HomeMy WebLinkAboutSWG2023-00311 - SWG As-Built - 4/2/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2023-00311 Parcel # 42209-50-00163
Applicant Name Diane Simon Subdivision (Name/Div/Block/Lot)
Applicant Address P.O. Box 1622 Lake Cushman Div.7 Lot 163
City, State, Zip Aberdeen,WA 98520 Installer Name T.J. Goos I
Site Address 341 N. Duckabush Dr. E. Designer Name Dale L.Tahis
INSTALLATION CHECKLIST
® Fuli System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type Pressure Bed Pretreatment Type NuWater BNR -500
>5 ft.from foundation? - - - ----------ff�i
❑NU ®Wss ❑ NO
>50 ft. from wells? ---- - - --------- ❑ e El='- >50 ft.from surface water? ❑
2Z IN
Fa- - Cleanout between building and tank? - -----_ ----- ❑ . ❑
V Tank baffles present? -- -- - -- ---- -- -- - ❑ i ❑
d24"access risers over each compartment?--------------- - ❑ e ❑
W Effluent fifter installed?------- ------------------- - ❑ � ❑
Septic tank capacity(working) 1.250 gal Manufacturer Hagerman
0 D-box water level and speed levelers used? - ---------- - -- - ON/A ❑yes NO
00 Manifold/D-box accessible from surface?--------- -- - - - - - - ❑ ® ❑
a?Z,>Check valves installed? - -- -- -- ----------- - - - - - -- ❑ ® ❑
0Q
f-Transport Line Size 2 inch Schedule/Class Sch.40
Bedrooms installed(check one) E2 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>t OR from foundation?-------------------------- E] NIA ® Yes E] NO
0 >100 ft.from wells?----------------------------- ❑ ® ❑
W >100 ft.from surface water?----------------------- - ❑ ® ❑
LL >I0 ft.from potable water lines?- --- ----------------- - ❑ ff ❑
Q. - > 5 ft.from property lines and easements?- ---- -- --------- ❑ ® ❑
C: >30ft.from downgradienl artainfloundation drains?--------- - ® ❑ ❑
Drain field level and observation ports present -- -- - ❑ ® ❑
❑ Graveless chambers or E Clean gravel used? (check one)
Proper cover installed over drainfield?- --- - ------ -------- ❑ ® ❑
Pump tank setbacks consistent with septic tank?------------ - ❑ NIA ® ves ❑ NO
Y Pump tank capacity(flood) 1.000 at Manufacturer Hagerman
Q- 24"access riser(s)and accessible from surface?------------- ❑ . ❑
IL Alarm or Control Panel Installed? -- - -- -------------- - ❑ ® ❑
_ ? Control Panel equipped With Timer I ETM/Counter-----------
❑ ❑
g- Pump installed In ❑ Bucket or ® On Block or ❑ Other
(L Pump Make/Model Liberty 280 ❑ Floats or E Transducer
IL
Tank draw down 1 in/min Pump capacity 22 gpm Squirt Height 8 ft
Pump on flme 225 min Pump off time 5 him 57.75 min Daily flow set at 180 gpd
V�eNE M1r101B
Mason County OSS installation Report pg. 2 Parcel# `��- �C1b1C^
ABANDONMENT RECORD
Were misting septic components abandoned as part of this WIect7 -________ _____ ❑ YES * NO
It Yes, please describe:
Were all components pumped out and property abandoned per WAC246-272A-C W7 ' -'--''" rES
RECORD DRAWING
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Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNERI ENGINEER
I car*that I installed the system in a000nlence 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 dOdi na eppmved 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
1 further ce�y that all information contained on this I further certify that all Udonnation contained on this
form and attached Reoord Dlawf Is CO rats. form and attached Record Drawing is a=nate-
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Signature Inafbler •Defs
t � (� r �',P
Printed Name of Sign" h g�a�
=COUNTYPUBUCTY PUBLIC HEALTH d approves this Installation Report and5tW714
g on behalf of Mason County Public O _ DALE L.TA_H)ALICENSED DSIGNER
I nAMIO�CYV� ��I� EXFlronmehtel Health Specialist Date (stamp, signature and(1ata)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE upmeemrro+s
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