HomeMy WebLinkAboutSWG2024-00341 - SWG As-Built - 10/22/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 'JI)L`t- C%Z'j `f/ Parcel #
Applicant Name r'e. :��.:iKO Subdivision (Name/Div/Block/Lot)
Applicant Address ,f
City, State, Zip l'e,4 .. „ (/ Q pinstaller Name
v` i tL
Site Address Q Designer Name
INSTALLATION CHECKLIST
❑ Full System Installation kTank(s)On ❑ Drainfield Only ❑Repair ❑Other
System Typed ✓I IN Pretreatment Type /`:DNC
>5 ft. from foundation? --- -- ----- ❑ WA EYES ❑ NO
Z >50ft. from wells? -- - - - - - - - -- - - \��{1�� � a ❑
Y >50 ft. from surface water? ---- -- - �_✓ ❑
FCleanout between building and tank? -- O-� g���___- ❑ ❑
O Tank baffles present? - - - - -- - - - - - - ❑
d24"access risers over each compartment?- - -- -- - -_ _ ❑ ❑^ ❑
ulEffluent finer installed?-- - -- _ _ _ _ ___ 8l � ❑ ❑
Septic tank size_ lle gal Manufacturer
�o D-box water level and speed levelers used? - - - -- --- - - - -- . ❑ WA ❑ YES NO
OO Manifold/D-box accessible from surfs . -- - - -_ _ ❑ ❑ ❑
192 Check valves installed? .- - - -- -- --� _ _ __-_ _ _ ❑ -= ❑ ❑
f Transport Line Size Schedule/Class
Bedrooms installed (check one) ❑ 2 ❑3 ❑4 ❑5 ❑6 ❑CommerciatrOther
>10R from foundation?-------------------------- ❑ WA El YES ❑ NO
p 1100 R.from wells? ---------------------------- ❑ ❑ ❑
W >100 ft- surface water?•----- ❑ ❑ ❑
M >10ftfrompotablewaterlin •--.�A- -- _______- ❑ El ❑
Z >5 ft. from property lines a d aasemaltts'+ /- ❑ El El>30 ft. from downgradient c -____ - ❑ ❑ ❑
Drainfield level and observation ports present - - -- ---------- ❑ ❑ ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield? - _- ❑ ❑ ❑
Pump tank setbacks consistent with septic tank?-- ___
❑ WA ❑ yES ❑ NO
Y Pump tank size gal
Z nufacturer
Q 24'access risers)and accessible f:O/n
urface?- --------- -- ❑ ❑ ❑
~ Alarm or Control Panel Installed? ❑ ❑
jControl Panel equipped with Ti r MM Counter ❑ ❑ ❑
0- Pump installed in ❑ Bucket or Block or ❑ Other
IL
Pump Make/Model ❑ Floats or ❑ Transducer
a Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
�bemeemame
Mason County OSS Installation Report pg. 2 Parcel# 723/ �5 -SO "00 113
ABANDONMENTRECORD
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? --- --- -- WYES NO
RECORD DRAWING
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econl Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNERI ENGINEER
1 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 all information contained on this I further certify,that all information contained on this
form tilt hed Record Drawing is accurate. form and attached Record Drawing is accurate.
0/-0/-
Installer Date
,C�-,PZIAJ )0, ��66
printed Name of Signee
MASON COUNTY PUBLIC HEALTH "� f
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
Signature ofEnvironmentid Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE IbdwCamrmrs
RECORD DRAWING cont)nu
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R�PI��,�.�s I2Ua 2,1, �
APPROVED
OCT 2 2 204
MASON COUNTY ENVIRONMENTAL HEALTH
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