HomeMy WebLinkAboutSWG2022-00157 - SWG As-Built - 10/31/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2022-00157 Parcel# 42216-53-00024
Applicant Name Tara 6 Justin Jerrells Subdivision (Name/Div/Block/Lot)
Applicant Address P.O.Box 1933 Lake Cushman Div. 16 Lot 24
City, State, Zip Shelton, WA 98584 Installer Name Payton Goos
Site Address N. Dolly Circle Designer Name Dale L.Tanis
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type Pressurized Trenches Pretreatment Type BNR 500 NuWater
>5 ft.from foundation? ----------- -- ��� NIA ®YES ❑ NO
>50 ft.from wells? -------- - --- ---- IL+N3 e ❑
Y >50 ft.from surface water? --- --- ----- ® ❑
F Cleanout between building and tank? ------ _----182�<2 ® ❑
0 Tank baffles present? - -- -- -- - -- -- __- ® ❑
R 24"access risers over each compartment?.-- Hy — ® ❑
NEffluent filter installed? -_______ ____- ❑ ® ❑
Septic tank capacity(Working) 500 gal Manufacturer Hagerman/NuWater
�'Q D-box water level and speed levelers used? --------- ---- -- WA ❑YES NO
00 Manifold/D-bbox accessible from surface?---- ---- ------- -- ❑ ❑ ❑
m= Check valves installed? -- -- ------ --- ---- --- --- - ❑ ® ❑
Transport Line Size 2 inch SchedulelClass Sch.40
Bedrooms installed (check one) ® 2 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>1Oft. from foundation?- - - - - ---- -- -- - -- -- ------ -- ❑ WA . YES NO
0 >100ft. fromwells?-- - - - - --- -- - ---- - - ----------- ❑ ® ❑
W >100 ft.from surface water? ---- -.------- --------- - -- ❑ ® ❑
E: >10ft.from potable water lines?- - -- --- -- - -------- -- -- ❑ ® ❑
Z > 5ft. from property lines and easements?-- - ------- -- ---- ❑ ® ❑
>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 dreinfield?-- ----------------- ❑ ® ❑
Pump tank setbacks consistent with septic tank?-- ---- ---- --- ❑ NIA ❑ YES ❑ No
ZPump tank capacity(flood) 1,000 gal Manufacturer Hagerman
f 24"access riser(s)and accessible from surface?- - -- - ------ -- ❑ ❑
a Alarm or Control Panel Installed? - -------- ------- ----- ❑ ff ❑
jControl Panel equipped with Timer/ETM/Counter- - -- ❑ ® ❑
0. Pump installed in ❑ Bucket or e On Block or ❑ Other
Pump Make/Model Liberty 280 ® Floats or ❑ Transducer
IL Tank draw down 1.75 in/min Pump capacity 20 gpm Squirt Height 9 ft
Pump on time 2.5 min. Pump off time 5 hrs. 57.5 min. Daily flow set at 180 gpd
Vp]HVG flRt/tp18
Mason County OSS Installation Report pg. 2 parcei a 42216-53-00024
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - YES Q NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-03007 ❑ YES ❑ NO
RECORD DRAWING
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Q Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I 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 clearedtapproved by both the designer shown here have been clearedtapproved 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 wromined on this
form and attached Record Drawing is accurate form and attached Record Drawing is accurate.
f�Lfeo2✓ 7- Iq -22
sigriliture of
installer Date
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Panted Nameof Signee �d`A`Wh
MASON COUNTY PUBLIC HEALTH fSt
The undersigned approves this Installation Report and y; 5100214
Record Drawing on behalf of Mason County Public O _ ALE L. A _
Health: �/Ltn r UQK40 DESIGNER
Signature of Environmental H Im Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED ANDAVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE 12m.
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OCT 31 2024
MASON COUNTY ENVIRONMENTAL HEALTH
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