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Home My WebLink AboutSWG2024-00027 - SWG As-Built - 12/10/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUB HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG `/. 37,'4 (W 2-7 Parcel# 2 ?- Applicant Name QTY(1.1� Mom— Subdivision (Name/Div/Block/Lot) RFOF� Y Applicant Address (Ptt E mii (ftap .1-FPK� City, State, Zip 5hP1't17Y\rwR gMN Installer Neme C�`^I^p e.Appys�= Site Address low F tNniYA(lo I16av+tb e'Is goer Name (�� INSTALLATION CHECKLIST ❑ Full System Installation Tank(s)Only ❑Dramfield El Repair ❑Other System Type ov;M Onl Pretreatment Type >5ft.from foundation? .--------------------- -- --- ❑ N/A ❑YES ❑ No >50 ft.from wells? ----- ---- -- -------- -- --- ---- - ❑ ❑ ❑ Y >50ft.from surface water? - - - -- --- - - - - - - - - - - - - - -- ❑ ❑ ❑ fCleanout between building and tank? --- -- -- ---- --- - --- ❑ ❑ ❑ U Tank baffles present? ------------- ------ -------- ❑ ❑ ❑ F- 24' access risers over each compartment?---- - - ---- -- --- - ❑ 1-1 ❑ Q. Effluent filter installed?------- ---- ------ -- - ❑ ❑ ❑ fA Septic tank capacity(working) ael Manufacturer Cl D-box water level and speed levelers used? -------------- - ❑ WA El YES El No 00 Manitold/D-box accessible from surtace?---------------- - ❑ ❑ ❑ mZ Check valves installed? -- - -- - - - - - - --- - - - --- --- - -- ❑ ❑ ❑ ❑ Transport Line Size Schedule/Class Bedrooms installed(check one) ❑ 2 ❑3 r❑4 ❑5 ❑5 ❑Commercial/other >10ft.fromfoundation?- - -- - --- ---- ---- --- ------- ❑ NIA ❑ YES NO 0 >100 ft.from wells?--- -------------------------. ❑ ❑ ❑ m >loo ft.from surface wateR - ---- ------------------ - ❑ ❑ El LL >10ft,from potable water lines?- --- ----------------- - ❑ ❑ ❑ Z >5ft.from property lines and easemenis?--------------- ❑ ❑ ❑ 9 >30 ft.from downgradlent curtain/foundation drains?--------- - in Drainflekl level and observation ports present -------------- ❑ ❑ ❑ ❑ Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?----------- -------- ❑ ❑ ❑ Pump tank setbacks consistent with septic tank?------------ - N/A ❑ YES NO Y Pump tank capacity(Flood) gal Manufacturer I f-Y I2 Q24"access riser(s)and accessible from surtace?----------- ❑/ ❑ ~ Alarm or Control Panel Installed? ------- ------------- - ❑ Lr7 ❑ O ❑ ❑ � Control Panel equipped with Timer/ETM/Counter- ------ ---- 7 IL Pump installed in ❑ Bucket or ❑ On Block or ❑ Other a Pump Make/Model m Zb y ❑ Floats or ❑ Transducer a Tank draw down in/min Pump capacy qpm Squirt Height ft Pump on time Pump of Daily flow set at apd Mason County OSS Installation Report pg. 2 Parcel # ABANDONMENTRECORD Were existing septic components abandoned as part of Uns project? - - - --- - - ---- -— ❑ YES No if yes, please describe: Were all components pumped out and properly abandoned per WAC246-272A-0300? - -- ----- ❑ YES ❑ NO RECORD DRAWING w--t no—al.ne mart W.em.ne.ne d-1,11r.—.,m nJenu m N..-a N manbn.nn.nhnl...na Ntun a.-'eIxn oil T,01 R.0 DrmNnes wesln crelnuld a mama!ai.nlation a IaroN.seruWxmp lenx I—u,NUM ui nu,.kahfield,e.s in,-d omxxxil Wid0l.bc.uon 0—IIx —,&Anes. vW.ppxmnm Pons.d.—,s,W oh.,mYnlenmu encase ruin¢. Narnplele RecanI Dmairgs mev ae de etldtlonel d al In rnel I..WWW N,p .l end.lead lxx ih. ❑ Record Drawing Attached CERTIFICATION OF INSTALLATION INSTALLER DESIGNEW ENGINEER 1 certify that 1 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 cleared/approved 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 inforrnadon Contained on this 1 further certify that all information contained on this form and attached Record Drawing is accurate. form and attached Record Drawing is accurate. Signature of Installer Date shau Will � Pointed Name of Signee MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report and Record Drawing on behalf of Meson County Public Health: } t� 211a/z-1 Signature of Environmental keafth Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNN WES SITE uis w Vn.ne RECORD DRAWING continued x SY,oP ) r � a s s O ov i / APPROVED / DEC 10 2024 MASON COUNTY ENMOSMENIAL RET HEALTI