HomeMy WebLinkAboutSWG2024-00133 - SWG As-Built - 6/3/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATION
Permit Number SWG �i02q- 00133 Parcel# V? 3/ gsp00/9,C
Applicant Name Mlek Y. Yb I I A f (3 r,,vn Subdivision (Name/Div/Block/Lot)
Applicant s
City, State,, Zip
Zip b Installer Name
Site Address '',Designer Name No,v
INSTALLATION CHECKLIST
❑ Full System Installation VTank(s)Only ❑Drainfield Only ❑Repair ❑Other
System Type Pretreatment Type N/IW,v
>5 R from foundation? --------------------- ------ El WA "E�y" ❑ NO
>50@.from wells? --- --------___ I �Y ❑ 5r ❑
_ >SOR from surface water? ----_____ lf. ❑
F Cleanout between building and tank? ---- - _ ❑ �I ❑
U Tank baffles present? - - - -_______ _ 2024 ❑ �, ❑
1- 24"access risers over each cmp oartment?- ______________ ❑ �. ❑
y Effluent filter installed?--__ - B El , ❑
Septic tank size_=t"1 1 D 1&0 oal Manuf :turer_ ,ZNP y6 Tr1ar fcML
D-box water level and speed levelers used? -- -------___ J A ❑YES El No
MManifold/D-box accessible from surface - - ______ _ .aF ❑ ❑
CQCheck valves instilled? -- - - - - - - -rK____-____ 3° ❑ ❑
M Transport Line Size ScledukslCl 1
Bedrooms installed (check one) 2 ❑3 ❑4 ❑5 ❑6 ❑Commercial/Other
>10 ft from foundation?-------------------------- ❑ WA W&YES NO
from wells?- _____________________Y_ _f__ ❑ ❑
J >100 ft. wateR--- ---- p
W paa r�
S >10 ft.from potable v-- - J�__i ❑
Z >5 ft.from ro ❑ ❑
Q P PertY lines ande Is? ______________
R > 30 ft. from tlowngradient ndation drains?•-- ❑
Drainfield level an tottt����n....,���p,,,orts present - - - - ------___
❑ Grav hers or --Clean gravel used? (crock One) ❑
P r er installed over dramfield?- - - - - -- - ----------- ❑
Pump tank setbacks consistent with septic tank?--- - ----____. ❑ wA ❑ YES ❑ NO
Y Pump tank size dal Manufacturer
2
Q 24"access riser(s)and accessible from surface?--- -----_____ ❑ El El
aAlarm or Control Panel Installed? ___ ❑ ❑ ❑
Control Panel equipped with Tim / I dun
Pump installed in ❑ Bucket or ❑ On Block or ❑ OIhw
fPump MakelModel El Floats or ❑ Transducer
d Tank draw down in/min Pump capacity opm Squirt Height ft
Pump on time Pump off time Daily flow set at Glad
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Mason County OSS Installation Report pg. 2 Parcel# �fZ 3 I �SDpO/46
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? ---- ---- ------- NO
If yes, please describe:
Were all components pumped out and property abandoned par WAC246.272A-03M? •------- YEa � NO
RECORD DRAWING
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�ecord Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER(ENGINEER
1 certify that I installed the system in accordance with 1 certify that the system has been installed in arxor-
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
hem have been cleared/appmved by both the designer shown hem have been clearedfapproved 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 l further certify that all information Contained on this
form n tte ('e Record Drawing is accurate form and attached Record Drawing is accurate.
/ o szv
S- a fre o lnste rr/7/, Date
Printed Name of Sign
MASON COUNTY PUBLIC HEALTH
The undersigned appmms this Installation Report and
Record Drawing on behaMof Mason County Public
Health.'
Signature ofEnvi onmenta Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE azvmre
44 c�! N A7 geO �Z�rss000r96
RECORD DRAWING continued
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JUN 03 20A
MASON COUNTYE"R
� ONMc�NiAL HEALTH
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