HomeMy WebLinkAboutSWG2023-00475 - SWG As-Built - 8/6/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATION
Permit Number SWG 2023-00475 Parcel# 422103490281
Applicant Name Shelly Burtis Subdivision (Name/Div/Block/Lot)
Applicant Address 14237 NE 27th St
City, State,Zip Bellevue WA 98007 Installer Name Royal Flush septic
Site Address 10 N broken Arrow Dr Designer Name Dale Taiha
INSTALLATION CHECKLIST
Full System Installation ❑Tank(s)Only ❑Orainrield Only ❑Repair ❑Other
System Type SFR Pretreatment Type none
>5ft.from fountlation? ---- -- - - - - ----- - - ---------- ❑WA EVES ❑ rw
>50ft.from wells? -------------- ---- - - - - - -- --- -- ❑ e ❑
ZY >50fL from surface water? -- -- -- -- - --- - -- -- -- -- --- ❑ ❑
FCteanoutbetweenbuildingandtank? ---------- ---- - - --- ❑ ❑
0 Tank baffles present? -- - - --- - -- - -- -- - - - -- - - -- --- ❑ ❑
d24"access liters over each compartment?._ _______ _ _ __ __ . ❑ S ❑
W Effluent filter installed?----- - -- --- - --- - - - - -- ---- - - ❑ ❑
Septic tank capacity(working) 1250 gal Manufacturer Hagerman Precast
0 D-box water level and speed levelers used? - ----- - --_____ . ❑ WA ❑
gVEs ❑ NO
uManifold/D-box accessible from surface?--I_ ______ _ ______ . ❑ ❑
WE Check valves installed? - - -- -- -- - - ---- - - - - --- -- --- ❑ ❑ ❑
Transport Line Size 2- Schedule/Class 40
Bedrooms installed(check one) ❑2 ❑6 ❑Commercial/Other
>10 ft.from foundation?-- -- -- ��_� _ __ _. ❑ WA YES ❑ rro
>100 ft.from wells?--- ------ -- - ---- - ---. ❑ ■ ❑
J >100ft.fromsurfacewateR-- - -- - JUL26.2024 - _ ❑ e ❑
W --
2 >10 ft.from potable water lines?--- -- - - -- - -- - -- -- -- . ❑ ❑
>5 ft.from property lines and easem ?—--- __- ❑ ❑
G > 30 ft.from downgradient curtainrou a ion drains?-- - - -- - - -
El
- ❑
Drainfieid level and observation ports present ---- _ _. ❑ e Cl
e Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?-------------- ----. ❑ . ❑
Pump tank setbacks consistent with septic tank?-- -- -- ------ - ❑ WA YES ❑ No
Y Pump tank capacity(flood) 1250 at Manufacturer Hagerman Precast
a
F24"access risen(s)and accessible from surface?----- -- - ____. ❑ ® ❑
6. Alarm or Control Panel Installed? ----- ---- ----------- - ❑ ❑
Control Panel equipped with Timer/ETM/Counter--- - --- -- - - ❑ ® ❑
IL Pump installed in ❑ Bucket or ® On Block or El Other
IL
Pump Make/Model liberty 280 Floats or ❑ Transducer
a Tank draw dawn 2' in/min Pump capacity 44 gpm Squirt Height 68' ft
Pump on time 1.4 Pump off time 4 Daily flow set at 360 gpd
Mason County OSS Installation Report pg. 2 Parcel a 422103490281
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 abandometl per WAC246-272A-0300? - ------- ❑ YES ® NO
RECORD DRAWING
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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 clearedfappmved 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 forth+ ifyEallrmation contained on this 1 further certify that all information contained on this
form nd at' Drawing is accurate
. forth and attached Record Drawing is accurate.
07/11/2024
S" a re !Installer Data
Darin P.Ogg Roval Flush$BpItC
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH 'A
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health: �}--,� ��� `/lnn ,A,
E= 11 �J(NY�AIr Y' • I SAfl
Signature ofEnvironmenrek Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE upeemd s2utare
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