HomeMy WebLinkAboutSWG2020-00223 - SWG As-Built - 11/12/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SyyG - oo ZZt Parcel# Z.Z617_61}_�¢S
Applicant Name C jn - - r r&-Ad., Subdivision (Name/Div/Block/Lot)
Applicant Address 8'917- Ct e-rfa. Qt ?t N,.LvWeits f J-d
City, State, Zip Q,i fvMn dyY r.Jn 9Pi Z4 Installer Name Lr
Site Address SE-6 f I--Ycj&,ss_DAE Designer Name
INSTALLATION CHECKLIST
gj Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type OS t a r Ir &4 Pretreatment Type 0110 11i
>5 ft. from foundation? - - - - - -- - - - - -- - -- --- - ❑ NIA AYES NO
>50 ft.from wells? -- - - - - - - - ----�:- - _ El ElY >50 ft.from surface water? --- - -- - - }-- -�-/
Z � ❑ ❑
H Cleanout between building and tank? -- ----<- -- =
tl Tank baffles present? - - - - -- - -- - -- - - - <� - ' -- ' ❑ ® ❑
H 24"access dyers over each coin artment. - - - - - -- - El
WEffluent filter installed?--- - -- - -- - - - - - - -- -- -`- --- ❑ ®' ❑
Seiiiiii;tank capacity(working) ' p
�� al Manufacturer
❑
O D-box water level and speed levelers used? - - ---- - - - �'-- -- -- NIA ❑ YES NO
OLL Manifold/
D-b¢x accessible from surface?-- - -- - - - - - -- -- - - ❑ ❑
Q?2 Check valves installed? - - - - - ---- - - -- - -- - - - - - - - - - ❑ ❑
G� Transport Line Size / Schedule/Class ;/o
Bedrooms installed(check one) ❑ 2 R3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10ft. from foundation?- - --- -- - --- - -- - - - - - - - - - - - - ❑ NIA RYES NO
>100 ft.fromwells?-- - - ----- --- - -- - - ------ - - -- - ❑ 19 ❑
12
W >100 ft.from surface water? -- - - - - -- - ------ - - " - - '- - ❑❑ ❑
a: >10ft.from potable water lines?-- - - - - - -- - --- - - - - - -- - - ❑
Z¢ > 5ft.from property lines and easements?- --- - - --- --- - - - - ❑
K > 30 ft.from 0owngradient curtain/foundation drains?-- - - - - - - - - ❑ 54 E3
Drainfield level and observation ports present - - - - - - - - -- - -- - ❑ 9
❑ Gnt eless chambers or ❑ Clean gravel used? (check one) C-5b S—J-
. -- - ---- -- ❑
Proper cover installed over drainfeld?-- - --- - --- ❑
Pump tank setbacks consistent with septic tam-�-�- - - - - - ❑ NIA ® YES DI
z Pump tank pacify (flood) Sa>/ 9ral Manufacturer b t N&9 awtl
a 24"access ri r(s)and accessible from surface?-- -- --- -- - - - - ❑❑ rn Alarm or Control Panel Installed? -- - --- ---- --- - - - - -- - -
I Control Panel equipped with Timer/ETM/Counter- - - - - - - -
Pump - - - ❑
a installe¢Id in ® Bucket or ❑ On Block or ❑ Other
6. Pump Make11v1odel Ad W1 C0u w�a Q'2P7 ® Floats or Transducer
y Tank draw dQQll wn IP➢ n/min Pump capacity �a' gpm SquirtHeight �4A ft
Pump on tim' 16
1C&C Pump off time "6), - 3.6+k(S Daily flow set at ?U,*gPd
J uumaa vzvza�e
I
Mason County OSS Installation Report pg. 2 Parcel u Zj 6
ABANDONMENT RECORD
Were existing septic components abandoned as pad of this project? ---- --- -- ------ ❑ YES NO
If yes, please describe:
Were ail components pumped out and properly abandoned per WAC246-272A-0300? - - -- - - - - ❑ YES No
RECORD DRAWING
Thla Is a permanmt nwN aM moat Ca accuna aM..no-enou0tl m.4..In Ne np of mtlmmanu actlrlYae and IuNn dwalopmaM Tyl k l Rx
OnwNpa ruMeln'_ D-1—WA man[PW abnmbn d Yyaut.6apWpumP tme kultn,aWlm mew.ravens MYnMM.atlNnO anti PopPmO tuldhga.lace'.'nn atwNb,wa9raaa,
wells,onwnnnnm Men,ckmou4.and 0H 015 Inaxn ae Recwd XWM08 may male nddlWnal M"n Mal"nMW'`M eppcNl and nN Pam
'6 'Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
1 certify that I installed the system in accordance with 1 Certify that the system has been installed in acoor-
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 dearectapproved 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
form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
C Lp
Signature oflnstallorr Date
y 1 nr
Printed Name of S4ynee Vie±
MASON COUNTY PUBLIC HEALTH
The undersigned approves this installation Report and
Record Drawing on behalf of Mason County Public '1,
1
Health: /U—2 Qw -
�V�I`U � '�P`�'� ' 1' kay
Signature otEnvironmental Health Specialist Date (stamp, signature and date)
THISFORM MAY BE SCANNEDAND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB 317E
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