HomeMy WebLinkAboutABANDONMENT RECORD - SWG Letters / Memos 9-A1J Do nl M0Vr If OV-D
MASON COUNTY PUBLIC HEALTH
Mason County OSS Installation Report pg. 1
APPLI11 CANT11 /PERMIT INFORMATION
Permit Number SWG Parcel# 32213-23-00020
Applicant Name HCSE Subdivision (Name/Div/Block/Lot)
Applicant Address POBOX2169
City, State, Zip Belfair,WA 98528 Installer Name NA
Site Address
2061 NE Tahuya River Rd Designer Name NA
INSTALLATION CHECKLIST
❑ Full System Installation ❑7ank(s)Onty ❑
Drainfeld Only ❑Repair ❑Other
System Type Pretreatment Type
>5 ft.from foundation? --- ------ - -- -- - ❑ NIA ❑YES NO
>50ft.from wells? --- --- --- -- - -- - --- ---- ----- - - ❑ O ❑
Y >50ft.from surface water? -- - - - - -- ----- - - - - - - ❑
Z Cleanout between building and tank? __ __ _ __ _ _ _ _ _ ______- ❑ ❑
V Tank baffles present? ---- -- -- - - - ❑ ❑ ❑
6 24"access risers over each compartment?--__ -__ -____ ___- O ❑
W Effluent flier installed?- - - -- -- - - -
N gal Manufacturer
Septic tank capacity(working)
O D-box water level and speed levelers used? - -- - --- - -- - '--- NIA ❑
YES NO
J ❑ ❑
�O Manifold/D-box accessible from surface?- ---- --- - --- -- --- ❑❑ ❑ ❑
mu: Check valves installed? --- - --- - - - - --- - - ---
N Schedule/Class
2 Transport Line Size
Commercial/Other
Bedrooms installed(check one) ❑ 2 ❑3 ❑4 ❑5 ❑YES ❑ No
_ _ ___ - - ❑ NIA
>10 ft,from foundaUon?- - - --- - --- -- - - --- - ❑ ❑
___-
>100ft.fromwells?-- -- -- -- -- -- -- -
p ❑ ❑ ❑
J >100 ft.from surface water? - -- -- -- - --- '- --- ❑ ❑ ❑
a >tOft.from potable water lines?--- -- - - -- --- ❑ ❑
Z > 5ft.from property lines and easements?---- - -- ---- - -- ❑ ❑
>30 ft.from downgradient curtain/foundation or s?------ - --- 0 ❑ ❑
Drainfield level and observation ports press -- -- -- ----- - -
❑ Graveless chambers or ❑ Clean vel used? (check one) ❑ ❑
Proper cover installed over dreinfteltiv - -- - -- ---
Pump tank setbacks consistent septic tank? -- - ---- ------ El NIA ❑
YES ❑ NO
Y. Pump tank capacity (flood) at Manufacturer ❑
Q ❑
24"access riser(s)and ssible from surface?---- --- --- --- El Li
❑
~ Alarm or Control Pan nstalled? -- - - - - --- - --- - -- - ❑
6 ❑ ❑
'F Contol Panel equ etl with Timer/ETM/Counter- - - - - - - - - - -
6 Pump installs ❑ Bucket or ❑ On Block or ❑ Other
6 Pump M Mpdel ❑ Floats or ❑ Transducer
f
city 9P m Squirt Height ft
6 Tank w down in/min Pump capa
Pump off time Daily flow set at 9Pd
Pump on time uoe.,�a erz,rzma
Mason County OSS Installation Report pg. 2
Parcel# 32213-23-00020
ABANDONMENT RECORD
--- --- -- - --- -- - Q YES NO
Were existing septic components abandoned as part of this project?
If yes, please describe'. YES NO
Were all components pumped out and properly abandoned per WAC246-272A-03001 -- - -- ---
RECORD DRAWING
mb y.pprn,n.m nmN aM must be accmaee end eax,lwire enoWn to e-oOY In the MM of mamYnanca ahRin ana fuse darauommt "ro rt..E
000
Oes ec suntan: Dfainleld 8 mentloN alematian 8layou�septiclW^W rank bratim.NMh s�mw,exrve ne.fiea,iosa,Mlay sn Wna nstemsldon es—e end MeW polls.
wells,aservaron pads,deanouts,eM omm maims-ii-a¢ee pointy. I�mm-0bn ResO erowF9a may oea
0 Record Drawing Attached
CERTIFICATION OF INSTALLATION
DESIGNER/ENGINEER
INSTALLER
1 certify that I installed the system in accordance with 1 certify that the system has been installed in OVE
the septic design stamped"APPROVED"by Mason dance with the septic design stamped:4PPROVions
County Public nHealth and that any deviations shown roved by both the designer Masonown here haveublic Health and that any
been cleared/approved by both deviations
here have been cleared/app g
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
loan and attached Record Drawing is accurate.
form and attached Record Drawing is accurate.
gt}IeIeR�FhraleMar
M
of SlgneeNTY PUBLIC HEALTHned approves this Installation iONTHEMASOP
ing on behalf of Mason Count (stamp,nvironmental Health Specialist uwet.e arztrzme
THIS FORM MAY BE SCANNED AND AVAILABLE COUNTY WEB SITE
KURT'S SEPTIC PUMPING
SEPTIC TANK PUMPING
pV PUMP OUTS OpEMTmN A MNNTENPNCE -
HWESALESINSPECTIONS
KURT OLSON p.o.BOX 99,SELFAIR.WA 985M
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kurtsseptgma"Com KU97SP1923JC
(S8G)275-1996 MG10978
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Phone -- PhoneDan jNji,,,,Oww ---
Ship Via FO.B. I Term. Order No.
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Quantity Dmnpuon Pria Amoum /
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Description of lob -{
The Purchaser agrees that he has received the materials Or service
supplied under this Sales Contract in good condition and to said
Purchaser's satisfaction.
1
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Customer Signature
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A� pu WA-C 2NV—z72A-t3m s"r ,t�� ;�aell
B 23 2024 SITE DIAGRAM
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DYE PACKET RESULTS
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BACTERIOLOGICAL RESULTS
Site Date Reau{ta
Number
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