HomeMy WebLinkAboutSWG2024-00239 - SWG Application - 10/22/2024 o CSC EM
0D
Ma
son County OSS Installation Report pg. 1
MASON C
APPLICANT!PERMIT INF�CN
Permit Number SWG Z��( n�J'J..n' Parcel# , ,
Applicant Name �, t01
Subdivision (Name/Div/RIocWLot)
Applicant Address � RF�Fy 24
City, State, Zip g
Installer Name -Site Address i ^"✓ [rue'
Designer Name
INSTALLATION CHECKLIST
�f Full System Inetelledon ❑Tank(s)only
IY ❑Drainaeld Only ❑Repair ❑other
System Type Pretreatment Type
otion7 me
>5 ft.from I- unda _ me
>50 ft.from wells. -------- ❑WA �yM ONO
>50 ft from surface water? - ❑ 13
❑
H Clsanout hol veon building and tank? - ❑ 0
V Tank baffles present? - - ------ ------ ❑ ❑
24"access risers over each compartment?-__ ❑ ❑
N Effluent filter installed? __._ . - _ _ - ❑ ❑
Septic tank cepacrty(working)_._ 725 '� . _________ ❑ ❑
gal Manufacturer K r; '
A�q D•box WaMr level and speed levelere used? - ___ ____ ___
ManifoldrD-box scossible from wrf c9? _______________ wA ❑yes ❑ No
LL ❑
Check valves installed? -_______ ❑
Transport Line
❑e Size Z, rr ❑
--------�._y ._ Schedule/Class .V/7
Bedrooms installed(checkye one) 2 ❑3 ❑4 ❑6 ❑6 ❑Cg --_-- -
>10ft.from foundation?- mmerciel/Other
_._______________ _______.
9 >100 ft.from wells?-- - I ❑ NIA pJ res NO
W >100 ft from surface water?-- ❑ ❑ ❑
>10ftfrom potable water lines? _____________________ ❑ ❑
>5ft.from property lines and easements?---- ------------ ❑ 2 ❑
>30 ft from downgradient cudain/foundadon drains?--_______- ❑ Z ❑
Drainfield level and observation ports present _ _ ___________ ff ❑ ❑
❑ Graveless chambers or �f Clean gravel used? (check one) ❑ ® ❑
Proper cover Installed aver dra
infield?--_____- 0 ❑
13
Pump tank setbacks consistent with septic tank?.._____.___
' Pum tank capacity aci flood �} ' -- ❑ WA �ym ❑ .._ 1
P p ty( 1,i(�- _gal MaMlhCluMr vG�rleen P f`^e III
f 24-access risers)and accessible from surface?-
L Alarm of Centrol Panel Installed? ---_______ ________________ _ ❑ ❑
❑
Control Panel equipped with Timer/ETM/Counter-- --______. 13
S Pump installed in ❑ Bucket or ❑ On Block or ❑ ❑ ���
f Pump Make/Model At f„a key-iV �q 0 ❑ Other
Tank draw down 0 NFlosts or ❑Transducer
IL inlmm Pump rapacity Tx� �
--'�tlPm Squirt HeightY
Pump on lima .,75 ft i
----.ems Pump an time 4J� Dany now set of
—X- IJ/✓� �v %�l �VDu q; u:wmamsoie
/�ry �/�'�'I a�✓LGaI
PA ecaxf
Mason County OSS Installation Report pg. 2 Parcel s_ -
.J17 —tib --
ABANDONMENT RECORD
Were exlstin se tw: '9 p minWnnnh ebendonetl as pan of this pmjeG? -- _ __
It yes, please describe. -- --" ❑ YE9 NO •
Were all COmppn—Imts Pumped out and properly abandoned per yygC2ag.p72q-03007 --------
YES NO
-- �_ RECORD DRAWING
Tna In.wlm.lem I.c°n.ln mum a ssd,ne.m numl '—
Ww.nlnW m redoyb In nq n.eu a meingnonu swv,n as,lulus p W
�nWINnCOesm P.114W6myynYQ wknlslimn6byoW $yell[Ipunq ldn114GIlOn lyoMdi IeSerys Jianfinb a.i ti4 one ryP'y t✓ass
n.sA mnnr.nnl Maramuss.WOYplmahlendllmvice.apcinp. Intyrpgp gssn.praxinYa ma s 6ntl ymPo.etl Wibinpe b[al'unMyyAtyylnYw.
_�_"_1-,_- Y4male addllaMlE4eYa In M1nal in.W4l:plyp4yn enE lgepgrnliy
.e
i6 Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER
DESIGNERI ENGINEER
I certify that 1 installed the 101111111 accordance with
the septic design stamped APPROVED'b Meson I ande that the system has been installed in OVER
Y Masco with themy Public design andstRincet "APPROVED'by
County Public Health and that end devrations Shown Mason County Public Health and that any deviations
here have been cl"md/epproved by both the designer shown here have been cleamd/approved by both
and Mason Courtly Public Health and meet all State
end Meson County Codes. myselfand Meson County Public Hoalth and meat all
l further WHA93,that Be information contained on this State and Mason County Codes
I fudher certiry that all information contained on this 1
form and aitacnod Record Omwing is accwate
/J form and attached Record g is eCcdmte.
ea of lnatafle Data
41
Footed Nerne o/Srynee
9 • '
MASON COUNTY PUBLIC HaftrHO,G A raNre
The undersigned approves this lnatellation Report�flY+ f� 0 LICENSBNSED DESIGN
WAITEEq
Record Drawing on behalf ofMasgn County Public Fy ��O Lxvlkts oslm
Health I 7 O
/0/ �� Ud !2 43
Slgnatum ofEnmronmenhl Heaffh S bah 9<"
--- - _ (stamp, sgnatme end date)
THIS FORM MAY BE"NEDANDAMARAS,I.NUI1 pUBUw.h ON THE MASON COUNTY WEB SITE L9dns4emrote
0
9111111,
I � ~
I
.................................
s
�.�.....�i .................... .S
........
ca
t N a
N -J
m
Soy �Cj 4 N = o P X a
ZB a� j '8 o In ro O cr &
oliyryFyh� �o7y _ m F �. S. c o n' n ?
✓,q�y�tlF4,,. "c a CD 7 a con
g m
m, G
ni�'� •> -'� .,£ 0 3 0 obi /L
LICENSED O ama
t 7 —
exnwts