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Home My WebLink AboutABANDONMENT RECORD - SWG Letters / Memos � (3An�DvnMf►�"h91" �.R orct� Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION EAddress er SWG Parcel# 32213-32-00040 e HCSE Subdivision (Name/Div/Block/Lot) ress PO BOX 2169p Belfair.WA 98528 Installer NameNA 171 NE Neyhert Farms Ln Designer Name NA INSTALLATION CHECKLIST ElFull System Installation ❑Tank(s)Only ❑Dramfield Only ❑Repair ❑Other System Type Pretreatment Type 15 It.from foundation? _ __ N/A >50 I from wells? -__ _ ___________ _ ❑ YES o [��< >50 It from surface water? ------ --- --- --------- - - - ❑ ❑ Cleanout between building and tank? -________________ _ ❑ ❑ U Tank baffles present? -- - __ _ _ ❑ ❑ ❑ a24"access risers over each compartment?---------------- El lu Effluent fitter installed?-___ _____ ❑ ElN ❑ ❑ ElSeptic tank capacity(working) al Manufacturer 0 D-box water level and speed levelers used? -________ ____ _ 00 Manifold/D-box accessible from surface?-_______ ________ WA ❑res ❑ NO oQ Check valves installed? El _ 0 ❑ ❑ f TransF.'m ort Line Size Schedule/C s ❑ ms installed(check one) ❑ 2 ❑3 ❑4 5 ❑6 from foundation?--____ _ _____ __ __ ❑Commercial/Other ❑ N/A YES ❑ NO .from wells?--__ _______ _____ ----- ----- ❑ ❑ ❑ .from surface water?----- ---- - rom potable water lines?------ ______________ ❑ ❑ ❑ rom property lines and easeme ❑ ❑from downgradient curtain/F lotion drains? ____ _ _ _ _- O ❑ ❑ anield level and observation rts present -- - - _ __ _____-- ❑ ❑ ❑ ❑ Graveless chambers or Clean gravel used? (chack one) ❑ ❑ Proper cover installed ov rainfield?---_____ __________ ❑ Pump tank setbacks sistent with septic tank?-----________ ❑ ❑ Y Pump Wnk capac" (flood) gal ❑ WA ❑ YES ❑ NO Z Manufacturer F(- 24"access ris s)and accessible from surface?------ ------- IL ❑ ❑ Alarm or rol Panel Installed? -- ------ --- ---- --- --❑ Other ❑ ❑ jControl el equipped with Timer/ETM/Counter-----_____- El ❑ ❑ 4 Pum nstalled in ❑ Bucket or ❑ or On Block ❑ ❑ 1 Pump Make/Model ❑ Floats or ❑ Transducer Off- Tank draw down iNmin Pump capacity gpm Squirt Height % Pump on time Pump off time Daily flow set at qpd upa.�.e amrzore Mason County OSS Installation Report pg. 2 Parcel a 32213-32-00040 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - -- - --- --- -- -- - If yes, please describe: YES NO Were all components pumped out and propedy abandoned Per WAC24&272A-0300? -- ---- - - Q YES NO RECORD DRAWING This a a permanent awns,.nand his xarw and d""'ahtlae.hough to n-loom In the naeE or maingname.glraW and wWre darelo Dmings wMeb: oremfiNd a meniroa meMaum amyout sepdklpump"'s mraron. "a—''--I-dain4sid,evaung a. hem' o, RewN "in,06 Mu swn puta,dean.u6,e.cMermg hand—aaxu Poach Inwmplate Racal peyirga ma Oawa.Wudirga,b�adbn of xallc,waMrlp,ea, y frea18 asdldonal delays in fi.l inaUllabn appoVel a.m'gbd pe.ly Record Drawing Attached CERTIFICATION OF INSTALLATION INSTALLER DESIGNER/ENGINEER I certify that/installed the system in accordance with l 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 clearedla and Mason County Public Health and meet all State PPmved n both myself and M and Mason County Codes. Mason County Public Hearth and meet all State and Mason County Codes l further certify that all information contained on this /further certify that all information contained this farm and attached Record Drawing is accurate. dorm and attached Record Drawing is accurate . I�A'f NAB C DN%F, Date Printed Name of Signee MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report and Record Drawing on behalf of Mason County Public Health: 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 uodaad%mrmm KURT'S SEPTIC PUMPING RV PYMP ITS SEPTIC TMM PUMPING ACME"Lear INSPECTION CTEMTION A MAINTENANCE KURT OLSON kurtsseptlCl@gmaii.com P 0.WX99,BELFAIR,WAGSS28 (aB0)215-190E KURTBP1923JC NoIO979 Sold lb Shiph Phone Phone Date Delivery Dale Ship Vie FO.S. Terror Order No. Quantity Description Prim Amount Description or rob 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. Customer Signature 1-11 NEE Ntgkwp &� Ln � 7 #k 3ZZ13 -SZ-Mvo • AbamAv,-irn rvf p,,- WAG 7Nu2-7ZA -u360 817 2oZy SITE DIAGRAM ^--' z 4 � qs u�« pro Bet J, ofY1.e 4oi �4 'U,N DYE PACKET RESULTS OC ses mmv arc taa a�a. u.e � emm a.. o-rc cdw or n.e ._ .. 1 z � ly Z 4 V BACTERIOLOGiCALRFSULTS Site Date Remit Number •