HomeMy WebLinkAboutSWG2024-00012 - SWG As-Built - 5/3/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2024-00012 Parcel # 32232-55-00021
Applicant Name Benito Jimenez Subdivision (Name/Div/Block/Lot) lep 17
Applicant Address 21 E.Warren Dr. Rl� 610
City, State, Zip Union, WA 98592 Installer Name T.J. Goos F
Site Address 21 E.Warren Dr., Unio ,WA Designer Name Dale L.Tahia
INSTALLATION CHECKLIST
❑ Full System Installation OTank(s)Only ❑Drainfield Only E Repair ❑Other
System Type Gravity Trenches Pretreatment Type N/A
>5 ft.from foundation? -- - - - - - - - - -------- - --- ---- ❑NIA EYES ❑ No
>50 ft.from wells? - ----- - - - - - -- - ---- -------- -.. ❑ �7� ❑
_ >50 ft.from surface water? -- - - -- -- -- - - -- - - - -- - ❑
F Cleanout between building and tank? - -- --------- --- -UURR��II((l�flf ❑ ❑
C.1 Tank baffles present? -- ---- - -- -- - - - - --- - -- -- - - ❑ ❑
a24"access risers over each compartme t?--- ----------- - - ❑ E ❑
HEffluent filler installed?------- - - - - -------------J3-Y.10--------t ❑
Septic tank capacity(working) 1.200 at Manufacturer Premier
0 D-box water level and speed levelers un ed7 ❑ NIA E YES ❑ NO
Ou Manifold/D-box accessible from surface. -- --------- - - - - - - ❑ E ❑
ro= Check valves installed? -- - - - - -- - --- -- - -- - - ---- -- E ❑ ❑
GQ
i Transport Line Size 4 inch Schedule/Class 3034
Bedrooms installed (check one) (® ❑3 04 ❑5 ❑6 ❑Commercial/Other
>10 ft,from foundation?-- - - -- -- - - -- - - - - - - -- - -- -- ❑ NIA EYES ONO
C >100 ft.from wells?- - - - - - - - - - - - - - -- --- ❑ E ❑
J >100 ft.from surface water?--- --- --- --- - ❑ E ❑
W
M >10 ft.from potable water lines?- --- - --- - - - - - - ------ - ❑ E ❑
Q= > 5 ft.from property lines and easemen ?-- - -- --- --- - - - -- ❑ E ❑
K > 30 ft.from downgradient curtainlfoun ation drains?- - - - -- - -- - ❑ E ❑
Dminfield level and observation ports p sent -- - - - - - - - - -- -- ❑ E ❑
E Graveless chambers or ❑ Clear gravel used? (check one)
Proper cover installed over drainfield?- ---- - ------ - -- - -- ❑ E ❑
Pump tank setbacks consistent with sep tic tank?------- ---- - - ❑ NIA ❑ YES ❑ No
Y Pump tank capacity(flood) al Manufacturer
24"access riser(s)and accessible fromsurface?-- - - -- - -- - - -- ❑ ❑ ❑
SAlarm or Control Panel Installed? ------- ---- -- ------- - ❑ ❑ ❑
Control Panel equipped with Tmer/E7 /Counter- - - - - - - -- - - ❑ ❑ ❑
6. Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
a Pump Make/Model ❑ Floats or ❑ Transducer
g
a
Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at cpd
uoa.ree enirzo�a
Mason County OSS Installation Report pg. 2
PtvcdS �,d¢�-
AB NEW
_ YES ❑N
Were existing Septic m M"ft"mooned e6 tOT,
it yea, Osseo dM:".. YES Q
Were an camDorrentn pumped cid arilvwm ahead°n°d perV't nv«o3W'+-------'
RECORD DRAWING
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® Record Drawing Attached
CERFNICA11011 OF; INSTALLATION
DESIGNERi ENGINEER
INSTALLER I certify that the system has been installed in 11
I der*that f installed the system In accedence with ce
the Sepik design Stamped"APPROVED'by Mason dance wtth the public
design stamped"APPROVED"by
County Public Health and that any deviations shown Mason County Public Health end thaterty ved y both
here have been clearedlapproved by both the designer shown hem have been myself hero'Mason County red'Wm
Health and It all
and Mason County Public Health and meetjafl 5Ys0e State and Mason County Codes
and Mason County Codes.
1 further cattily that ag information contained on this
I form
an cart c that all information OrNwi contained on this form and attached Record Drawing is accurate-
fo�rm and�ettad+e�d,Re�cord D
Signature Inslaaer 1e
Prkned Name ofSlpnee
MASON COUNTY PUBLIC HEALTH 1`00214
' �i
The undersigned approvesapprovesthis Install and DALE
L.TA TAHIA _
Reconl Ora,mg on behalf of Mason C Public .0 n bESicWER
Haatth: - -
ZEXF"'t-�:
Signature ela"orrmernel ph Specialist Dora (stemµ ka9ture and data)
THIS FORM MAY BE SCANNEONJO AVM ABLE FOR pMUo NEW ON THE Mg60N COVNrY WEa 6ITE °��°
1 � Warner Or.
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- -LICENN D DESIGNER
;APPROVED
WAY 03 2024
MASON COUN1-YE§ORONMENTAI HE2LiP
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