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Home My WebLink AboutSWG2024-00077 - SWG As-Built - 9/18/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2024-00077 Parcel # 22113-24-00030 Applicant Name RANDY WILLIAMS Subdivision (Name/Div/Block/Lot) Applicant Address 1570 E GRAPEVIEW LOOP RD City, State,Zip GRAPEVIEW,WA 98546 Installer Name ACTIVE UNDERGROUND LLC Site Address SAME AS ABOVE Designer Name JAMES MEDCALF INSTALLATION CHECKLIST ❑ Full System Installation E Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other. System Type ADD PUMP BASIN FOR ADU Pretreatment Type >5 ft.from foundation? - - ------------------------- ❑NIA YES ❑ NO >SOft.from wells? ---------- --- --------------- .- ❑ e ❑ Y >50 ft.from surface wateR -------- ---------------- ❑ ® ❑ Z FCleanout between building and tank? ------------------- ❑ ❑ O Tank baffles present? - -- -- ---------------------- N ❑ ❑ t- 24"access risers over each compartment?--------------- - ❑ e ❑ L W Effluent filter installedl--- - - - - - - -- - ------ --------- ❑ ❑ N ORENCO Septic tank capacity(working) PUMP BASIN gal Manufacturer 0 D-box water level and speed levelers used? ------- ------- - WA ❑YES ❑ NO p0 Manifold/D-box accessible from surface?-- ------ -- - - - - - - - e ❑ ❑ mZ Check valves installed? - - -- - - - - -- - - -- - - - - - -- -- --- ® ❑ ❑ 04 2 Transport Line Size Schedule/Class Bedrooms installed(check one) ❑2 ❑3 ❑4 ❑5 ❑6 ❑CommerciallOther >10 ft.from foundation?- -- -- -- -- -- -- -- -- - -- - - - - -- WA ❑ YES ❑ NO C >100 ft.from wells?----------------------- - - - - -_ ® ❑ ❑ 0 W >100 ft.from surface water? - - - -------- - ------- - - - - - ® ❑ ❑ :< I�-1 ME >10ft.from potable water lines?- ---------------- - - - ❑ ❑t n QZQ >5ft.from property lines and easements?--- - ----- -- - - - -- ® ❑ ❑ K > 30 ft.from downgradient curtain/foundation drains?------ -- - - e ❑ ❑l G Dreinfield level and observation ports present - -- -- --------- e ❑ Ell /I t \M ❑ Greveless chambers or ❑ Clean gravel used? (check one) ! Proper cover installed over drainfield?------------------- ❑ ❑ ryi Pump tank setbacks consistent with septic tank?----- ------- - ❑ WA 0 YES Cl No `t Pump tank capacity(flood) Cal Manufacturer Z 24"access riser(s)and accessible from surface?------------- ❑ ❑ ~ Alarm or Control Panel Installed? -- --- - ----- --- - ❑ B ❑ a ❑ � Control Panel equipped with Timer/ETM/Counter---- -- -- -- - El ❑ a Pump installed in ❑ Bucket or ❑ On Block or E Other 2"SOLIDS PUMP IL Pump Make/Model LIBERTY LE41M Floats or ❑Transducer f a Tank draw down in/min Pump capacity opm Squirt Height ft Pump on time Pump off time Daily flow set at Opd Mason County OSS Installation Report pg. 2 Parcel# 22113-24-00030 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? -- -- - - - - - - - - - -- ❑ YES © NO If yes, please describe: Were all components pumped out and property abandoned per WAC246-272A-0300? -------- ❑ YES ❑ NO RECORD DRAWING This la apeohnnes,ncorE add must be amurM and dens tlra enough to rHaaals In Ms man of Mishana^u aNvaMa and Nrure dereblifini TYpaai RK°b Drawlya mMain: DreMaa6 reason adeMMion 6 leymr,segklWmp tank k aon.Novi mmw mserwdmiafieia,eashg and prgnmd tailored locagon ad wNis,-darirs, wars,oCxrvenon poi.aeamuh.and oner malmemnw areas pond laminate Retdd orewlnes may aeare additional Mil in final insmiaCm appravai and rNati penal'. 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 cleared/approved 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 at ormation on this I further certify that all information contained his ;n�hcst�e a ahed raw/ accurate. form and attached Record Drawing is a net . Date Printed Name of Signee MASON COUNTY PUBLIC HEALTH yt The undersigned approves this Installation Report and - R Record Drawing on behalf of Mason County Public S. NQ Health: Of 1(16fzy 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 upacrm emir ( AX OW FOR A�u� / (Te(aeV• \,049 RA. w , 30 _ Q lr L DCALF Ga ry D�rcum J' H&dae ti IMe�1 4.. � p drt/ar. po's✓PbT-�168 lodGR.l �t \ ' ® ell E b4 .1 'l ?y �k \00 a. Orenra SK,I:ds �...�+p Bar;n APPROVED -2 ~T��F Pipe Dbwloie tecAse *eo4vbt•4 uj%d ' ddJe0&-7 SEP 18 2M IMiA. 10#' H" 2odJ4Y ?;f�° +° Ge+L�+ MASON COUNTY ENVIRONMENTALHEALTH Z"ems SQe+� +6 TZZ RET t,KL--k of Soh dssK.