HomeMy WebLinkAboutSWG2023-00130 - SWG As-Built - 3/29/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number sWG2073 -(Jo I30 Parcel# ZOII
-
Applicam Name N�r.T n� K� Subdivision (Name/Div/Block/Lot)
Applicant Address .yyeJ�
City, State, Zip J_ Installer N_17� e S-OrJ 't't
Site Address A( /i E, — 'l cL �^.i�Sfg'rgrt"erTvame �i G�-- 17
(nL]"7� LATION CHECKLIST
ull System Installation - �ank(s)Only ❑ Drainflold Only ❑Repair ❑Other
System Type Pretreatment Type
>5 ft.from foundation? ---__ _ _ ___ ( ❑ NIA Y ❑ No
>50 ft. from wells? ------- - -- -_ -gL _ - ❑ ❑
2 >50 ft, from surface water? --- -- -- - - ❑ V
F Cleanout between building and tank? - __ _ _ _ _ _ _ _ _ _ _ _j- ❑ ❑
U Tank bafflespresent? - - - - - -- _ _ _ _ _ ______ ❑ /'-,
d 24"access risers over each compartment?�y' r- ❑ �-Ji„v / u❑
NEffluent filter installed?__ _ _ _ _ _ _ _ __ _ __ _ __ __ _ _ _ _ __ _ _ ❑ ❑
Septic tank size -b Nd- 56c) eat Manufactur
0 D-box water level and ape are used? - - - - - -- - - - -- --- ❑ NIA ❑YES ❑ No
00 Manifold/D-bo ssiburface?-_ _ _ _ _ ___ _ _ _ _ _ ___ ❑ ❑ ❑
m' Ch ves installed? - - - - - - - - - - - - - - - - -- - --- - - - ❑ ❑ ❑0
M Transport Line Size S ule/Class
Bedrooms installed(check one) ❑ 2 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10ft. from foundation?- -- - - -- - - - - - - - -- - - -- - - -- - - NIA ❑ Y No
>100 ft.from wells?- - - --- - - ------ --- - --- ---- --- - ❑ ❑
W >100 ft.from surface water? - __ __ _ _ _ _ _ _ _______ ______ ❑ ❑
ZQ >10 ft. from potab Ater lines?- --- - - -- -- ------------ ❑ � ❑
K >5 ft.from any lines and easements?--- - -- ---- - -- -- - ❑ f�( / ❑
> 30 ft. m downgradient curtain/foundation drains?-- -- - ----- ❑ I�J!
rOr eld level and observation ports present -- -- -- --- - -- _ - ❑ El
Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?-- - -- - - -- -- -- ------ ❑ ❑
Pump tank setbacks consistent with septic tank?- - - -- ----- — - ❑ NIA Y.es' / ❑ No
ZPump tank size. 9-457Dgat Manufacturer
Q 24"access riser(s)and accessible from surface?--- - - - - --- - - - ❑ ❑
0~. Alarm or Control Panel Installe -- - - - - - - - -- - - - ❑ ❑
J
Control Panel equipped Imerl ETM/Counter-- - - - - - -- - - ❑ ❑ ❑
0- Pump installed in Bucket or ❑ On Block or ❑ Other_
d Pump Make/Model Floats or
' / ❑ Transducer
a Tank draw downin/min Pump capacity 7LT apm Squirt Height�ft
Pump on time �i»�,�/ Pump off time %�.�- Daily flow sat at gpd
cra.ueerz+ao+s
Mason County OSS Installation Report pg. 2 Parcel u
ABANDONMENTRECORD
Were existing septic components abandoned as part of this project? --- - - - - - - -- - - - - YES ur-N9—
If yes, please describe: _
Were$11 Components pumped out and properly abandoned per WAC246-272A-0300? -- -- - - - - ❑ YES 0 NO
RECORD DRAWING
Thin b a permanent WON and met w¢canb and d.mnpuw enoogh to rv+ucaw In me men or maintenance acevxN..M Klan dsvempmanL TW"I Record
emwinga Nm&'m tHBII,N9a a nbmmH glOMenon a loyoat sWmlpump mnx Ittalron.rvam mow.mnalva ernmlum,exfnna and pmposAl nWpinQe,brAlpn Orvelb,wxeemes,
wale.vpavrvelron pwb,a9enwb.aM pgvr memlenanre attaea pOlnu. inmmpmm flamrtl Orewi,Ns may Imam eedlbrel Belays In MN InamAefion approval vA relered permlly.
Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
1 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 haw been cleored/approved by both the designer shown here have been cieasdrapprovi d by both
and Mason County Public Health and meet all State myself and Mason County Public Health and meet all
and Mason County Codes. Stale and Mason County Codes
I further certify that ail information contained on this l further certify that all information contained on this
7 .fo attach dR/ey�°rd Dr wing is accurate. form and attached Record Drawing is accurate.
Hr 7-7-0-z3
Signlns ller Date
06rw '
PrintedN eo/Sgnee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and ' �D r
Record Drawing on behalf of Mason County Public n
Health: ill r 2024,
a'JMENTAI H�ALTI
Signature ofEnvlronmentaf Health SpecSpec ali� st Dafo
(stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WES SITE uneaudea+ema
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