HomeMy WebLinkAboutSWG2022-00137 - SWG As-Built - 1/6/2025 Mason County OSS Installation Report pg. 1
MASON COUNTY PUBLIC HEALTH
APPLICANT. PERMIT INFORMATION
Permit Number SING 20 'LZ �tld L 'S-I Parcel# 174 3(33 f`)W��1
Applicant Name
Subdivision (Name/DivfBlock/Lot)
^ -� fl r yc.-bl
Applicant Address I'-k70 S Nyatt IJ. 1L'g I'r Sr✓:.-
City, State,Zip �Z`fic� E "� �tl°`r Lr; Installer Name 4JJYl
Site Address (e0
'c.c Designer Name
INSTALLATION CHECKLIST
[�Full System Installation ❑Tank(s)Only ❑ Oramfield Only ❑Repair ❑Other.
System Type Type_�—
WA .BYES NO
>5 ft. from foundation? ---- ----- --- ❑
>50 ft.from wells? -- ---- -- - - JAN0 8 ❑
Y >50 ft. from surface water? ---- - - �. ❑
Z
H Cleanout between building and tank? ----
Tank baffles present? -- -- - - - -- -- - - Bx ,# ❑
El
6 24'access risers over each compartment?- -- ----- -- -- - - -- El �, ❑
W Effluent filter installed?---- ---- -
N L2.S[) gal Manufacturer
Septic tank capacity(working)
YES NO
❑ D-box water level and spend levelers used? -----------'- -- gNu ❑ ❑
J
OLL ManifoldlD-box accessible from surfacer---==- - - -- - - - ---' ry El
❑
mZ Check valves installed? --- --- ---- - - - -F
bG I
f Transport Line Sae 7
Schedule/Class—
Bedrooms installed(check one)
❑ 2 03 ❑4 ❑ 5 116 ❑CommerciaUother
❑ WA BYES ❑ NO
>10ft.from foundation?--- ----- -- --- -- - - ❑ z ❑
>100 ft,from wells?-- - -- - - ---- - ---------- ❑ ❑
W
>100ft from surface water? - --- - - - --- - ----- - - - -- -- ❑
-- ------- - --- ❑
M >10ft.from potablewater lines?-- - - -- �. El_4 > 5ft.from property lines and easements?- -- ------ - -- ❑
C 130ft.from downgradient curtaintfoundation drains?- - --- -- - -- ❑
❑ Orainfield level and observation parts present - ----- - - -- - - - Cl
jo braveless chambers or ❑ Clean gravel used? (check one)--- ❑ ❑
Proper cover installed over dminfield?-- -- -- ---- - -----
-- ❑ WA YES ❑ NO
Pump tank setbacks consistent with septic tank? -- -- -----consistent .y
2 Pump tank capacity (flood) tiM.99 ggal Manufacturer t4 ❑
Q 24'access riser(s)and accessible from surface?-- ---- ❑❑ ❑
~ Alarm or Control Panel Installed? -- - -- - ------ --- --- ❑
a - -- -- - -- -- -
pump .0
� Control Panel equipped with Timer f ETM(Counter ❑
a installed in ❑ Bucket or 0 On Block or ❑ Other
ILAls c>� 12,Floats or ❑Transducer
Pump Make/Model r ft
ar Nmin Pumpcapacity V gpm Squirt Heigh 3
Tank draw down a h i
Pump off time Daily flow se[at 9Pd
Pump on Gme vpmuaerz�rzare
Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? ------- - ---- --- ❑ YES ❑ NO
H yes, please describe
Were all components pumped out and pmperly abandoned per WAC246-272A-03001 --- ----- ❑ YES ❑ NO
RECORD DRAWING
TNb 6 a psnnsnairt nceN sM mwt Es aaaurob and wscd"....an b mIo In the nsvE w malmensnca srLrhles and Nsm dsvabpmmt TygW Rewm
amrtNs cdmn: nnN ma mwibandenueb S Year,SBPWNM lank N W,Na vmn,m 4nlyda,wW,Pm paP^s^d Eulldtya,YKNmweN,rYedinw.
Mlle..Me con Psb.OYnWn,ak aNar mnkdeniws wva>Palls- In-MW.RacalP Inpa bmd Pmn3s.
❑ 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 clearedvapproved 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 1 further certify that all information contained on this
fomnandalpirclmclRecrordPcawing is accurate. form and attached Record Drawing is accurate.
Signatureoflnstaller Date
/4(le,
Printed Name of Sign"
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health_ ,, L�yy� /I V �)
" ` Ill
Signature of Environmental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE epOa�ptl BQ9R°1B
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