HomeMy WebLinkAboutSWG2022-00414 - SWG As-Built - 7/18/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG;7A7-2--O 9 ) `4 Parcel# ZzoltnSoolotU
Applicant Name yyklp,H W MkLLS Subdivision (Name/Div/Block/Lot)
Applicant Address ?S-7 Ar QKEws 13eacN RDNC
City, State, Zip Bl1-AYW? o wW pSSI(c Installer Name T@3S`A 14MT
Site Address 19.1 C rp-l4-Wo DVL Designer Name N/W
,.,� INSTALLATION CHECKLIST
El Full System Installatibn L7 lank(.)Only ❑Drainfield Only ❑Repair ❑Other
System Type %124 Pretreatment Type
>5 ft.from foundation --------------------------- ❑NIA [a4Es ❑ NO
>50 ft.from wells? - ---------------------------- ❑ [� ❑
Z >50ft.from surfacewteR - -- - -- -- -- --------------
❑ [� ❑
FCleanout between buiding andtank? ------------------- ❑ 2, ❑
U Tank baffles present?.- ---- -- -------------------- ❑
a24"access risers over each compartment?--------------- - ❑ ❑
NEffluent filter installed?- --- ------------------- ---.- ❑ ❑ ❑
Septic tank capacity(working) 1'LOO aal Manufacturer St pop ?LVW.Gw 8toT
im D-box water level and speed levelers used? -------------- - B*A ❑YES NO
OLL Manifold/D-box accessible from surface?---------------- - [Er ❑ El
oZ Check valves installed? -- --- - -- -- -- -------------- Er]— ❑ ❑
Transport Line Size Schedule/Gass
Bedrooms installed (check one) 42 ❑3 04 05 ❑5 ❑Commercial/Other
>10ft.from foundation?-------------------------- �IIA ❑ YES NO
>100 ft.from wells?- ---------------------------- ❑ ❑
W >100 ft.from surface water?----------------------- - Be ❑ ❑
Z >10ft.from potable water lines?--------------------- - [(,� ❑ ❑
>5ft.from property lines and easements?----- ---- ❑
>30 ft.from downgradient curtamKoundation drains?- -- ------ - ❑
Dreinfield level and observation parts present ------- ------- ❑ ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drairfield?------ - -- ------ ---- ❑ ❑
Pump tank setbacks consistent with septic tank?-- ---------- - B WA ❑ YE. ❑ No
ZPump tank capacity(flood) at Manufacturer
Q 24"access rtser(s)antl accessible from surface?------------- 0� ❑ ❑
aAlan or Control Panel Installed? ---------- ---------- - 13� ❑ ❑
f Control Panel equipped with Timer/ETM/Counter---------- - ERI� ❑ ❑
7
a Pump installed In ❑ Bucket or ❑ On Block or ❑ Outer
Pump Make/Model 64/14 ❑ Floats or ❑ Treneduoor
d Tankdmwdown IV21 in/min Pump capacity -/4 P. Squirt Height ,✓//A ft
Pump on time k Pump off time Daily flow set at N pd
up szrrzoie
Mason County OSS In tallation Report pg. 2 Parcel#
ABANDONMENTRECORD
Were existing septic componsints abandoned as part of this project? ------ - --- - - - -- Eg"FES ❑ NO
If yes, please describe' _ e.PO orF SIfE
Were all components pumped out and property abandoned per WAC246-272A-0300? ---- ---- e-fES ❑ NO
RECORD DRAWING
mle la a pprmew,R mcard and must be ammusee,nd desnlnew ensure is nappate In tad dead a malmawnw sell and butune deselopmem Typk9l RewN
Dmxinrawnbin: D2i4eldamamroaodenmfwna Wp Sep umptankb .N encw,m d2mMld.m¢ aWprcns Lulldl�a.lnumon dwells.waledlnae.
walls.plaena4un cerm.aw n erma noa ,and pmlmederce eaeva garde. lnwmpwa aewm o,ainra m.raaam eddlcow eaays m rwl insmWeon apprown and relalea cemars.
❑ Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that 1 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 myseHand Mason County Public Health and meet all
and Mason County Codes. State and Mason County Codes
1 further certify that all information contained on this I further certify that all information contained on this
form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
9 /L•'U-/
of installer Date
7t5Sax h 1�
Printed Name of Sign"
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
e)022 un`�')'t -� ((�XZ
Signature otEmamnmenthl Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED ANOAVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTYWEB SITE umewbatcole
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APPROVED
`c JUL 18 2024
MASON COUNTY ENVIRONMENTAL HEALTH
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