HomeMy WebLinkAboutSWG2022-00002 - SWG As-Built - 9/18/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY P BL33� A
APPLICANT/PERMIT INFORMATION
Permit Number SWG 2022-00002 Parcel# 22221-53-00080
Applicant Name Glenn Petersen Subdivision (Name/Div/Block/Lot) `
Applicant Address PC Box 2883 �
City, State, Zip Belfair WA 98528 Installer Name Shumaker Construction
Site Address 181 E Hillside Dr.Beftair Designer Name Advantage Perc&Design
INSTALLATION CHECKLIST
Full System Installation ❑Tank(.)Only ❑Ominfield only ❑Roper ❑Omar
System Type Graft Pretreatment Type
>5 R.from foundation? -----------------
j ❑NIA ■YES ❑ NO
>SO ft.from wells? -_________________________ _ ❑ e ❑
_ >50 ft.from surface water) ------------------------ ❑ ❑
fCleanout between building and tank? ._________________ . ❑ ® El
Tank baffles present? --------------------------- ❑ ® ❑
IL24'acces
s risers over each compartment?-----._-_ ❑ S El
W Effluent filter installed?-- --------------- ❑ El
tank capacity(working) l Manufacturer
�0 D-box water level and speed levelers used? -______________ ❑WA Yes ❑ No
O LL klanifold/D-box accessible from surface?-________________ ❑ ® ❑
GZ Check valves installed? --------- - - - ------------- - . ❑ ❑
f Transport Line Size 4- Schedule/Class 3034
Bedrooms installed(check one) ® 2 ❑3 04 ❑5 ❑0 ❑CommerciallOther
>1Oft.from foundation?------ - ------------------ - ❑WA ■vss NO
I] >100 ft.from wells?-________ ____________________ ❑ . ❑
Ij -100 R.from surface water? ------------------------ ❑ ■ ❑
Z110ft.from potable water lines?---------------------- ❑ . ❑
m
> El El
5R.from property lines and easeenis?-______________ _
>30ft.from downgradient curtain/foundation drains?-------__.Cl
❑ ® ❑
Drelnfield level and observation ports present -----_ _
❑ Graveless chambers or d?Clean gravel uaei(tlgok one) ❑ � ❑
Proper cover installed over drainfiekt?-- -_______________ _ ❑ ® ❑
Pump tank setbacks consistent with septic tank?------------ - WA El YES NO
Y Pump tank capacity(flood) gal Manufacturer
Z
;5 access nser(s)and accessible from surface?.______ _____ _ ❑ ❑ ❑
y Alarm or Control Panel Installed? --------------- ------ ❑ ❑ ❑
Control Panel equipped with Timer/ETM/Counter--------__. ❑ ❑ ❑
a Pump installed in ❑ Bucket of ❑ On Block or ❑ Other
a Pump Make/Modal
� ❑Floats or ❑Transducer
aTank draw down in/min Pump capacity wpm Squirt Helght ft
Pump on time Pump off time Daily flow set at gpd
IlpiiM MI309
Mason County OSS Installation Report pg. 2 Parcel It 22221-53-00080
ABANDONMENT RECORD
Were existing septic campaenw abandoned as part of this projS,7 .------------- . ❑ YES ® NO
If yes, please describe!
Were all components pumped out and property abandoned per WAC24&2T2A.03007------- - ❑ YES ® NO
RECORD D WING
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Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that I installed the system in accordance with 1 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 cleered/approved by both the designer shown here have been deared/app oved by both
and Mason County Public Health and meet all State myselt and Mason County Public Health and meet all
and Mason County Codes. State and Mason County Codes
I further certify that ell information contained on this I further CEIVY that all infomrafion contained on this
form and wing is accurate. form and attached Record Crowing is accurate.
9/l/2024
m of Installer Dale
Aaron Shumaker
Printed Name of Signs, *kv��
MASON COUNTY PUBLIC HEALTHThe undersigned approves this Installation Report and
Record Drawing on behalt o/Mason County Public
Health �wL Ci(lia/zcf
Sgnature aJ Env ealth SI U&,st Date
(stamp, signature and date)
THIS FORM MAY BE SCMINED AND AWMIABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Mwr<v ver,rora
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