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Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SING Parcel# 32213-2300010
Applicant Name HCSE Subdivision(Name/Div/Block/Lot)
Applicant Address PO BOX 2169
City, State, Zip Belfair,WA 98528 Installer Name NA
Site Address 2021 NE Tahuya River Rd Designer Name NA
INSTALLATION CHECKLIST
❑ Full System Installation ❑Tank(s)Only ❑Dminfield Only Pret Repairreatment tm Other
ent Type❑
system Type
>5 ft.from foundation? --------------------------- ❑raA ❑YEs ❑
>50 ft.from wells? --- - -----
El ❑ {,
X >50 ft.from surface water? ------- --------- 0 ❑ ❑ 1
F Cleanout between building and tank? ------- ----_ _ _ _ ❑ ❑
V Tank baffles present? -- - - - - ---- ----- ❑
6 24"access risers over each compartment?- --- - ----- - --- -- ❑ ❑ ❑
W Effluent filter installed?--------
Septic tank capacity(working)
at Manufacturer -
❑
0 D-box water level and speed levelers used? -- ------- '-'-'- q YES ❑ No
❑ ❑
DO Manifold/D-box accessible from surface?------- ------- "-- ❑ ❑ ❑
___ _ __
19Z Check valves installed? ------ - ----- -----
-C Schedule/Cle
f Transport Line Size
3 ❑4 5 ❑6 ❑Commercial/Other
Bedrooms installed(check one) ❑ 2 ❑
❑ NIA ❑YES ❑ NO
,to ft.from foundation?---------'- '-'"-- ❑
❑ ❑
G >100 ft.from wells?-- -----""-"--- ❑ ❑
W >100ft.from sudacewater?--------" -------------- ❑ ❑ ❑
U. >10ft.from potable water lines?------- - ❑ ❑ ❑
2 >5 ft.from property lines and Basemen ------- ---"'--- ❑
Q ❑
lY >30 ft.from downgmdient curtain/foyptlation drams?---------- ❑ ❑ ❑
to Drainfieltl level and observation ppAs present - --------'-
__-
❑ Graveless chambers or.0 Clean gravel used? (check one) ❑ ❑ ❑
Proper cover installed over drain0eld?------- ----------
❑
Pump tank setbacks sistenl with septic tank7---------'-'- ❑ turf ❑ YES NO
Y. Pump tank caps (flood) gal Manufacturer
Z ❑ ❑
Q 24"access rt (s)and accessible from surface?------ ----'_- ❑❑ ❑ ❑
~ Alarm or trol Panel Installed? - - - --- --- ---- --- ❑
IL ❑
e Control Panel equipped with T r9r I ETM/Counter------ ❑
a Pump installed in ❑ Bucket or ❑ On Block or Other
a Pump MakelModel ❑Floats or ❑Transducer
Tank draw down in/min Pump capacity opm Squirt Height
ft
a Daily now set at opd
Pump on time Pump off time uvnrzme
Mason County OSS Installation Re=7!777���
2
Parcel 32213-2300010
RECORD
0 YES
El NO
Were existing septic components abandoned
If yes, please describe: S YES NO
Were all components pumped out and property6-272A-0300? '--' ---
RECORD DRAWING
Tnb k a pannan ix ncoN.na m .t M1 .¢.nn.all aasniP .elankabcation4No al�nw reae e2inlleYl aNn n9allLsoWaoa Ouiairgc.lorelbn Of well.wale?nee.
D.1vi¢inull oninfiele5—a ,I.Iaownwt,onalayoutse um I and relatesrnmi-
v ms,oxxnvalion pals.deanou6,ana an.,—inlaunra ac Wxrn' Inmmdalo ReuaE Dna 11may ueele eatil'unal alleys In rirelinWretion appm'a
Record Drawing Attached
CERTIFICATION OF INSTALLATION
DESIGNER/ENGINEER
INSTALLER
I certify that I installed the system in accordance with 1 certify that the system has been installed in the septic OVE
the septic design stamped"APPROVED"by Mason dance with 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 m own hem have been and Mason County Public Health andapprevond by all
and Mason County Public Health and meet all State St to and Mason County Codes
and Mason County Codes.
I further certify that all information contained on this 1 further certify that all information contained on this
form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
pflj ftAw_ GaNST
'3 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:
(stamp, signature and date)
Signature of Envimnmentaf Heafth Specialist Date upael.a srz+nore
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE
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