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Home My WebLink AboutSWG2024-00272 - SWG As-Built - 8/20/2024 Docusign Envelope ID:BDCAFC05-F0774DBF-958F-E83C89B4DC89 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG SWG2024-00272 Parcel# 51901-50-01055 Applicant Name MILBOUF N. DAVID E& MELODY Subdivision (Name/Div/Block/Lot) Applicant Address pa BOX 183 LOST ILAKF Lot 55, Block 1 City, State, Zip HUMPTULIPS WA 98552 Installer Name Jamie Workman Site Address 1072 W LAKESIDE DR Designer Name Micah Halverson INSTALLATION CHECKLIST © Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair ❑Other System Type ATU to Pressure Trench Pretreatment Type BNR-600 >5 ft. from foundation? - -- - - - - - -- - -- - - - - -- - -- - - - - - ❑ wA [DYES NO >50 ft. from wells? - - - - ❑ ® ❑ Z >50ft. from surface water? - - - - - - - - - - - - - - - - -- - - - - - - El ID ❑ F Cleanout between building andtank? -- -- - - - - - -- - - - --- - - ❑ ❑ V Tank baffles present? - - - - - - - - - - - - ❑ x❑ ❑ 4 24"access risers over each compartment?- -- -- - - - - - - - - - -- ❑ ® ❑ W Effluent filter installed? -- - - - ❑ ❑ rn Septic tank size 10Bn gal Manufacturer Infiltrator o D-box water level and speed levelers used? - - -- - -- - ❑ wA ❑YES x❑ No J 00 Manifold/D-box accessible from surface?- - -- - - - - - - - - - - - - - ❑ x❑ ❑ 00Z Check valves installed? - - - - - - -- - - - - - - - - - - - - - - - - - - ❑ x❑ ❑ QM Transport Line Size 2" Schedule/Class 40 Bedrooms installed (check one) x❑ 2 ❑3 ❑4 ❑ 5 ❑6 ❑CommerciallOther >10 ft. from foundation?- - - - -- - - - - - - - -- - - ❑ N/A ® YES ❑ No >100 ft. from wells?- - -- -- -- - - - -- - - -- - - ❑ x❑ ❑ � >100 ft. from surface wateR - - - - - - - -- - - - -- ❑ W c rL >10ft. from potable water lines?- - - - - - - - - - - - ❑ ❑ '< Z > 5 ft. from property lines and easements?- - - - - Q ❑ R > 30 ft. from downgradient curtain/foundation drains? ❑ ® [�..4T�+ Q Drainfeld level and observation ports present - -- - - - - - - - - - -- ❑ ElErP ❑ Graveless chambers or ® Clean gravel used? (check one) No Proper cover installed over drainfield?- - ❑ ® EF Pump tank setbacks consistent with septic tank? ---- - - ---- - - - ❑ NIA %❑ YES Y Pump tank size l nan gal Manufacturer Infiltrator 24"access riser(s)and accessible from surface?-- - - ❑ ® ❑ It. Alarm or Control Panel Installed? - - - - -- - - - - -- - - ❑ ® ❑ f Control Panel equipped with Tmer/ ETM/Counter- - - - - - - - - - - ❑ ® ❑ 7 a Pump installed in ❑ Bucket or ❑ On Block or ® Other Orenco PVU48 Pump Make/Model O enco PF 3005 ❑x Floats or ❑ Transducer IL Tank draw down 1" in/min Pump capacity 26 gpm Squirt Height 6' fit Pump on time 2 min Pump off time 6hrs Daily flow set at 208 gpd Dommign Envelope ID:BDCAFCG5-F0774DBF-958F-EB3C89B4DC89 Mason County OSS Installation Report pg. 2 Parcel a 51901-50-01055 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? © YES NO If yes, please describe:Tank Pi mrwd and filled with Rnil Were all components pumped out and properly abandoned per WAC246-272A-0300? © YES NO RECORD DRAWING This Is a permanent mwM and must be accunb and desctlpMry mwu9M1 W m-bcNe In Me reetl a malmmname activMx and NNn development Typical Reoom DmangswMein: Dmimed6mer soltivienlalon&W,xvaeaw,umptanaloutim,NMnanox,reservedmff M.e.imimandprop dWIltli�e,br Mwelb,Wal iae, sells,miumm Yw wds,tlmwNs,eM Wller meirdman[e arose mints. Inwmmms Recall Drawings may ones,addinmad delays in final ineWl4lgn epVa'al and related psi E] Record Drawing Attached CERTIFICATION OF INSTALLATION INSTALLER DESIGNERI 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 1 further certify that all information contained on this =gpched Record Drawing is accurate. form and attached Record Drawing is accurate. 8/9/2024 Signature of Installer Date Jamie Workman Printed Name of Signes a- Signature MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report andRecord Drawing on behal/of Mason County PublicHealth:ature of Envirmuldhental Health Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE upmmd amrzots 0 9 g G 54 sc� m i .�sF o�ogy ��!F�psm �{ rWy �� o 3 3c yg€ s 0^4 ^ wHG R O n• A T m T 70•+� m I ns � � IQ I c?*, � IQ� e� D ar'-tt � f z � s G / & 81 \ O 1 i N W / A a_ o � � N � V O � N N C {I x. �i 9 -AZ yo o O 3� tiv o w i r �r Z m o > m C, o_ t` rrCD D °x_ r^ v N m B IFe➢` O C C N A ej C C C ID 3 N N S W 3 JO d N a O a m n n c w u � ym3� 3a AEo 0�on mm o » 4 m � y o wnmm m 'cww Cr amo x H } O 11 d N v� N N 0 C � INI � V• Abbreviated Description: LOST LAKE Lot 55 8 56 Block 1 °wnar/ pfi"n` David Milbourn �o 1072 W LAKESIDE DR ETNu "q M.Halverson Design LLC Asbuilt PO Box 1519 Shelton Wa 98584 PO Box 183 Parcel's# 51901-50-01055 (Structure) Halversondesi nllcoutlook.com HUMPTULIPS WA 98552 51901-50-01056 (Parts of) aE�soN.