HomeMy WebLinkAboutSWG2023-00191 - SWG As-Built - 9/23/2024 1
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number swD ao — awl Parcel# 3,2o/6 —53— 0400,7.
Applicant Name �i¢ydy./� /nh. /,tJL Subdivision (Name/Div/Block/Lot)
Applicant Address 4A-, `&V 249 /
City, state,Zip ZQFK Z4'r AJAR SS 3S{e Installer Name -5;0 �dGc�tJ' �/.hicd��dR
Site Addret er Name 0. 1t
d
INSTALLATION CHECKLIST
)Eull System Installation ❑Tank(s)Only ❑ Dreinfield Only ❑Repair ❑Osier
�- O
System Type Pretreatment Type
>5 ft.from foundation? --------------------------- ❑, WA YEs ❑ No
>50 ft.from wells? ----------------------------' I� —❑/ ❑
Z >50ft.from surface water? ------------------------ ❑ ,�" / ❑
tQ- Cleanout between building and tank? ---------- ------ ❑ ❑L—
U Tank baffles present? --------------------------- ❑ IId' j. ❑❑
a 24"access risers over each compartment?---------------- ❑ —®//
NEffluent filler installed?------t�--------------- ❑3 IId' !� � ❑
Septic tank capacity(working) al Manufacturer `,j*"Y&U�AA//2R!r 7-
o D-box water level and speed levelers used? --------------- ❑ wA Lyr[s ❑ No
0J /
0 Manifold/D-box accessible from surface?----------------- ElM- ❑
a?Z Check valves installed? -------------------------- ❑ Ly' ❑
02 Transport Line Size �t Schedule/Class
Bedrooms installed(check one) - ❑2 1f4l' ❑4 ❑ 5 ❑6 ❑Commercial/Ot. hey
>10 ft.from foundation?------------- -------- ❑ wa yEs ❑ No
>100ft.from wells?----------------------------- Ly" ❑J ❑
>100 ft.from surface water?------------------------
❑ L'-7 / ❑
LL >10 ft.from potable water lines?---- ------------------ ❑ (� ❑
QZ >5 ft from property lines and easements?---------------- ❑
C >30ft,from downgredient curtaintfoundation drain?---------- ❑ [.�/ ❑
Dreinfield level and observation ports present -------------- ❑ L7 ❑
M�Graveless chambers or ❑ Clean gravel used? (one&one)
Proper cover installed over drainfeld?------------------- ❑ ❑
Pump tank setbacks consistent with septic lank?------------- ❑ wa yEs ❑ No
Y Pump tank capacity(flood)�al Manufacturer 14is�---✓✓✓✓ 180 F'UMa-✓ ^7��
Q24'accessriser(s)and accessible from surface?------------- �(,y280 ❑
y Alarm or Control Panel lnstalled7 --------------------- ❑
Control Panel equipped with Timer/ETM/Counter----------- ❑ ❑
7
a Pump installed in u''c//k��et or ❑ On Block or ❑ Other
tl Pump Make/Model �5PG�7fir/ �i19T loafs or ❑ Transducer
Tank draw down�inimin Pump capacity DSO gpm Squirt Height ft
iL ��//�, _
Pump on time 25 N�u.1 Pump off time Daily flow set at yv pd
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Mason County OSS Installation Report pg. 2 parcel#
ABANDONMENTRECORD
Were totaling 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-03007 -------- ❑ YES NO
RECORD DRAWING
Thn m.Inm,mmt r.paa-it...I ss axame.m w.nui anwsh to m locate in m.noon m meman.nr..activities and fume.aavelapmmt. Tno-I R.
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IN Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
l 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 Clearedrapprovetl by both the designer shown hue have been cloamNapproved 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 all information contained on this
form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
Signature ller Date
�N.vY /?f(CRf
Printed Name of Signet 9/23/24
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and -
Record Dmwing on hall Mason County Public rG,
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Healtt h u ,
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own g Iz31z�
Signature of Environmettall Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBIC VIEW ON THE MASON COUNTY WEB SITE ikawentrmte
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