HomeMy WebLinkAboutAFTER THE FACT FOR MAIN HOUSE - SWG As-Built - 9/9/2024 111- I A ter ¢he- 4 f &bUrtf- forill hoU5L-)�-
Mason County OSS Installation Report pg. t MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATION
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Permit Number 4WG. Parcel# ZZIZ!- /-oeol0 /111
Applicant Name W 7re�g,n1 Subdivision (Name/Div/Block/Lot)
Applicant Address III E. Tr c�nAr1 C+- l 2 - 1 2w - L F16 9
City, State, Zip c>)r ion wA 985R4 Installer Name
Site Address f Designer Name
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INSTALLATION CHECKLIST
❑ Full System Installation ❑Tank(s)Only ❑ Dralnfeld Only ❑Repair ®Other IZ r n
System Type 6rftV'A4 Pretreatment Type O
>5 ft.from foundation? - -------- ------------------ [I NIA ®YES NO
>50 ft.from wells? ---- - - - - ------ -- --- Cl ® ❑
Z >50ft.from surface water? -- - - -- -- -- - - -- ElZI El
fCleanout between building and tank? ------ --------- - --- ❑ ® ❑
V Tank baffles present? - __ _ _ _ _ __ __ ____ ____ _ _ _ __ __- ❑ ® ❑
C24"access risers over each compartment?--------------- - ® ❑ ❑
NEffluent filter installed?- - - - - --- --- - - - - - - --- - - - -- - - ® ❑ ❑
Septic tank capacity(working) [,0o 0 oal Manufacturer Unk"WA
D-box water level NIA YES NO
00 Manifold/D-box accessible from surface?- - - - - --- -- - ---- - - ® ❑ ❑
GQ Check valves installed? - - - - - -- -- -- - - - - -- - - - -- -- -- m El El2 Transport Line Size-4/-A— Schedule/Class—d/A
Bedrooms installed (check one) ® 2 ❑3 ❑4 ❑5 ❑6 ❑Commercial/Other
>10ft.from foundation?- - - - -- -- -- - - - - - - - - - - - -- --- ❑ NIA ® YES NO
>100 ft.from wells?- - - - - - - -- - - - - ❑ R1 ❑
W >100 ft.from surface water? - - - --- - - - - -- - - - - - ❑ ® ❑
LL >10ft.from potable water lines?- --- -- - -- - - - - ❑ K) ❑
QZ >5 ft.from property lines and easements?- - - - - - - - ❑ m ❑
K >30 ft. from downgradient curtain/foundation drains?- -- -- -- -- - to ❑ ❑
Drainfield level - -- -- -- -- - - --- ❑ ® ❑
❑ Graveless chambers or 1g Clean gravel used? (check one)
Proper cover installed over drainfield?- - - - - - - -- - - - - - - - --- ❑ ❑
Pump tank setbacks consistent with septic tank?--- -- -- ---- - - NIA ❑ YES ❑ No
X Pump tank capacity(flood) oat Manufacturer
Q24"access riser(s)and accessible from surface?---------- --- ❑ ❑ ❑
~ Alarm or Control Panel Installed? -------------------- - El ❑ El ,,-WQ
a
Control Panel equipped with Timer/ETM I Counter- -- -- -- - - -- ❑ ❑ ❑ ; m '
a Pump installed in ❑ Bucket or ❑ On Block or ❑ Other r
t o
0. Pump Make/Model ❑ Floats or ❑ Transducer I '
Tank draw down in/min Pump capacity epm Squirt Height fq N
a r
Pump on time Pump off time Daily flow Set at r pd
upaaue arzinoie O
py 04 3
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Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENTRECORD
Were existing septic components abandoned as part of this project? - - - - --------- -- ❑ YES NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - - - - --- ❑ yES ❑ No
RECORD DRAWING
Thb a a ponnarem ncera and m..be accurate aral E+acrMlw emuyN m re4a[a41n"rwG of nand nancn+cflvltln aM NWn Eas*dp,a nt Twodi RacaN
Dmwinpa corawn: Dra of eld&maMr fa onendtion 8layaul,SnptiNpump sank location.Norh arrow,reserve dreinred,edatiig and pmp+ad ba digs.bmtion of and,waterline,
vrelle,Mesnalron pals.Gmiwub,eM a1Mr maintenance aa'zaa paint. Inwmplda Rem�d DreMMrga meY ureale addlllpwl dNeys m hul'rresalletim approval and iesal�pemJts.
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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 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 clearedtapproved 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
form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
Signature oflnstaller Date
Printed Name of Sign"
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report andow,o P7 .
Record Drawing on behalf of Mason County Public
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Health:
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Signature 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 upeama n+adle
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