HomeMy WebLinkAboutSWG2023-00388 - SWG As-Built - 6/7/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2023-00388 Parcel * 12019-21-90011
Applicant Name JESSICA SHUBERT Subdivision (Name/Div/Block/Lot)
Applicant Address 671 E ISLAND SHORE RD
City, State, Zip SHELTON WA. 98584 Installer Name SHOENING EXCAVATION
Site Address 341 E IShrYNp Stf*W, R Designer Name CINDY WAITE
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type GRAVITY Pretreatment Type
>5 ft. from foundation? -- - - - - -__ _ _ _ - ❑ N/A E YES ❑ NO
>50 ft. from wells? -- - - - -- - - .� -0_�_� - ❑ ❑
19 >50 ft. from surface water? - - - - --
H - _) �777111...IIIIIIµµIIIIIIJJJJJJIIIIIIII - El ❑Cleanout between building and tank? -- - 11N_Q d 2Q24_ ❑ ® ❑
V Tank baffles present? -- - - - - - - - - - - - - - - - - - - - - - ❑ ® ❑
a 24"access risers over each compartment By. ❑ ® ❑
rW Effluent filter installed?- __ __ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ - ❑ ® ❑
Septic tank size 1200 gal Manufacturer HAGERMAN
D-box water level and speed levelers used? - - - -- - - - -- - _ _ _ . ❑ NlA VE3 ❑ No
QLL Manifold/D-box accessible from surface?-_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - ❑ ❑
CQ Check valves installed? - _ _ _ El
❑
Z Transport Line Size 4" Schedule/Class 3034
Bedrooms installed (check one) M1 2 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
soft. from foundation?- - - - - - - - - -- - - -- - - - - - - - - - - - ❑ NIA ® YES NO
>100 ft. from wells?-- - - - - - -- - - - --- -- - - - - -- - -- - - - ❑ ® ❑
W >100 ft. from surface water? - - - - - - - -- - - - - - - - - - -- - - - - ❑ ® ❑
2 >tOft. from potable water lines?- - _ _ _ _ _ _ _ _ _ _ _ _ __ _ __ _ _- ® El>5ft. from property lines and easements?- - - - - --- - -- - - -- - ❑ ❑
0 > 30 ft. from downgredient curtain/foundation drains?- - -- - - - - - - E ❑ ❑
Drainfield level and observation ports present - - - -- - - - - - - - _ . ❑ O ❑
❑ Graveless chambers or 0 Clean gravel used? (check one)
Proper cover installed over drainfeld?-- - - -- - -- - - -- - - - -- -
Pump tank setbacks consistent with septic tank?-- - - - --- ----- ❑ N/A ❑ YES NO
ZPump tank size_ gal Manufacturer
H 24"access riser(s)and accessible from surface?--- - ---- ____. ❑ ❑ ❑
a Alarm or Control Panel Installed? -- - - - - - -- - - - -- - --___. ❑ ❑ ❑
Control Panel equipped with Timer/ETM/Counter- - - - - - - -- - - ❑ ❑ ❑
a Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
Pump Make/Model ❑ Floats or ❑ Transducer
a
Tank draw down in/min Pump capacity apm Squirt Height ft
Pump on time Pump off time Daily flow Set at gpd
upe.w an�rzore
Mason County OSS Installation Report pg. 2 Parcel* 12019-21-90011
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - - - - - - - - - - - - -
If yes, please describe' - El YES NO
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - - - - - - - ❑ YES 0 NO
RECORD DRAWING
This is a permanent stood and must be accuraa and aasctlptiva enough to Is 1pus In the need of maintenance a,tlVlues and rutum rlevelo
Drawings mnlan: crashed 8 menMk om nlat'on B layout Se b pment Typical Record
Y s Wmptanklocdllon.NtM armwreserve tlesfi aid.Hilslingendpr0%al ashit"s,bcmim Wwadiwderl,Ao1ms,WdE,pbEBrymIm IVIIs,Gleinputi,and piker mdldknepy a¢GSa p]ip1E Inmmpkle RBCOM DIawingE may GCm88dd1110pd11W8yS In M81tl8181N1iOn appmVe and ralalad
/ permhs.
0 Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNERI ENGINEER
I 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 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
form and�d Record Drawing is accurate. form and attached Record Drawing is accurate.
Signature ofInstaller Date
�Yuat� �tgµ'<A'1• YEt.I T
Printed Namr a of Signee
P
MASON COUNTY PUBLIC HEALTH A
The undersigned approves this Installation Report and L a o Waliff
Record Drawing on behalf of Mason County Public
Health: Edrials UL I&
0`M 6 h 121`1 �W
Signature of Environmental Aealth Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE °pn"e°'b,21Rmb
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