HomeMy WebLinkAboutSWG2024-00295 - SWG As-Built - 8/21/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC TH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2n2q-0029,g- Parcel #Z-22 33 - 571- 06 1 yS q
Applicant Name Jh✓le4 /;P/Sa Subdivision (Name/Div/Block/Lot) qF
O
Applicant Address 21I//mo N WG t AJ 04 CFI` 01�
City, State, Zip YOnco gLw4AIJ 12665- Installer Name
Site Address 57700 C filMcn Designer Name
,{/ INSTALLATION CHECKLIST
❑ Full System Installation E Tank(s)Only ❑ Drainfeld Only ❑Repair ❑Other.
System Type pyjjWaD &Aomrl Pretreatment Type
>5 ft.from foundation? ---- -- - --- --- -- - - - - - - - - ---- ❑NIA KYeS ❑ r+o
>50ft.from wells? - -------- ---- --------- --- - -- -- ❑ ls[,M�g/ ❑
Z >5oft.from surface water? ---- -- - -- - - - -- - - - - -- -' ❑ ❑
FCleanout between building and tank? ---- ----- --- ------- ❑ Jarsf ❑
V Tank baffles Present? --- --- -- ---- -- -- ---- - - - ----
❑ ❑
F 24'access risers over each compartment?-- --- -- - - ------ - ❑ ❑
CL ElW Effluent filter installed?- -- - --- --- - -- - -- -- - -- - - -- - - ❑
tlJ SPA
Septic tank capacity(working) Manufacturer
O D-box water level and speed levelers used? -------------- - ❑ NIA YES NO
0O Manifold/D-box accessible from surface?- ---- - - - - ------- - ❑ ❑
m- Check valves installed? - ---- -- -- --- - - - - - - - -- -- -- El ❑
04 ulelClass° d 4t0 •
M Transport Line Size Z Schad
Bedrooms installed (check one) 2 ❑3 ❑4 ❑ 5 ❑6 ❑CommerciaVOther
>10ft.from foundation?------ -- -- -- -- -- - - - - -- -- -. ❑ NIA &Y'ES ❑ No
G >100 ft.from wells?- ---------------- -- ---- - - -- -- ❑ IX ❑
13
-1 >100 ft. from surface water? ----.---- - -- - - - - -- - -- - -- - ❑ ❑
a >10ft. from potable water lines?-------- - - -- - -- ----- - ❑
2 >5ft.from property lines and easements?------ -- -- -- ---- ❑ ❑
G ❑
G >30 ft.from downgredient curtain/foundation drains?--- -- ----- ❑
Drainfield level and observation ports present -- - -- - - -- ----- ❑ ❑
4 Graveless chambers or ❑ Clean gravel used? (check one) ❑
__ -_ -
Propercoverinstalledovertlrainfeld?---------- ❑
Pump tank setbacks consistent with septic tank?------- ----- - ❑ NIA tKYes ❑ NO
Y Pump tank rapacity(flood) lymb pal Manufacturer SPS
Zsurface? �( ❑
Q 24"access riser(s) accessible From ------------ 0 H Alarm or Control Panel Installed? ---------- -- - - -- --- - -
a ❑ ❑
f Control Panel equipped with Timer/ETM/Counter- - - -- - - - -- -
7 k
tl Pump installed in ❑ Bucket or Ip On Block or ❑ Other
1 Pump Make/Model AOmlr r'i 0V 30 Q9 Floats or ❑ Transducer
6 Tank draw down rd� in/min Pump capacity �� opm Squirt Height
�� ft
T19D Pump off time 7-80 Daily flow set at 2j opd
Pump on time upm W erz,ame
Mason County OSS Installation Report pg. 2 Parcel# W-43— Sf'
ABANDONMENTRECORD
Were existing septic wmponenls abandoned as part of this projecl7 - - - - - - - - - -- -- - K YES NO
If yes, please describe.
Were all components pumped out and property abandoned per WAC246-2T2A-03004 ---- - - -' 10 YES No
RECORD DRAWING
Tmi is a mmumem me>d and mum as N hudd me apnlWw enough to roi«and in the name m mamummum.activism and rmu s develo edurd. Tm-1 RaNm
Drumm,[amain. changed a maNlnaerenmaon n Issout,senewpump ianx bynon.Nonn em..use—maimlen.anzuny ane emeosea amd,ud, a,unnnel loan,.wmmu-1
avelb,oh..tam,de.c.. emits—eppmem and/mane pmmn:.
Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER] ENGINEER
I certify that I installed the system in accordance with 1 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 clearedrapproved 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.
(2.- � a13 by
;%Signature o/Installer Date
a am4j .
Printed Name of Signse
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
��h� glztlz-�1
Signsfure of Environmental Health specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE
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