HomeMy WebLinkAboutSWG2022-00226 - SWG As-Built - 10/31/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2.pYL- CEO 2LU Parcel# 7F- Q d Z
Applicant Name �NtL)h \� f�y,r�� Subdivision (Name/Div/Block/Lot)
Applicant Address { tit a, lalnh ,
City, State, Zip krl. Qrstcr Installer Name
Site Address Designer
INSTALLATION CHECKLIST
[Full System Installation ❑Tank(s)Only ❑Orsinfield Only ❑Repair ❑Omer
System Type NJlwl h -t T- Pretreatment Type
>5 ft.fromfoundation? -----__ ❑N/A E9 ❑ No
>50 ft. from wells? -- -- -_____ __ _ u ❑
Z >50 ft.from surface water! •---___ _ _ �'�tI''''�,'�' ❑
F 13
Cleanout between building and tank? • -- _OCr 3-I �IYG _I.11 ❑ ❑
rJ Tank baffles present? . - _ ' - - ' ' - _ - By ❑ ❑
a 24"access risers over each compartment. ❑
q Effluent filter installed?- __ ___ _- -----
_ __ ___ __ _____ - ❑ ❑
Septic tank capacity(working)_ (25 O cal Manufacturer )�hi
RO D-box water level and speed levelers used? - _ __ __ ________ . w9 ❑YES ❑ NO
C2 Manifold/D•box accessible from surface?-__ _________ ____ . ❑ ® ❑
m= Check valves installed? - - - --- --- -- --------- - ---- ❑ ❑
O u
Transport Line Size Z Schedule/Clese yn
Bedrooms installed (check one) []2, JR 3 ❑4 ❑5 ❑0 ❑Cemmerclal/Other
>10 ft.from foundation?---- -- _------ - ---------- -- ❑ NIA PUYES NO
C >1001t.from wells?-- -- - --------- -- ----_- - ---- -- ❑ ® ❑
W >100ft.from surface water? - - ___---- --- ----------- - ❑ ® ❑
Z >10ft.from potable water lines?• _________ ___________ . ❑ ® ❑
>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? • - ---------- - ❑ N/A YES ❑ NO
2 Pump tank capacity(flood) 12 OQ oat Manufacturer If R
24"access riser(s)and accessible from surface?- ---- ---____- ❑ ❑
y Alarm or Control Panel Installed? - ------- - - -- -------- - ❑ ❑
Control Panel equipped with Timer/ETM/Counter- -- - - - ---
- - ❑ ❑
d Pump installed in ❑ \ A
Bucket .or P On Block or ❑ Other II
EL Pump Make/Model LLy i4j [7Floets or
p ❑ TrafnIstlucer
C Tank draw down _ 2 in/min Pump capacity Sa apm Squirt Height 5i-r ft
Pump on time ma&ALf(Sc1 ump off time 4 11e ass Daily flow set at �gpd
4 +r.J�stis� CFiJ 2'10 r id
Mason County OSS Installation Report pg. 2 Parcel# C-201 7 - 73;OOO .d 3
ABANDONMENT RECORD
Were existing septic components abandoned as pan of this project? - - - --- - No
- - " - - -- YES
If yes, please describe.
Were all components pumped out and properly abandoned per WAC246.272A-0300? -- --- - -- 13 YES NO
RECORD DRAWING
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Ej�<ecord Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNERI ENGINEER
I certify that I installed the system in accordance with I certify that the system has been installed in actor,.
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 beencleared/approved by both the designer shown here have been cleared/approved by.both
and Mason County Public Health and meet all State myself and Meson County Public Health and meet all
and Mason County Codes. State and Mason County Codes
I further certify that ell information contained on this I further certify that all information contained on this
form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
Si alure
of Installer Dan
cl ae. 6v%c-
Printed Name of Sgnee
MASON COUNTY PUBLIC HEALTH A,�
The undersigned approves this Installation Report andRecord Drawing on behalf of Mason County Public Health:
Signature of Environmenbl Health Specialist Dare (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE uptl.l.pe2122'.
APPROVED
- CT 31 2024
MASON COUNTY ENVIRONMENTAL HEALTH
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APPROVED
OCT 31 2024 �I
MASON COUNTY ENVIRONMENTAL HEALTH
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