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HomeMy WebLinkAboutSWG2021-00290 - SWG As-Built - 7/18/2024 Masbn'County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/PERMIT INFORMATION Permit Number SWG 2021-00290 Parcel# 22009-51-00005 Applicant Name Jon Sergeant Subdivision (Name/Div/Block/Lot) Applicant Address 70 E Scenic View Rd City, State, Zip Shelton, WA 9a584 Installer Name B-Line Construction Inc Site Address Same Designer Name INSTALLATION CHECKLIST ❑ Full System Installation ❑Tank(s)Only ❑ Drainfield Only 0 Repair ®Other G VYt System Type Pressure Pretreatment Type Sand Filter >5ft. from foundation? -_________ _________________- ❑NIA ❑YES NO >50ft.from wells? - __ _ _ _ _ _ _ _ _ _ __ ____ ___ _ _ _ ____- ❑ ❑ ❑ Z >50 ft.from surface water? - - - - -- - --- -- - - -- - - -- ❑ ❑ ❑ rCleanout between building and tank? ❑ ❑ ❑ L) Tank baffles present? - - - - - - - - - - -- - - - - --- - - - ---- . ❑ .❑ ❑ a24"access risers over each compartment?- - - - - -- - - - -- - - -- ❑ ❑ ❑ rW Effluent fitter installed?- - - - - - - - - - --- - - - ---- - ---- -- ❑ 11 ❑ Septic tank capacity (working) 1200 gal Manufacturer �0 D-box water level and speed levelers used? - -- - - - - -- - - - - -- ❑ NIA ❑yes ❑ No OO Manifold/0-box accessible from surface?- - - --- ❑ ❑ ❑ _ _ _ G= Check valves installed? ----- - - -- - - - -X�? _ _ _- ❑ ❑ ❑ Transport Line Size Schedule/Class Bedrooms installed(check one) ❑ 2 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10ft. from foundation?- - ---- - - - --- - -- - - - - - - - - - -- ❑ NIA ❑ YES ❑ No >100 ft.from wells?- _________ _ __________ _______ _- ❑ ❑ ❑ W >100 ft.from surface water? --- - - - - -- -- - - - - - - - - -- ❑ ❑ ❑ M >10 ft.from potable water lines?--- - -- ��C/1�- - ❑ ❑ ❑ QZ > 5ft. from property lines and easements?-- --- - - - - - -y-- -- ❑ ❑ ❑ 1' > 30 ft.from downgradient curtaintfoundation drains? - - - -- - - - - - ❑ ❑ ❑ Drainfield level and observation ports present - - - - - ❑ ❑ ❑ ❑ Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?- --- -- ----- - ---- ---- Pump tank setbacks consistent with septic tank? ---- - - --- - - - - ❑ NIA ❑ YES ❑ NO NdPump tank capacity(flood) gal Manufacturer Q 24"access riser(s)and accessible from surface?- - ----- ----- - ❑ ❑ ❑ ~a Alarm or Control Panel Installed? - - - ---- - -tTT)-�-y/_1� ❑ ❑ ❑ Control Panel equipped with Timer/ETM/Counidr'-�`�� ❑ ❑ ❑ o- Pump installed in ❑ Bucket or ❑ On Block or ❑ Other Pump Make/Model ❑ Floats or ❑ Transducer CL Tank draw down in/min Pump capacity gpm Squirt Height ft Pump on fime Pump off time Daily flow set at gpd up m wi mrs Mason County OSS Installation Report pg. 2 Parcel# 22009-51-00005 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? --- - - -- . YES ® No If yes, please describe: Were all components pumped out and properly abandoned per WAC246-272A-0300? - - - YES NO RECORD DRAWING Thia.a a permanent rowro and must as accura4 and a H,ANa andugh m rvwwpv m ere road of ms nanu aa.wwa and rumro Eaaampnanc Tyy..R.m Dmemgewndin. Droinfiew BnuNfotl nrenmwnakywt sedWp,mo mnxw®ow,,Nonnammv.rewva dramriae.exwerg am poposm hwdxipa.Malwn arwa6,warnrFres. welt.oitsenakn MMs g Wins,aM rarer meirda.once a[msa dmnra. rnrpnrieb RerpJ Draui�may vearc aJdbpai MR ye in firer i�appovel aM r&aRE pam,pe. ® Record Drawing Attached CERTIFICATION OF INSTALLATION INSTALLER DESIGNER/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 attached Record Drawing is accurate. form and attached Record Drawing is accurate. Sign re of Installer Date ev ilac Printed Name of Signee MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report and Record Drawing on behalf of Mason County Public Health.' /// / { I Signature of Environmental He h Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE updaim earao+e RECORD DRAWING continued fYb"�E ,cote pr 6' s� z3' LSbi