HomeMy WebLinkAboutSWG2021-00530 - SWG As-Built - 3/11/2024 t, I�
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Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATION
Permit Number SWG zazr-voc 3a Parcel# ol ot7�
Applicant Name PAN,D Ce,cc tit-t Subdivision (Name/Div/BlocklLot) Fe (k,:
Applicant Address tt,t E c.iziy LO s� `'
City, State,Zip S1.�1(.=", r 1g jTc
Installer Name sp F�-w �
f C0 `,4'/
Site Address 1)43 E vrt.,' 1)✓ Designer Name (T Lku` ('��� k/ 2F0
INSTALLATION CHECKLIST
Full System Installation 0 Tank(s)Only 0 Drainfield Only 0 Repair 0 Other
System Type 'Re.sSIA- c.. um ei4.5 i4ef Pretreatment Type
>5 ft.from foundation? - - ❑N/A DYES 0 NO
>50 ft.from wells? - - 0
D 0
Z >50 ft.from surface water? - El �, El
Cleanout between building and tank? - - 0 0
V Tank baffles present? - -
0
Q, 0
d 24"access risers over each compartment?- - El E111 l filter installed?- 0
r/ 0
Septic tank capacity(working) ,2..” gal Manufacturer JI+( ,.,L�-jJ
ii a D-box water level and speed levelers used? - dwA ❑YES 0 NO
OLL Manifold/D-box accessible from surface?- - 0 ,-,/ 0
CQ Check valves installed? - - 0
L7r,/ 0
2 Transport Line Size 1.5- Schedule/Class S4J-•. t-t 0 Dr
Bedrooms installed (check one) 0 2 Cfc❑4 0 5 ❑6 ❑Commercial/Other
>10 ft.from foundation?- N/A �
- ❑ ErES ❑ NO
0 >100 ft from wells?- ❑ 0
W >100 ft from surface water? 0 ❑. 0
li >10 ft.from potable water lines?-
- ❑ Q. ❑
qZ >5 ft.from property lines and easements?-
0 >30 ft.from downgradient curtain/foundation drains?- - ❑ 0
Dra' field level and observation ports present - 0 O El
ElGraveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - 0 ❑ 0
Pump tank setbacks consistent with septic tank?- - ❑ N/A Er-YES ❑ NO
ZPump tank capacity(flood) 1)41, gal Manufacturer 4-6..>+G d�
Q 24"access riser(s)and accessible from surface?- - ❑ 12K 0
I0.- Alarm or Control Panel Installed? -
? Control Panel equipped with Timer/ETM/Counter- - 0 � 0
d Pump installed in 'Bcket or El On Block or El Other
2 Pump Make/Model L.y.v 1;4t,co floats or 0 Transducer
a. Tank draw down in/min Pump
P capacity P crtY gpm Squirt Height ft
Pump on time Pump off time Daily flow set at qpd
updated 8R12018
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Mason County OSS Installation Report pg.2 Parcel# Z o7.--
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - „/
If yes, please describe: YES LJ
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: Drain%Id&manfold onentat;on&layout,Septic/pump lank location,North arrow,reserve drainfeld,existing and proposed Sof'dogs,location of wells,waterlines,
wells,observation ports,cleanouts,and other maintenance access points. Incomplete Record Drawings may create ad6tional delays in foal imnlallabn approval and related perrrats•
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Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that I installed the system in accordance with l 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
l further certify that all information contained on this
I further certify that all information contained on this
form and attache ecord Drawing is accurate.
form and attached Record wing is accurate.
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7(eofThstoller Date t;�' ''b
111___ in• of•t
Printed Name of Signee { t��? '1••
MASON COUNTY PUBLIC HEALTH 3caci:y.i r:::er '•
The undersigned approves this Installation Report and v.• lr
er�r.,a
Record Drawing on behalf of Mason County Public
Hea .
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di,r, _,___(1--- -y
Sigma re virDnmenta!Health Specialist •Date •
(stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE updated&212a18
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