HomeMy WebLinkAboutSWH2024-00116 - SWG As-Built - 6/14/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATION
Permit Number SWG ✓-- Parcel# 47Z bQeft 604Qa
Applicant Name Subdivision (Namme�/Div/�Block/Lot)
Applicant Address X 11141
City, State, Zip S1161 Installer Name
Site Address Iv Desi ner Name
INSTALLATION CHECKLIST
❑ Full System Installation ❑Tank(s)Only ❑Drainfield Only ❑Repair ®Other M` li4DYO
System Type 17L I' Pretreatment Type
>5 ft.from foundation? - - - - - - - - - - - -- - - -- - ❑ NIA C&YES ❑ NO
>50ft. from wells? - - - - - -- - -- - - - - - - - - - - - - - - - - - - .- ❑ ❑
Y >50 ft. from surface water? - - - - - - - - - - - - - - - - - - -- -- - - ❑ ❑
Z
Cleanout between building andtank? - - - - -- - - - - - - - - - - - -- ❑ � ❑
U Tank baffles present? - - - - - - - - - - - - - - - - - - ❑ ® ❑
1 24"access risers over each compartment?- - - - - - - - - -- - -- - - ❑ ® ❑
W Effluent filter installed?- - --- - - - - - -- - - - - - - - - - - - - - - - ❑ ❑
0)
Septic tank capacity(working) gal Manufacturer
0 D-box water level and speed levelers used? - - - - - - - - - -- - - - - ❑ NIA ❑ YES ❑ No
Q0 Manifold/D-box accessible from surface?- - -- - - - - - - - - - - - - - ❑ ❑ ❑
m= Check valves installed? - - - - - - - - -- -- -- - - -- - - - - - - -- ❑ ❑ ❑
04
f Transport Line Size Schedule/Class
Bedrooms installed (check one) ❑ 2 J0 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft.from foundation?- - - - - - - - - - - - - - - - - -- ❑ NIA ❑ YES ❑ No
0 >100 ft. from wells?- - -- - - - - -- - -- - -- - -- - -- - -- --- . ❑ ❑ ❑
-1 >100 ft. from surface water?-- - - - - - - - - - - - -- -- ❑ ❑ ❑
a >10ft.from potable water lines?- - - - - - - - - - - - - - - - --- - - - ❑ ❑ ❑
Z >5 ft.from property lines and easements?- - - - - - ❑ El ❑
a
0: El El El
30 ft_from downgredient curtain/foundation drains?- - - - - - - - - -
0 Drainfield level and observation ports present - - - - - - - - - - - - -- ❑ ❑ ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over datrifiell- - - - - - - - - - - -- - - - - -- ❑ ❑ ❑
Pump tank setbacks consistent with septic tank?-- - -- - ❑ NIA ❑ YES ❑ No
X Pump tank capacity(flood) at Manufacturer
Q24"access riser(s)and accessible from surface?- - - - - - - - - - - -- ❑ ❑ ❑
~ Alarm or Control Panel Installed? - - - - - - - - - - - -- - - - - -- - - ❑ ❑ ❑
a
f Control Panel equipped with Timer 1 ETM/ - - - - - - -- - -
0- Counter ❑ ❑ ❑
a Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
Pump Make/Model ❑ Floats of ❑ Transducer
a
Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
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Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
Were epsbng septic Components abandoned as part of this project? -- -- - -- - ----- -- ❑ YES 171, NO
tf yes, please describe: /"`•
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - -- -- -- ❑ YES ❑ NO
RECORD DRAWING
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❑ Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that/installed the system in accordance with /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 cleared/approved 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
fv_m and attacchle+d'Record Drawing is accurate. ,f form and attached Record Drawing is accurate.
/ I.I.r4 .A
Sigr;tu4lf ins! r Dete
Printed Na ofSigrmee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
Signature of EnNi o mental Health Spedalisf Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLICVIEW ON THE MASON COUNTY WEB SITE uomue erziama
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