HomeMy WebLinkAboutswg2018-00296 - SWG As-Built - 11/26/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATION
Permit Number SWG 2018-00296 Parcel# 421257800020
Applicant Name Ronald Holden Subdivision(NamelDivfBlocklLot)
Applicant Address 5173 E Brockdele Rd
City, State,Zip Shelton.WA 98584 Installer Name Bay Shore Construction
Site Address Same Designer Name Dale TENS Design
INSTALLATION CHECKLIST 'L
a Full System Installffimn ❑Tank(s)OMy ❑Dfamneld Only ❑Repair ❑Other
System Type Pressure Bed ant Type NA
>5 ft.from foundation? ----- -- --- B - - ❑N!A ■YES ❑ W `
>50 ft.from wells? ---- - - ---- -- ___ _____ __ __ ❑ a ❑
Z >50 ft.from surface water? -------- -NOY-2424U- - ❑ a ❑
f Cleanout between building and tank? -- ❑ a ❑
V Tank baffles present? --- - ------- a ❑
I- 24-access itsers over each compartment Bg a ❑
IL
W Effluent titer installed?-- --- -- --- ------ -- ----- --- - ❑ . ❑
fe
Septic tank capacity(working) 1250 gal Manufacturer Everore mi Pre-Cast
a D-box water level and speed levelers used? -- - ------- - - - - - ❑wA a YES ❑No
DO ManifoldlD•bori accessible from surface?- ---- ---- ------- - ❑ ❑
R= Check valves installed? -- -- ------ - - - --- -- - ---- ---- ❑ a ❑
Transport Line Size 2" ScheduletClass 40
Bedrooms Installed(check one) ❑ 2 ®3 ❑4 ❑5 ❑6 ❑CommemiaVOther
>10ft.from foundation?---------------------- ----- ❑ NIA 0YEE ❑ No
.l >100R. from wells?-- --- ------- - --- -- ----------- ❑ a ❑
W >700 ft.from surface water? - ---- ------ -- ------- --- - ❑ a ❑
µ >10 ft.from potable wafer lines?-- ---------------- --- - ❑ a ❑
>5ft.from property lines and easements?- --- - -- ------- - - ❑ a ❑
> 30 it. from downgradlent curtain/foundation drains?- - -- - - ---- ❑ a ❑
Oramfield level and observation ports present - -- -- -- -- - --- ❑ a ❑
a Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over dramfield?-------- -- - -------- ❑ a ❑
Pump tank setbacks consistent with septic tank?- - - - - -- - ----- ❑ NA a YES ❑ No
Y Pump tank capacity(good) 1250 at Manufacturer Evernreeri Pre-Cast
24"access riser(s)and accessible from surface?---- ---- ----- ❑ a ❑
6 Alarm or Control Panel Installed' -- -- - -------- ---- --- - ❑ a ❑
7 Control Panel equipped with Timer i ETM; Counter-- - - -- - ---- ❑ a ❑
6 Pump installed m ❑ Bucket or a On Block or ❑ Other
Pump MakelModel 280 Liberty a Floats or ❑Transducer
Tank draw down 2 Within Pump capacity 5o bpm Squirt Height 68 R
Pump on time 85 sec Pump old time 6 hr Daily now set at 270 opd
�me�zras
Mason County OSS Installation Report pg. 2 Parcel A 421257800020
ABANDONMENTRECORD
Were existing septic components abandoned as can of this project? -- -- - ---------- ❑ YES NO
It yes, please describe:
Were as components pumped out and properly abandoned as,WAC246.272A-03007 •------• ❑YES ❑ NO
RECORD DRAWING
TN.s.a,maam,.uxin....W.Ccur.N and a..<NpN..,,wph N r.a..N I, rann
am.,ss.m.¢, o,r*...wfl-r aw„r.r.w flwraa S.p:-s..ro•s.wur
. ..a,,,:.n.•..rna..-.n.e..we,,.m,.r�.,r.,.e....-r+.. u,..-aww a.e.v on.vi.-..v.."„•,s"..,a.,N,,, w,rww :-.x 1.11 a-d sir,.
® Record Drawirg Aftach.0
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 cfeared/approved by both Me Designer shown here have been clearedlapproved by both
and Mason County Public Health and meet all State myeaN and Mason County Public Healy,and meet all
and Mason County Codes. State and Mason County Codes
I further cerqfy that all information contamad on this I further certify that all intannation contained on this
form a Record Drawing is accurate. form and attached Record Dra ng is accurate.
1V262024
Signalu a of Installer Dale
qA_Brandon Thompson r
Prinletl Name of Signee
MASON COUNTY PUBLIC HEJII�711 L
The undersigned approves this Ins�l n Rr➢WxY2gd " F/� y� b1002N F;
Record Drawing on behalf of Mason Co0;; ubfic!!!!IO v O' Dale L.Tahp
Health: 6119, 1 LICENSED DESIGNER
02�IN�FNTq< Fq
Signature or Environmental Meatth Spacralrsf Date �rh (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC InEV/ON THE LIASON COUNTY VIEa SITE
fi
A k 6
f
51 W214
I O" DALE L.TAH�A
/ I ICEND DESIGNER
' EXPIRES: -
W�^
i 4AA
" 1 ,4sO�� , � �
II oO�F�hF ig?,t 40
- O✓AON�FNr"�H
I LP
31I/