HomeMy WebLinkAboutSWG2021-00388 - SWG As-Built - 10/15/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number S1kW,G 213ti1- 6�) 38 ( Parcel# 3ti02) -SID- OSd10
Applicant Name LGyv) cr�k\�.hr� Subdivision (Name/Div/Block/Lot)
Applicant Address `1va1 W-le 4 ,3cC— 0 1 ` , ` 1 �y
City, State, zip (nrc.Hc.,., I wY\ Rtg ZDo Installer Name 6\t)N1 L brck k71.
Site Address C'lp.\ . Wnty) Ln. Designer Name (2i'hw'\ �Y\�t(X'
INSTALLATION CHECKLIST
Full System Installation ❑Tank(s)Only ❑Drainfield Only ❑Repair ❑Other
System Type kkx'2)bn Pretreatment Type
>5 ft.from foundation? - ------------- ------------- ❑N/A krYEs NO
>50 ft.from wells? -- -------- ------------------ - [I8r ❑
Z >50ft.from surface water? ------------- - -- -- ------ ❑ �R" ❑
Cleanout between building and tank? ------------------- ❑ ❑
U Tank baffles present? - --- ---- --------- ----- - ---- ❑ ❑
1 24"access risers over each compartment?-- -- - ------ ---- - ❑ ❑
rW Effluent flier installed?------ -------------------- - ❑ ❑
Septic tank capacity(working) gal Manufacturer \U . MA4,-t ,
O D-box water level and speed levelers used? ---------- --- - - ❑NIA ❑YES ❑ NO
G2Manifold/D-box accessible from surface?--------------- - - ❑ ❑ ❑
s?— Check valves installed? ---------------- -- -- ------ ❑ ❑ ❑
O
Transport Line Size Schedule/Class
Bedrooms installed (check one) 1�'2 ❑3 ❑4 CIS ❑6 ❑Commercial/Other
>10M,from foundation?-- --- - - - -- --- ------ ----- -- ❑ NIA JR'YES NO
G >100 ft.from wells?-- ---- ----------------- ------
Lid ❑ �' ❑
>100 ft.from surface water?------- - - - --------- -- -- - ❑ �' ❑
M 110 ft.f-om potable water lines?---- ------ -------- - -- - ❑
Q > 5ft.from property lines and easements?--- ----- ----- --- ❑ ❑
IY >30 ft.from downgradient curtain/foundation drains?--------- - ❑ ❑
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? ------------ . ❑ NIA YES ❑ No
Y Pump tank capacity(flood) 17"`YT3 cal Manufacturer 121-2
F24"access riser(s)and accessible from surface?------------. ❑ �' ❑
a Alarm or Control Panel installed? ------------ - ------- - ❑ a ❑
Control Panel equipped with Timer I ETM/Counter---- ---- --- ❑ e' ❑
lL Pump installed in ❑ Bucket or [�[On Block or ❑ Other
fPump Make/Model 2oe)\Jgx M\S-L ❑ Floats or KTransducer
y Tank draw dawn it Pump capacity apm Squirt Height ft
Pump on time •30 �Ser., Pump off time Mt Daily flow set at gpd
Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? ------ ----- -- -- ❑ YES NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAG246-272A-0300? ---- ---- ❑ YES ❑ NO
RECORD DRAWING
TMs la a grmawnI nmrd and..at ba a¢unal and on-1 llva a ,h to rNooala In Iba and or maintenance sclivlMa and fuwm davabprnant Typical RawN
o»winpawnpn. orainuip d man w orientation a layout sapbdpump pink Ipnlbn.Npfb army mane dranfew.ntiadnp aM proan.full bGlmn ptwells,mli.
wN...yilgn poll.ca.a.and Diner ,..caaWaa poin6.Ircpmplale Rac.DTyintso,fl.aY awapanl daps,in Mal coutapm apwcWa and rallied P.-af
❑ Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I cimily that 1 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
fo and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
ij�gnfn of Installer DateSIL`1
17� CU
Printed Name of S/gnee
�o
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalfofMason County Public '{r.
Health: -
� 2 <
4.VY�Y�YM �O�I�Z`1
Signature of Environments Health Speualist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE uomeduuzpre
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