HomeMy WebLinkAboutSWG2024-00006 - SWG As-Built - 3/11/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY P a =LIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2024-00006 Parcel# 42018-14-00000 FF6 47
Applicant Name Heidi & Forrest Bailey Subdivision (Name/Div/Block/ . RFC 73202,
Applicant Address 7271 W. Shelton -Matlock Rd. F/VFO
City, State, Zip Shelton, WA 98584 Installer Name T.J. Goos
Site Address 7271 W. Shelton -Matlock Rd. Designer Name Dale L.Tahja
INSTALLATION CHECKLIST
t Full System Installation ❑Tank(s)Only 0 Drainfield Only ❑Repair 0 Other
System Type Gravity Trench_ Pretreatment Type
>5 ft. from foundation? - .d a -- 0 N/A Ill YES ❑ NO
>50 ft. from wells? - - z •- 0 .10
T Jar 21 2024
Z >50 ft. from surface water? - - 0 EN El
1- By
Cleanout between building and tank? - ---- - 0 MI
By A !-
V Tank baffles present? - - ❑ ® ❑
a24"access risers over each compartment?- - El II
`W Effluent filter installed?- - II II ❑ 0
Septic tank capacity(working) 1.250 gal Manufacturer Hagerman
C3 D-box water level and speed levelers used? - - ❑ N/A ® YES ❑ NO
DO Manifold/D-box accessible from surface?- - 0 ® 0
u.
GQ Check valves installed? - - ill 0
2 Transport Line Size 4 inch Schedule/Class 3034
Bedrooms installed (check one) ❑ 2 ®3 ❑4 ❑5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - 0 N/A III YES 0 NO
CI >100 ft.from wells?- - 0 ® 0
it! >100 ft.from surface water? - - 0 IN 0
ti >10 ft.from potable water lines?- - ❑ ® 0
z > 5 ft.from property tines and easements?- - 0 11 0
d > 30 ft.from downgradient curtain/foundation drains? - - II 0 0
Drainfield level and observation ports present - - ❑ ® 0
® Graveless chambers or 0 Clean gravel used? (check one)
Proper cover installed over drainfield?- - 0 ® 0
Pump tank setbacks consistent with septic tank?- - ® NIA ❑ YES 0 NO
Y Pump tank capacity(flood) gal Manufacturer
Q24"access riser(s)and accessible from surface?- - 0 0 0
aAlarm or Control Panel Installed? - •- 0 0 ❑
Control Panel equipped with Timer/ETM/Counter-- - 0 0 0
a Pump installed in 0 Bucket or V ', ... 0
EPump Make/Model 1 1 2Q�4 H Floats or ❑ Transducer
a Tank draw down in/ Purt'tp cap •t pt��1EN�A��EP`gpm Squirt Height ft
Pump on time ,sOPii Hoff 1 %V(d Daily flow set at gpd ,
Updated 8/21/2018
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Mason County OSS Installation Report pg.2 Parcel# \W\-,.- --)
ABANDONMENT RECORD
Were existing septic components ab�done� as of iwl� ----- II YES 0 NO
�
if yes, please describe: , \c_ h1� 4 C 4 �
Were all components pumped alt and properly abandoned per WAC246-272A-0300? -------- ® YES 0 NO
RECORD DRAWING
Thw la a permanent nent record and must be accurate and descriptive enough to re4ocass in to need of maintenance activities and fute development 'typical Record
Drawings contalm Draintleld d manifold orlsidadon&layout.Septdp+mp tank krrsuon,North arrow,reserve dralileid,existing and proposed beadirps,beattot of wags,waterlines,
wed,absan ailon ports,deerrouts,and other mini aoos amass points. Inc mpiete Record Drawings may seats additional delays in final Instigation approve'and related permits.
PPROVE
MAR 1 1 2024
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MASON COUNTY ENVIRONMENTAL HEALTH
AJaw
• 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
end 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 accu te. form and attached Record Drawing is accurate.
.77
OcA 47,
01
Signature ofThstaller �i �f
t-, ( v S — .0., P� le
Printed Name of Signee ,, '�c"• •.1
tl'
MASON COUNTY PUBLIC HEALTH 4/ - <`e.
i >` +
The undersigned approves this installation Report and 51 tk)214 .�. 1
Record Drawing on behalf of Mason County Public O DALE L. TAHJA +�
', LICENSED DESIHeattl -GNER �t
'LI)/(i"-Vi //7/..2 i7. mh.lborory. "i7r.,M.57,-.0.. .0.0.01.......ca.
Si attire vironmental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE UPde°"d e12112o1e
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