HomeMy WebLinkAboutSWG2023-00396 - SWG As-Built - 3/19/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATION
Permit Number SWG 2023-00396 Parcel# 32021-56-05015
Applicant Name Saul Cortez Subdivision (Name/Div/Block/Lot)
Applicant Address 24221 105th PI W SHORECREST TERRACE 3RD ADD BILK 5 LOT: 15
City, State,Zip Edmonds,WA 98020 Installer Name owner install
Site Address 501 E Wood Ln,Shelton,WA Designer Name Arrow Septic Designs
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only ❑Drainfeld Only ❑ Repair ❑Other
System Type pressure bed Pretreatme Type
>5ft.from foundation? --------------------------- ❑'wA ®YES ❑ No
>50ft.from wells? ------- ---------------------- Q' ® ❑
Y >50ft.from surface wateR ----------- - --- Z�1il24- a-.Y1 ® Elz F�
H Cleanout between building and tank? ------ ----- `/./ ❑ ® ❑
U Tank baffles present? --- --------------- -t'/- - ® ❑
t- 24'access risers over each compartment?--- ------------- ❑ ® El
Q.
W Effluent filter installed?--------------------------- ❑ ❑
in
Septic tank capacity(working) 1200 gal Manufacturer Hagerman
o D-box water level and speed levelers used? ----- ❑ wa ❑YES m No
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00 Manffald/0.box accessible from surface?--- --- -p ��l/ ❑
LL
GQCheck valves installed? -------------- --- ❑
E Transport Line Size 2 inch ule/ 4
Bedrooms installed(check one) ❑ 2 ®3 ❑4 l56 �
,V B Co , I/Cther
110ft.from foundation?--------------------- - dMEjy} A ® YES ❑ NO
0 1100 ft.from wells?-- ------------------------ le- 0 HFHc rN 8 ❑
W >100 ft.from surface water?------------------------ ❑ ❑
LL >10ft.from potable water lines?---------------------- ❑ ® ❑
Q >5ft.from property lines and easements?---------------- ❑ ® ❑
K >30 ft,from downgradient curtain/foundation drains?---------- ❑ I� ❑
in Drainfield level and observation ports present -- ------------
-I Graveless chambers or E Clean gravel used? (check one)
Proper cover installed over drain8eld?------------------- ❑ ® ❑
Pump tank setbacks consistent with septic tank?------------- ❑ WA YES ❑ NO
Y Pump tank capacity(flood) 1.000 gal Manufacturer Hagerman
z
Q 24'access risers)and accessible from surface?--0.--- El
0
Alarm or Control Panel Installed?--------- ----------- ❑ ❑
E Control Panel equipped with Timer/ETM/Counter----------- ❑ � ❑
7
a Pump installed in ❑ Bucket or ® On Bkxdk or ❑ other
Il Pump Make/Model Liberty 250 Floats or ❑Transducer
a
Tank draw down 1.5 in/min Pump capacity 28.5 gpm Squirt Height 4 ft
Pump on time 3 minutes Pump ofttime 6 hours Daily flow set at 342 gpd
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Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
Were existing septic components abandoned as part of this protect? -- -- -- -- - - -" -
YES NO
If yes, please describe: YES NO
Were all components pumped out and properly abandoned per WAC246-272A-0300? --- - - --- ❑
RECORD DRAWING
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1*0 Eft7prid 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 clearenvapproved 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
A and ttached Record Drawing is accurate. form and attached Record Drawing is accurate.
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Signature of installer Date
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Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
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The undersigned approves this installation Report and .-> PAULA JOY JOHNSON
Record Drawing on behalf of Mason County Public Tr E f �
Sig to Environmental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY VVEB SITE avdaaa erzirsme
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C\° e Assn lLT
P-a.n-�Jp21-$b-05015
E WOOD LN.
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NON$4 3 AudiO-Vianal Alarm
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ZZ' 3 Cleanout
1200 Gallon Septic Tank
2-Compartment with
Effluent Filter
' O4 1000 Gallon Pump Chamber
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APPRO VIEMAR 19 2024
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