HomeMy WebLinkAboutSWG2023-00344 - SWG As-Built - 1/8/2025 Maso® OSS Installation Report pg. 1 MASON COUNTY PUBLIllLTH '
APPLICANT/ PERMIT INFORMATION
Permit Number swG 2023-00344 Parcel# 123315100009
Applicant Name Nancy&Douglas Ray Subdivision (Name(Div/Block/Lot) j
Applicant Address 991 NE Larson Blvd BEARDS COVE DIV S LOT.9 RFL` ZS
City, State, Zip Belfair WA 98524 Installer Name AAron Shumaker
Site Address 991 NE Larson Blvd Designer Name Jim Lmny
INSTALLATION CHECKLIST
❑ Full System Installation ❑Tank(s)Only N Drainfieid Only ❑Repair ❑other
System Type Gravity Bed Pretreatment Type
>5 ft.from foundation? --------------------------- ❑NIA 0 YES ❑ NO
>50ft.from wells? ----------------------------- ❑ a ❑
Y >50ft.from surface water? ------------------------ ❑ 0 ❑
Z ❑ ® ❑
FCleaoout between buiMing antllank? -------------------
O Tank baffles present? --------- ------------ ❑ ® ❑
24"access nsem over each compartment?---------------
IL
❑ ® ❑
W Effluent fifter installed?--------------------------- ❑
N
Septic tank capacity(working) t200 gal manufacturer
0 D-box water level and speed levelers used? --------------- ❑ N/A ®YEs ❑ No
0J
O Manifold/D-box accessible from surface?----------------- ❑ ® ❑
mZ Check valves installed? -------------------------- ❑
oa a" Schedule/Class
3034
f Transport Line Size
Bedrooms installed(check one) ❑2 as ❑4 ❑5 ❑6 ❑Commercial/Omer
>10ft,from foundation?-------------------------- ❑ NIA ®vEs El No
>100 ft.from wells?----------------------------- ❑ ® ❑
J >100 ft.from surface wate? ----------------------"- ❑ ® ❑El
W ----
LL >10ft.from potable water tines?------------ -" ❑
ZZ >5ft.from property lines and easements?---------------- ❑
C >30ft.from downgcadient curtaintfoundation drain?---------- ❑ a O
a
Drelnfiekl level and observation ports Present -------------- ❑
❑ Graveless chambers or a Clean gravel used? (check one) ❑ ■ ❑
Proper cover installed over dminfield?-------------------
Pump tank Setbacks consistent with septic tank?------------- a NIA We ❑ NO
Y Pump tank capacity(flood) gal Manufacturer
Z 24-access nser(s)and accessible from surface?------------- ❑ ❑ ❑
dAlarm or Control Panel lnslalletl? ------------------"-- ❑ ❑ 11
Z Control Panel equipped with Timer ETM/Counter----------- ❑ ❑
a Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
❑ Floats or ❑ Transducer
a Pump Make/Model
a
Tank drawdown in/min Pumpcapacity, gpm Squirt Height fl
Pump on time Pump off time Daily flow set at owa�avnO/md
1 1
Mason County OSS Installation Report pg. 2 noel n ^p(J0 T
ABANDONMENT RE CORD
Were sualio, sepllc components abandoned as pan of Ihs ,nn ecV
.- ____ ____ ____ . YES
B Yes.please describeoleL Na
Wanalcwnpompe PUmpedoutarq --_----pnOpBdyaMndonedperWAC246212A-03001-------- YES E] NO
RECORD DRAWING
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Record Drawing Attecbed
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I caddy that I installed(he system in accordance with I codify that(he system nas been Installed in ace0r-
ME septic design stamped"APPROVED"by Mason dance with the septic design stamped`APPROVED"by
County Public Health and Mat any deviations shown Mason County Pudic Health and that any deviations
hate have been deared/approverl by both the designer shown note haw been Geared/epla ovod by both
and Mason County Public HeaIM antl meet all State myself and Mason County Public Health am mesa all
and Mason County Codes. State and Mason County Codes
I hrdher cemly(hat all mlanna eon com ah,nn this I hoThet ceMfY that all inhinuatbn Contained on loss
foml a rd Drawmp is accurate fomr and odached Record Dmifnny,. accurate.
3 1-1 2
Safineseeo Inaraner oalu
an,rNot nun»w Sao,
MASON COUNTY PUBLIC HEALTH
The undersigned appmYss this Installation Report and
Record Drawing on behalf of Masan Coady Public
Health:
- . R muyvx� l/ 0 Y zy
tagco.or CaYmorsdav Health Specialist Dole (stamp, slgnettee and date)
THIS FORM NAY BE SCANNED AND AVAK-ABLE''OR WBLIC VIEW ON I HE MASON COUNTY WEB SITE 4uawa n,:an,e
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