIA DYES ❑ NO
0 >100 ft. from wells?- - a ❑ ❑
W >100ft.fromsurfacewater? - _ El ❑
Z >10 ft. from potable water lines?- - ❑ El
>5 ft. from property lines and easements?- - an. ❑ ❑
ii > 30 ft. from downgradient curtain/foundation drains? ❑ ❑
o
Drainfield level and observation ports present - - 0 JET 0
❑ Graveless chambers or M Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ IA 0
Pump tank setbacks consistent with septic tank?- - 0 NIA AYES 0 NO
Y Pump tank size /Z S 0 gal Manufacturer A-/-6!'R /-iq.,j tf'-e e4 52(
Q24" access riser(s) and accessible from surface?- - 0 g 0
aAlarm or Control Panel Installed? - - ❑ 0
Control Panel equipped with Timer I ETM I Counter- - ❑ O 0
Il Pump installed in 0 Bucket orQn Block or ElOther
2 Pump Make/Model ,r k Floats Ori
1 Tank draw down in/min Pump capacity ((;U
R. qpm Squirt Heighf P Y�tia� I Pump on time / h-ii,i Pump off time 1--,44 Daily flow set at 1' pd
upda.d arrpe
i
Mason County OSS Installation Report pg. 2 Parcel# 32 3 3 / Z c/ O 0 ( ? 0
•
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - AYES NO
If yes, please describe: /'e, - 7 4�r T o!0 .f' .� t t eci f�//��1�-)-j Se,/S
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ES ❑ 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: Drainfieki&manifold orientation&layout,Septic/pump tank location,North arrow,reserve drainfield,existing and proposed buildings.location of welts,waterlines,
wells,observation ports,cleanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
S/9/Y1 4s Ves(c)
❑ 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 an att ch Record Drawing is accurate. form and attached Record Drawing is accurate.
1
".0..• al--- - ,-.
k .ram:
Sig are o Installer Date V `
—PiVebti ,P .1;-* Xyla---, ..,:;')//c •
".. ?r
Printed Name of Signee fv!•,,,, u.r.,,,*-? ..
MASON COUNTY PUBLIC HEALTH ' •s
The undersigned approves this Installation Report and s• 1 OU r 2 •;
L,�: ADAMJ.HUNTER •/
Record Drawing on behalf of Mason County Public ••11i':f'^i5i'5lipE;:i.', 1r•h••`
Health: ``u i.,:�.�Es u;:r2'
(\b-NyvirtilA
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 821/2018
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