HomeMy WebLinkAboutSWG2021-00009 - SWG As-Built - 9/3/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATION
Permit Number swGf]�OZl-000C 9 Parcel# ,"&W-M-981IM3 123�26t0o,52 0
Applicant Name Patricia Gneiding Subdivision (Name/DivBlock/Lot)
Applicant Address 111 NE Rivewmill Dr Lot 3 SP#2789
City, State,Zip _Allyn WA 98524 Installer Name Tom Weaver/Allied Desi n
Site Address 160 Old State Hwy 3;Allyn Designer Name Tom Weaver
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type Gravity Pretreatment Type
7 15 ft from foundation? -- --------------- --- - - ----- ❑wA YES ❑ ao
>50 ft.from wells? -- -------------------------- - ❑ ❑
Z >50R.from surface water? --------------------- --- ❑ K1 ❑
F Cleanout between building and tank? ------------------- ❑ In ❑
tl Tank baffles present? --------------------------- ❑ ❑
d24"access risers over each compartment?---------------- ❑ K1 ❑
N Effluent finer installed'---------------- - - -------- - ❑
Septic tank size Two tank51,259al Each Manufacturer Hagerman
I 0 D-box water level and speed levelers used? ------ ------ - -- WA YES ❑ No
j 0O Manifold/D-box accessible from surface?-------- ------ --- ❑ ❑
1 Check valves installed? ------ ------ ---- ------ --- ® ❑ ❑
f Transport Line Size 4" Schedule/Class 3034
Bedrooms installed(check one) ❑ 2 ❑3 )C 4 ❑5 ❑8 ❑Commercial/Other
>10R.from foundation?---------------------- ---- ❑ WA ®YES ❑ xo
0 >100RRomwells?----------------------------- ❑ ❑
W >100 ft.from surface water? ----- ---------- --------- ❑ ® ❑
LL >10ft.from potable water lines?---------------------- ❑ ® ❑
?
a >5 ft from property lines and easements?----------- ----- ❑ ® El
R >30 ft.from tlowngretlien[curtainttountlalion tlrelns?---------- ® ❑ ❑
Drainfield level and observation ports present----- ----- - --- ❑ ® ❑
® Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfiekf?------------------- ❑ ® ❑
Pump tank setbacks consistent with septic tank?------------- WA ❑ rEs � Ro
ZPump tank size eai Manufacturer
FQ- 24'access nser(s)and accessible from surface?--- --- - ----- - ❑ ❑ ❑
R Alarm or Control Panel Installed? -- ------------- --- --- ❑ ❑ ❑
Control Panel equipped with Timer/ETM/Counter----- --- --- ❑ ❑ ❑
Il Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
a Pump Make/Model ❑Floats or ❑Transducer
aTank draw down in/min Pump capacity apm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
umweersimrs
Mason County OSS Installation Report pg. 2 Pence l Y 22221-53-00050
ABANDONMENTRECORD
Were existing septic components abandoned as pall of this project? --------------- ❑ YES ® NO
If yes, please descAbe:
Were all components pumped out and properly abandoned per WAC246272A-03007 --- --- -- ❑ YES ❑ NO
RECORD DRAWING
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See Attached
Qt Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
/certify that I installed the system in accordance with /certify that the system has been installed in accor-
the septic design stomped'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 clearedlapproved by both the designer shown here have been clearedlapproved 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 al/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.
% A�1, 09/28/2023
Signature of installer Date
Home Owner
Printed Name or SW&a
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and ' stdblt3
Record Drawing on behalf of Mason County Pubic iHofus E'vAl'vEa`'
N p"
Health/ 0 rsN J-lL l
Date ,
Signatu oI nmAnmenta/H al Sr Spadalist Dote (Stamp, Signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEN SITE uwwsarmn
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