HomeMy WebLinkAboutSWG2019-00285 - SWG As-Built - 9/3/2024 1
Mason County OSS Installation Report pg. t MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERIM INFORMATION
Permit Number SWG 20/5 -oo f Parcel# 3z-I z -7 S- -'To � G/
Applicant Name _ciga,eua cusr ' Subdivision (Name/Div/Block/Lot)
Applicant Address Z/22 3'_ Wrc4Gxc,v rr _SP *2rro for i
City, State, Zip 77f4um,,,9. u ,f 9sr6. 3 Installer Name
Site Address Designer Name G'-,.,i 'Fc,rr.,75-
INSTALLATION CHECKLIST
uA SYat—Installation ❑Tbhla)Only ❑aainrisid any ❑Repair ❑Dawr
System Type S,1 // Prc r Pretreatment Type 4Vfil-
>5ft.fram foundation? --------------------------- ❑NIA YES ❑ NO
>50ft.from wells? --- --- ------------------------ ❑ ❑
Z >50 ft.from surface water? _______________________- ❑ ' ❑
FCleanout between building and tank? ------------------- ❑ ❑
O Tank baffles Present? . . . . ...................__- ❑ ❑
O~. 24"access risers over each compartment?.__....._______. ❑ . ❑
WEffluent filter wlstalled?----- -- ----- --____________.- ❑ . ❑
Septic tank capacity(working) ail Manufacturer
�0 D-box water level and speed levelers used? ._____ , NIA ❑ve9 ❑
Ou Marifold/D-box accessible from surface?---------------- - ❑ ■ ❑
C= Check valves installed? -_________ _ _ ______________ ❑ ■ ❑
Transport Line Size 1mr Schedulanass 40
Bedrooms installed(check one) ❑2 03 ❑4 ❑5 ❑S ❑CcmmandoCitti
>10A.1romfoundation?----- --- - - - - ------ -------- ❑WA ■vEs ❑ No
G >100R from wells?---- ------------------------- ❑ . ❑
m >100 It.From surface water?-__ _____________________ * ❑
M 110R from potable waterlines?-- --------- 0 ❑
Z >5ft.from property lines and easements?---------------- ❑
9 Q ❑
>30 ft.from downgradient curteintfoundetion drains?--_____.__ . ❑ ❑
I O Drainfield level and observation ❑ ❑
ports present -_______.--------- -----
9 Graveless chambers or ❑ Clean gravel used? (check tine)
Pmper cover installed over drainfiekl?------- --- --------- ❑ ■ ❑
Pump tank setbacks consistent with septic tank?---_________ . ❑ NIA i vea ❑ No
= Pump tank capacity(flood) fade at Manufacturer ILx`�efv..a.vx
24`access risers)and accessible from surface?------------- ❑ . ❑
S Alarm or Control Panel installed? -------------------- - ❑ . ❑
Control Panel equipped with Timer/ETM/Counter-----------
'p ❑ ❑
a Pump installed n ❑ Bucket or On Block or ❑ Other N Q4,1 W
� - I 12h,ms -bn-0.r Blselu�
Pump MakeMtodel L--�N,f A:j z" Floats or ❑Transducer
2 k Tan draw down �r in/min Pump 6 p capacity yr gpm Squirt Heigh/ 1.2 p
Pump on tlme y3,nr.. Pump off time /Z .4es Daly flow set m J 6o apd
a v,m.exvmne
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Mason County OSS Installation Report pg. 2 Parcel/ ITllO S350o70
ABANDONMENTRECORD
Were existing septic components abandoned as can or Nis protect+ --- - ----------- ❑ YE7
If yes. please describe:
Were aY components pumped out and properly abandoned par WAC246272A-03009 -------- Yes NO
RECORD DRAWING
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uieeeamn+dmm�mewammssmwm�bw amaon.umn.Aw.mw.aar.a.msv.�a wwven saalma camdwn..e.aw.
Nb.Mnvaban KN.W.rai4.Yn Mx.Waenammxx Mntc Irccrnd.0 FbmJ IAew9cmaYaaiw sWarW Jtlan In MI mWYbn Ym/YMiMW O..a..
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 acrxar-
the septic design stamped'APPROVED'by Mason dance with the septic design slampad"APPROVED'by
County Public Healer and that any deviations shown Mason County Public Health and that any de Nations
here have been deeredlapproved by both the designer shown here have been dearedilapprved by both
and Mason County Public Health and meat all State myself and Masan County Public Health and meet all
_ and Mason County Codes. State and Mason County Codes
I further cattily that all information contained on this I further comity that all information contained on this
to"and attached Record Drawing is accurate tor,end starred Drawing is accurate.
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Signature dlnafalbr Data
Efi c br aA�
Pdnred n/ema orsig a x
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MASON COUNTY PUBLIC HEALTH O 246080
The and Report
rNsigned appzves this Installation Re m and 6f ey
MA a
Record Drawing on behalf of Mason County Public
Health. �--
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Signature of EnNronmenref Meetth spacialiat Data
(stamp,signature and date)
THIS FORM MAYBE SCANNEDANO AVNUBLE FOR PUBLIC NEW ON THE MASON COUNTY WEB SRE las"`°.1.1
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