HomeMy WebLinkAboutSWG2024-00086 - SWG As-Built - 9/16/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG LD24 — Cn[MJ(,y� Parcel# j Z4 C) G COLA
c 1
Applicant Name /- J ��n,,.cy I<I?—t1-� Subdivision (Name/Div/Block/Lot)
Applicant Address PO bOX Jul _
City. State, Zip /„�{7-7 y'<£4J IJh S Installer Name dl! N £1`,, LamY
Site Address S-q Mt= Designer Name J N
ALLATION CHECKLIST
[:] Full System Installation Tank(s)Only ❑Drainfield Only ❑Repair ❑Other Z
System Type Pretreatment Type R 24
>5f.from foundation? ------ - - --- -- --- -- ---- - ---- ❑ NIA ❑
>50 ft.from wells7 --- ------ - -- ----- ❑ lq�/�/ ❑
z >50 ft.from surface water? ----- B -9J -0 TE ❑ "/ ❑
H Cleanout between build end tank - ----------- - ❑ l� ❑
p Tank baffles preaenl7 .- ---- -- --l};}jr;;Q-2l}2�" - ❑ ❑
F 24•access risers over each comps ?"---------- -- ❑ ❑
NEffluent filter installed?- - -- --- BY----Y.l�"-+----- -- ❑ ❑
Septic tank Size Ay oa
0 D-box water level and speed levelers used? --------------- NIA YES ❑ NO
QUO Manifold/D-box accessible from surf --------- ----- ❑ ❑
yr- Check valves ----- --- --- --------------- ❑ ❑ ❑
C
aneport Line Size ScheduldClees
Bedrooms installed(check one) 02 ❑3 04 ❑ 5 06 ❑C a/Other
>10ft.from foundatioM------------------------ WA ❑YES NO
r..s >100 ft.from wells?-- - -- --------------- ------ ❑ ❑ ❑
C7� >100 ft.from surface water? ---------- ------------ ❑ ❑ ❑
ti >10 ft.from potable water lines?--- ----------------- ❑ ❑ ❑
<Zca >5ft.frompropany lines a sements?---------------- ❑ El ❑
O >30 from down a ft. it curtain/foundation drains?---------- ❑ ❑ ❑
CCC Drainfialtl end observation ports present -- - ----------• ❑ ❑ ❑
veleas chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?------------------- ❑ ❑ ❑
Pump tank setbacks consistent with septic tank?------------- ❑ WA ras ❑ No
Y Pump tank size /OOU at Manufacturer erwlIII
a^Z ❑
H 24"access riser(s)and accessible from surface?---- ---
------
4 Alarm or Control Panel installed?- ---- -- --- ---------- ❑ ❑
� Control Panel equipped with er/ETM(Counter----------• ❑ ❑
a Pump Installed In cket or ❑ On Book Or ❑ Other
O. Pump Make/Model Y LAO Frtl or ❑Transducer
f
a Tank draw down in/min Pump ospeciy 7-1 opm Squirt Height�ft
Pump on time Pump off 6ne Deily How set at t,,k LAypd
ll{MMBR1R00
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-03004 - - -- ---- ❑ YES ❑ NO
RECORD DRAWING
TM.Is•ynm-ent WON and mun M.awa,and a..ctivnw enough m n.IMa.In one;need el ah.'W—o..en.uln and wmn a..nugn.nv T".agNO
oi.,:rs.ao.ul.. d .. 'ednnaeawdwdd,rean swdos.- mweuon.rcrn—'W.. dh.,.an....imv-deWvohdoeuay.,mmona..x..«a.m...
wNl..aee.v.ron om..Wnwl..end onamaam.nu.wn gams. mmmq.i.n.wm Dianna.Con t..a.seauldne dd.r.in m.i m.wa.wn......'.I.ra nlaw vaddu.
B�,Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that 1 installed the system in accordance with 1 certify that the system has been installed in eccor-
the septic design stamped"APPROVED'by Mason pence with the septic design stamped"APPROVED"by
County Public Health and that any deviations shown Meson County Public Health and that any deviations
here have been c/aandvipproved by both the designer shown here have been clearetl/eppov i d 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 s#informat/on Contained on this
111�m Br afte etl ecoN rewing is accurate. form and attached Record D is accurate.
i Signetura nstaller Data
1 � Ce -22- 2
Pn'nted Ne orsignee J y1ual"'+ T
MASON COUNTY PUBLIC HEALTH 3P - ° 3 �
H A
The undersigned approves this Installation Report and stern y,
Record Drawing on behalf of Meson County Public (AMES t MafTER .
tic IF fsFttfitlER
Health:
kJpP`Cy�� v1p`i6� q
Signafum of En a,,msnfal Health spasnalist Date (stamp,signature and dale)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE u.aaaerzndu
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