HomeMy WebLinkAboutSWG2021-00275 - SWG As-Built - 5/3/2024 Mason County OSS Installation Report pg. t MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATIONc�
Permit Number Swe n- ( —c 1 Parcel# 2- (�' �Z� (�� )
Applicant Name I_.� CA .-.�- c4k;1 Subdivislon (Name/Div/Block/Loq
Applicant Address 14A-P P
City, State,Zip L�'lti Installer Name
Site Address .1 Designer Name /a-,! ;_r_-- ;r
INSTALLATION CHECKLIST
'.®Full System Installation ❑Tank;s)Only ❑Grainfield Only ❑Rspar ❑Other
Syslam Type OSCA- '- Preboatment Typo NiA&, uz giUK.2)0
>5 it,from foundu9on? --- - - ----- �� �p l� f� -- -- ❑WA SIVES NO
>50 n.hum weirs? -- - - -- - - - -- t5-�J f5 9�9-15}IFI IF ❑
2 >50 R.hum senate water? - - - --- - - - - - ❑ in ❑
F .Cleenout belwoen building and tank? - AeQ 2/-4 ZQ21 ❑ ® ❑
Tank bafllos present? . --- - - - -- - - - - - pt�-- - --- ❑ W ❑
24"accuse rivers over each aompatkn 189- - }� - ❑ ® ❑
W Effluent filter installed?- - - - ----- - - - - -- -- - - - - -- - - - ® ❑ ❑
W
Sopkc tank capacity(vrorking) gN �5717 aai Manufacturer l /a
9 D-box water level and speed laveluts used? -- - -------- - - - - � NA ❑YES ❑ NO
;??0 ManrfeldlD-box accessible from ourface?- - -- --- -- ----- - - ❑ ❑
26L Check volves instagad? " - .- - - - - -- --- - --- - - --- -- _ _ _ . ❑ ❑ ❑
Tronsport Llno Size ilk SchedukuCfass �l 0
Sodroams Installed(Check Cho) ❑2 ❑'3 ❑4 ❑5 ❑S ❑CommmclakDgler
>10n.ham foundatlon?-------------- ----------- - ❑ WA 'YES ❑ +Kr
>tooft,from wells?-- - -- ---------- -------------- .❑-
E >100 g. from sulfate water?------------------------ ❑ ❑
❑ 10 ❑
E >10 ft.(Tom potable water knee?---------------------- ❑ .B ❑
>5it.som properly lines and oasemanls?--- - - - ------- - - - ❑ .❑ ❑
qR >30 n.from dawn0radionl curtasofoundation st airs?---- -- -- - - ❑ .[� ❑
braln5uld level and observation ports present -- -- -- ------- • ❑ ❑
❑ ()level."chumbete or ❑ Clean graval mod? (cheek Cho)
Proper cover Installed oval dralhflotd?- -- - -- --- - -- ------ - ❑ !g ❑
•Pump lank setbacks conslalant with septic tank?----------- -- ❑ NIA EYES NO
Nd pump tankcapacily(Iload) lr>�&b gal Mahufaclurar -1 " ' T
Q24"access dsar(s)and accessible from surface?-- - - ------ ---
~ - ----- - - - -- R
fl Alofm ar Ganhal Panel Installed? ❑ ya
2 Control Pool equipped eom Timor I rTM 1 Counter-- - - ---- - - - ❑ i❑ ❑
a Pwrp Installed in ❑ Bucket ar eon 81ack or El Other
IL Pump MakalModal r , �Crn r 12MICals or ❑ Transducer
a Tank draw down Inimin Purlp copocily gpm Squirl Nnlght rl
Pump an time _ Pump on kme_ Daily flow sot of gpd
Vp4AJ Y.liN lq
Mason County OSS Installation Report pg. 2
ABANDONMENT RECORD
Were existing Spore Components abandoned as part of this project? - ^-- - ^'` " "" • ❑ YES ❑ NO
If yes,please dawlibe:
Were all oomponenta pumped out and properly abandoned per WA0240-272A-010M - -"" ❑YES No
RECORD DRAWING
This le a McWPrI MUM she loud Ya Quvf b aJ euaWH.rnauek 1a"W.I.In The m4J a 4raapnalaa axleiPtl eM NNn ervtbiaanl. Tiyka Pao4•a
a14'Mfai WYJYr:aaaraN a IM,rnJoamhlka a a14l(EaprJryuyrankeol4+.,Naar e.M W W a'a•I-14 AW-P�4JHop14J W gnP:, xyiul HwGE.waulllwc,
016h,vise wakaka!41M.4N AV lllar�9meoaa{C oWi.Imo"eau ThumWQaAb*^dl[IYIIBOd'Y.O.4 GI P(GJ i m i -iahl wl"Wil iaa NYiV Pssslt
❑ Rcamd Drawing Allauhud
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER(ENGINEER
t calory that I instaYad the system in accordance AM f cadily that the system has boon rhsfahad m accwN
the septic desl'gn stamped'APPROVEO'by Mason dance with fho septic dasfgn stamped'APPROVEO"by
County Public rfdalih and that any da oAttons sham Mason Counly Public Hoahh and file(say doVialtans
hors,have boson cluared/approVod by bath the dusignar stlowo hold have boon cruwad/approved by both
and Mason County Pubire Haahh and moat art State myself and Masan Ccunly ftbiic Neailh and mast aft
and Massa Chi Codes. Slate and Mason County Codes
f further codify that air Information contained an this Ifurther eorhfy that ao)ntwmadon contained an this
rwm and at(achad Record Draedhg'rs accurate, form and attached Record Deawing rs accurate.
��
Slgnstune al a] relief flat
Pnnrad Name or Signes 4/24/24
MASON COUNTY PURUC HEALTH *;
the undomigned approves this lnsfaitofian Raporl and �.'.4..
Record DJammg on behaff dT Mason County Public r�.r
!Iaaifh: `
y 1YIWi�'.'f�w\i�J
Stgnelula of Envimlonantel eadN Spechaasf Date (stamp, signafure and date)
THIS FORM h1AY BE SCNNNEOANDAVNLABLE FOR PUBLICVIEWON THE MASON COUNTY WEB SITE rrP°1�sn'r" '
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