HomeMy WebLinkAboutSWG2023-00322 - SWG As-Built - 7/24/2024 Mason County OSS Installation Report pg. 1
MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATION
Permit Number SWG 2023-00322
Applicant Name ROYAL SAGE Parcel# 22017-51-00026
Subdivision (Name/Div/Block/Lot)
Applicant Address 1291 E LAKESHORE DR W
City, State, Zip SHELTON.WA, 98R84
Site Address SAME Installer Name A
Designer Name CINDY WgITE
INSTALLATION CHECKLIST
❑ Full System Installation ❑Tank(s)Only
System Type Drainfield Only ❑Repair El Other
GRAVITY Pretreatment Type --
>5 ft.from foundation? _______ _ _
>50ft. from welts? _ __ _______ _ __ _ _ __ _ ___ _ _ _ _ El N/A YES ElN
Y >50 ft.from surface water? -_ ___ _ __ _ _ ❑ ❑ NO
F2 �T f2 JI0-J2 ❑
Cleanout between building and tank? -__ _ _ Vu lS B V IS-
t) Tank baffles present? . _ __ _ __ _ _ _ --- - ® O
IL 24"access risers over each compartmeM?- _'�__- r7 1024-- ❑
W Effluent filter installed?-___ _ _ _ ____ _ - -- --' --
g_ _ _ _ ❑
Septictanksize_7000 y ❑
oat ac urer
9 D-box water level and speed levelers used? .-___ _ __-__STING
oR Manifold/0-box accessible from surface?-_ __ ____ _ wA ❑YES NO
C2 Check valves installed? - _ _ __ ___ _ ______ ® ❑ ❑
Transport Line Size ❑ ❑
--� — Schedule/Class
Bedrooms installed (check one) 92 ❑ 3—�— L 034 `n� '�Y'�`'�"
>10 ft.from foundation?---_ _______ 3 ❑4 ❑ ❑6
5 ❑CommerciaVOther
9 >100 ft.from well,?- - -- ------ --- ----- - - ❑ N/A AYES ❑ No
>100 ft.from surface water? -______ ___ ______ _ ___ ■
W ❑ ❑
Z >10 ft.from potable water lines?- - - __ __ __ _ __ - ❑ El>5 ff.from property lines and easements?- -_ ❑ ❑
a >30 ft.from downgradient curtain/foundation drains?- - __ _ _- -_- ❑ ❑
Drainfield level and observation ports present - -- __ _ _ _ _ __ _ _ El
❑ Graveless chambers or ® Clean ❑ �
gravel used? (check one)Proper cover installed over tlrainfield?- -- - _ __
Pump tank setbacks consistent with septic tank?- -_____- ____ ® ❑
Y Pump tank size ❑ NIA ❑ res ® No
IC 2 Dal Manufacturer
A24"access riser(s)and accessible from surface?--_tL Alarm or Control Panel Installed? - -__ _ __ _ _ _ ___ _ __ ___ Cl ❑ ❑
Control Panel equipped with Timer/ETM/Counter- - - - _ _ _ _ - _- ❑ ❑ ❑
a Pump installed in ❑ ❑ ❑
or On Block or Other__—_
a ❑ Bucket [I ❑Pump Make/Modal _
aTank draw down ❑ Floats or ❑ Transducer
In/min Pump capacity
Pump on fime gPin Squirt Height t
Pump oft time Daily now set at
9Pd
�P�FlIa�B/y1 Pill
Mason County OSS Installation Report pg. 2 Parcel# 22017-51-00026
ABANDONMENT RECORD it
Were sidsbng septic components abandoned as part of this project? ------------ -- _ O ip
If yes,please describe: YES
Were all components pumped out and pmpedy abandoned per WAC246-272A-0300? •------ -
0YES �;ry
RECORD DRAWING
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wNla Wevrvvtlon.siu.a®nsua,.na dM1e'meNmn..ce acne P.Ime. MrvmP�me R.em orewm.,ma 9.ne Pmpnnea Wddlis,loos.^orxsf.wawllnes.
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-------------------------
-�NI/ dr1Yd Gtl3t/s� � C7n YJ�-P'�r
Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER
OESIGNERI ENGINEER
I certify that I installed the system In accordance with 1 certily that the system has been Installed in actor-
the septic design Stamped'APPROVED"by Mason dance with the septic design stamped"APPROVED"'py
County Publk Health and that any deviations shown Mason County Public Health and that any deviations
here have been clearedfapproved by both the designer shown here have been clsamd/approved by both
and Mason County Public Health and meet ail State myself and Mason County public Healh and meet el�
and Mason County Codes.
f further certifyState and Meson County Codes/y that all information contained on this I further G2rtlty that all information contained on this
form and a ad Record Drawng is accurate. form and attached Record Drawing is accurate.
`ZVIZ
S/g reoflnstallsr Data
Printed Name ofSIgnea e e
MASON COUNTY PUBLIC HEALTH t / �
The unders/gned approves this Installation Report and "d
an
Record Drawing on behalf o/Mason County public - YE, At
Health: LICE NSEp DE8IGNETi
�1 VI � EFnigE50Y1N .11',
Slgnanua ofEn✓Irasmenle/ aan specie➢at Data
(stamp, signature and date)
THIS FORM MAY aESCANNEDANO AVAILABLE FOR PUBLIC VIEW ON THE MA SON COUNTY WEB SITE uWa.a endsom
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