HomeMy WebLinkAboutSWG2023-00026 - SWG As-Built - 12/11/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 202'� - C)u O'z.A-t Parcel# �j Iq_V 1
Applicant Name Sr
'Frc,r\Pc.N[n (^'1nl!Y i W Subdivision (Name/Div/Block/Lot)
Applicant Address a13 LA) CM-C�. PS-
City, State, Zip S 1 li N q 1r r Kii Installer Name N
Site Address y�l_? ()� i-�1.k1 /QI Designer Name/f ryt �lfl�ft—
INSTALLATION CHECKLIST
tPull System Installation ❑Tank(s)Only ❑ Dramfleld Only ❑Repair ❑Other
System Type Pretreatment Type
>5 ft.from foundation? -- ----- - �l��.lt1�t1�({Jl�r��.
B _ _--R.ll ll_IS ❑N/A YES ❑ NO
>50 ft.from wells? - ----------- El
Z >50 ft.from surface water? -- -- __ ❑ ❑
F Cleanout between building and tank? - -NQl/-2_Z 224-_❑❑ ❑ ❑
L) Tank baffles present? - __ _ ______ _ -- ❑ V ❑
24"access risers over each comps tme a
e __ ❑y_ ❑
N Effluent filter installed?--------- ---------_ ❑ /1 Septic tank capacity(working) {. at Manufacturer- J-Npk Jrt
OJ D-box water level and speed levelers used? ---- - ______ _ 13 NIA ❑YES ❑ No
00 Manifold/D-box accessible from surface?- -_____ ® ❑
QCheck valves installed? . ___ _ __ _ _______________ � ❑
f Transport Line Size Zt Schedule/Class 561 (ib
Bedrooms installed(check one) ❑2 ❑3 ❑5 116
>10ft.from foundation?-________________ ❑CommerciaUOther
❑ WA ®'VES ❑ NO
� >700 ft.from wells?----______________ ❑
w >100 ft.from surface water? -______________________ - ❑
LL >70ft.(rom potable water lines?-_________________ _ O ❑
>Sft.from property lines and aasemente?-__ __ __________- ❑ �,
>30 ft.from downgradienl curtain/foundation drains?---______- ❑
Drainfield level and observation ports present - ------ ---- ---
to
❑
❑ Graveless chambers or ® Clean gravel used? (check one) ❑ ❑
Proper cover installed over drainfield?----_ O
Pump tank setbacks consistent with septic tank? ---________ . ,p. ❑
Y Pump tank capacity(flood) al ��"❑ WA Nd YEs ❑ NO
Z l2llll c Manufacturer 1'�L"Y� }tn trl nt�-
24"access Marts)and accessible from aurlace?--_____......
�.
y Alarm or Control Panel Installed? -- --- -------------__ ❑
Control Panel equipped with Timer/ETM/Counter---- -- ----- ❑
1 Pump installed in Bucke`t or ❑ On Block or ❑ Other ❑ ® ❑
a Pump Make/Model Lr 6tl-T`N �
- ® Floats or ❑ Transducer
IL Tank draw down 2 5 in/min Pump capacity 50
�ugpm Squirt Height 5.�� ft
Pump on time �r 5 i h Pump off time 1 h eerc Daily flow set at .36Q Oct
U..a 8L1.1.6
Mason County OSS Installation Report pg. 2 Parcel tP
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - - - - - - - - - - - - — ❑ YES NO
It yes, please describe:
Were all components pumped out and property abandoned per WAC246-272A-0300? - --- ---- ❑ YES NO
RECORD DRAWING
TnN is a parmanam nvord and Man la accurau and eesctlptive enough to re.locaor in IM road or mamUnanca acavnlm and bWra eevaapmam Typical per
Drawiyadpion, Mamfieltld manROB INMnblgn 6byput.aepOUpump tank bmtipn.Nora artow.reaerve tlgin6eb.exisnrq and proyned bNailys.bonpn ofwella.watemnes
Wlb.pburvticn ppla deawul,and olMr T2mRrance areal.[p}nLL. ImxnpMb Recpd Dnwn,pa mBy rAale pre l deata In final insUNlgn approval and related perm Iz.
❑ 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 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 furthercerttfy that all information contained on this /further certify that all information contained on this
form and attached Record Drawing is accurete, form and attached Record cawing is accurate.
Sgnat ollnstaller Date �''•.
�. /p/til�tY
J OC �rnu SC tee. �:?
Printed Name o/Sgnee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and ADAM J.HU,TER 'Y
Record Drawing on behalf of Mason County Public
a'L1C@NSFDUmGNE•R•- -
Health: rm.n.e ornv
W Iz�
Signature of Env/mnmenta/Health Specialist Date (stamp,signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Wddad nt¢ote
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