HomeMy WebLinkAboutSWG2021-00584 - SWG As-Built - 10/22/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
n ,r APPLICANT/PERMIT INFORMATION
Permit Number SWIG yp�- (,(���gig,
P.a-rcrel#
Applicant NameMLM,
lvision (Name/Div/Block/Lot)Applicant AddressCity, State, Zipff/ Installer NameSite Address Designer Name K
INSTALLATION CHECKLIST
❑ Full System Installation nk(s)Only ❑ Drainhad Only ❑Repair ❑Other
System Type '.xA"rY Pretreatment Type
>5 ft, from foundation? - --- ,_ 1 ffrC ^=�h_ _ _ _ _ _ _ __. ❑ NIA YES ❑ NO
>50 ft.from wells? -- - --- - --- - - - - - - _ _ _.- ❑ ❑
Z >50 ft.from surface water? - - w`-�AAk*A'd _ _ _- ❑ ❑
HCleanout between building andtank? - - -- - - -- - - - - - - - ---- ❑ X ❑
V Tank baffles present? - - - - - - - - - - - - - - - - - - - - - - - -- -. ❑ LY'I' ❑
1 24"access users over each compartment?-- - - - - - - -- - - - - - - ❑ -//Y`_'q ❑
u1 Effluent filter installed?- - -- - ---- - - -- - -- - - -- - - - - - - - ElI
N
Septic tank capacity(working) Q% sal Manufacturer KQ A-A.
J D-box water level and speed levelers used? - - - - - - - - - - - - - - - �IA ❑ YES ❑ No
p0 Manifold/D-box accessible from surface?- - --- - -- - --- - -- - - ❑11-
'Kzl' ❑
G< Check valves installed? Lid❑ U`❑-'\ ❑
r
f Transport Line Size Schedul lass
Bedrooms installed (check one) ❑ 2 -.Y " ❑4 ❑ 5 ❑6 ❑Commercia]/...O,,,///ther
>10 ft.from foundation?- - - - -- - -- - - - - - - - -- ❑ NIA (�I yES ❑ NO
>100 ft. from wells?-- - - --- - -- - - - 6
-sit Cl ❑
W >100 ft.from surface water? - - - - -- - - - - - - - - - - - - - - - - - - ❑ El
LL >10ft.from potable water lines?- - - -- - - - - - - - - - ❑ ❑
QZ >5ft,from property lines and easements?- - - -- - - - - - - - -- -- ❑ ❑
K >30 ft.from downgradient curtain/foundation drains?- - - - - - -- - - ❑ ❑
Drainfield level and observation pods present ❑ ❑
❑ Graveless chambers or Clean gravel used? (check one)
Proper cover installed over drain field?- - - - - - -- -- -- - -- ---- ❑ ❑
Pump tank setbacks consistent with septic tank? - --- - - -- - -- - -/❑ NIA YEs ❑ No
2 Pump tank capacity(floo
d)j LI v 2 _gal Manufacturer o
Q 24"access dsli and accessible from surface?- - ❑ ❑
LLAlarm or Control Panel Installed? -- - - -- - -- - -- - - - - - -- - - ❑ ❑
Control Panel equipped with Timer/ETM/Counter- - - -- - - - - - -
IL Pump installed in ❑ Bucket or On Block or ❑ Other
a Pump Make/Model / ]oats or ❑ Transducer
IL Tank draw down min/min Pump capacity gipm Squirt Height ft
Pump on time Pump off time Daily flow set at pd
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unty OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
ng septic components abandoned as part of this project? - - ❑ YES NO
e describe:
mponents purriped out and property abandoned per WAC246-272A-0300? - - --- - -- ❑ YES No
RECORD DRAWING
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w Is.c usvaoon Wis.aeanwu.aM oNnr maimere access wino. Incaryku Rd rmWyas,aeala.&..Idea,in final iradutenawmvalaM M.ba w/min.
❑ Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that/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 clearedlapproved 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 Crowing is accurate.
/d li 5/2Y
Signature of Ins Iler Date
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
CjrreEyvvh 10 I wzz v
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 uw.iea azvmla
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Printed t?
A---ad,,,--+lason Cou ; DMS
M'q.�County OMS