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HomeMy WebLinkAboutSWG2023-00464 - SWG As-Built - 9/25/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/-PERMIT INFORMATION Permit Number SS\W� G ZDVL CIWAy Parceln cCIGl7'S,C- 0(yyl b Applicant Name � "o ij nn. Lk k % . Subdivision (Name/Div/Block/Lot) Applicant Address ki R)(1v tL 1`� City, State, Zip t�A t%on .k zR9t7h91 d Installer Name j�(yut. Qflwua Site Address 1l W LmiOl' Designer Name GP M R-U't1�Cr ,INSTALLATION CHECKLIST " 4Full System Installation ❑Tank(s)Only ❑Dralnneld Only ❑Repair ❑other System Type (P,t" XnZ Pretreatment Type >5 ft.from foundation? --------------------------- ❑MIA YES NO >50 ft.from wells? ------------- --------------- ❑ ❑ ZZbd >50ft.from surface water? ---- -- ----- ------------- ❑ ❑ FCleanout between building and tank? -------- ---------- ❑ ❑ C -Tank baffles present? -------------- ------------- ❑ ❑ F 24"access risers over each compartment?-_-------------- ❑ L��y(L/� ❑ 'N ,Effluent filter installed?-------------------------- ❑ Septic tank capacity(working) i1uz) sal Manufacturer ti}® (JYPPAA- I� gO D-box water level and speed levelers used? -------------- - [5�'MIA ❑YES ❑ NO gJ O ManlfoldlD-box accessible from surface7---------------- - (� ❑ ❑ fQ Check valves Installed? ------------------- ------- [(� ❑ ¢ :: Transport Line Size I Schedule/Class _ Sc41 � Bedrooms installed(check one) P 2 ❑3 ❑4 ❑5 ❑6 ❑CommerclaVOther >10ft.from foundation?------------- ------------- ❑ WA (SI YES ❑ No G >100 ft.from wells?-- ----------------- ---------- ❑ ® ❑ wJ >l00 ft.from surface water? ----------------------- - ❑ �f ❑ :W`.. >10ft.from potable water lines?--------------------- - ❑ ® ❑ ,Z >5ft.from property lines and easements?•-------- ------- ❑ ® ❑ >30 ft.from downgmdient curtain/foundation drain?---------- ❑ LRJ ❑ Dreinfeld level and observation ports present-------------- ❑ L�j ❑ ❑ Graveless chambers or ❑ Clean gravel used? (check one)9 A -Servel Proper cover Installed over drainfield?------------------- ❑ ® ❑ Pump tank setbacks consistent withseptic tank?------------ - ❑ MIA OYES ❑ No d Pump tank capacity(flood),��gel Manufacturer �TIfPPnd� ,F 24"access riser(s)and accessible from surface?------------- ❑ .®; ❑ Alarm or Control Panel Installed? -------------------- - ❑ ❑ �, '.. Control Panel equipped with Timer/ETM/Counter- -------- -- ❑ ❑ IL Pump installed in ❑ Bucket or [a On Block or ❑ Other " a Pump Make/Mcdel L$Floats or ❑Transducer IL Tank draw down in/min Pump capacity N'O� apm -V Squirt Helght Dr-r AA ft Pump on time ier _ Pump offtime-p� r _ Daily flow set at apd updrudsavMIS Mason County OSS Installation Report pg.2 Parcel# ABANDONMENTRECORD Were existing septic components abandoned as pan of this project? --------------- YES MNO If yes,please describe: 7"'f Were all components pumped out and properly abandoned per WAC246-272A-03007 -------- ❑ YES N NO RECORD'DRAWING Ts.b a g o..t record end muer he..cunt.end dee dxf-e1e41 eo nAmeb In an roved el melnbnencs eglvlbf anti Nrvn devabpmenl. Typkel WwN OmNrge conbin:OIBFfieltl 6 menilotl oMnlatlsl8 LSynK ae0tlrlgmD IeN butlan,NDnh enow.lefm'e dreWbld,nlflin0 eM ycpYed gltivga.kmlionolwelle,webMnu, walb,oMervelbn Woe,ckanwlf,aM clMl mainbnarcf ecceu gYnb. YNenlpbb Repyd omM,pe grey ueale edlWoneldelryf bficl InNeMbneppmrel eMreleW pmiy, ❑ Record Drawing Attached CERTIFICATIONIOF INSTALLA ION INSTALLER DESIGNER/ENGINEER I certify that I installed the system in accordance with I certify that the system has peen 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 clearedlepproved 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. � q I 20 t Si natwa of Installer -- Date Printed Name ofSynee MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report and Record Drawing on behalf o�hM�asso�n County Public Heelth `'• 1 - �-�1 Signature ofEnvlronmental lissith Specialist Date (stamp,signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE upe.bdanlaola / APPROVED © paA MASON c,ENVIRONMENTAL HEALTH m . , � � | ) � � - \ � :