HomeMy WebLinkAboutSWG2024-00355 - SWG As-Built - 12/18/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SwG 2'v2K- 00355 Parcel# 4lZzj ('- 53- coo97
Applicant Name ADA i�14 till v Subdivision (Name/Div/Block/Lot)
Applicant Addresa'Z)61 53r AAe N'
City, State, Zip O`� (P 14 2IDS1 Installer Name ROYAL F[uSr( L r'I L-
SiteAddress � K) V641u06W WY Designer Name XAMTER FFSSc .
INSTALLATION CHECKLIST
,Full System InstallaU°°,� ❑Tank(S)Only ❑ l) Infield Only ❑Repair ❑Other
System Type /'re5sup a JO S�r�wv- t"r retreatment Type rtro�e
>5ft. from foundation? -------------------------- - ❑ NIA Yes NO
>Soft. from wells? - -- ------------------------- - ❑ ❑
Z >50ft.from surface water? - - -- - ------------------- ❑ ® ❑
rCleanout between building and tank? ------------------- ❑ ® ❑
V Tank baffles present? -- - - ---- - ------------------ ❑ [a ❑
d24"access risers over each compartment?------------ --- ❑ ® ❑
W Effluent filter installed?- --- - - -------------------- ❑ ® ❑
N
Septic tank size /V C-50gal manufaCWrer +41Adgee g*As ,O/r .r
❑ D-box water level and speed levelers used? -------- ---- WA ❑YES ❑ No
0J
0 Manifold/0-box accessible from surface?-- ---------- ❑ ❑ ❑
aeZ Check valves Installed? -- - - -- ------------------ ❑ ❑ ❑
❑2 Transport Lin ze Schedule/Class
Bedrooms installed (check one) 02 ❑3 ❑4 ❑ 5 08 ❑Connmsrcial/Other
>10ft. from foundation?-- ------------------------ ❑ WA aYes ❑ No
>100 ft.from wells?----------------------------- ❑ ® ❑
W >100ft from surface water? - ----------------------- ❑ ® ❑
M >10ft.from potable water lines?---------------------- ❑ ® ❑
m > 5 ft, from property lines and easemenis?--- - ------------ ❑ A ❑
> 30 ft,from downgradient curtain/foundation drains?-------- -- ❑ ® ❑
❑ Dralnfield level and observation ports present ----- ❑ ❑
❑ Graveless chambers or ❑ Clean gravel used? (Check one)
Proper cover installed over drainfield?------------------- ❑ ❑
Pump tank setbacks consistant with septic tank?---- --------,t' ❑ WA ®'vas ❑ No
X Pumptanksize gal Manufacturer flH'lM ✓pcec /
Q24"access dser(s) and accessible from Surface?---- ------ ❑ - ❑
r
C Alarm or Control Panel lnstalled7 --- ------------------ ❑ ® ❑
2 Control Panel equipped with Timer/ETMI Counter--- ------ - - ❑ E ❑
M
(L P p iinstalIs n ❑ Bucket or ❑ On Block or I& other ?y6t;
f P)/p Mak//eAAodel �✓Cr- CD �['[p8 :T1 / 12 Floats or ❑Transducer
IL Tank draw down z r inlmin Pump capacity /6 Bpm Squid Height N"4- ft
Pump on time '30 z&.e. Pump off time ion Deily flow set at f��/l'') gpd
Mason County OSS Installation Report pg- 2 Parcel# 4V-Ib - ) 3 - u00� C
ABANDONMENTRECORD
Were existing septic components abandoned as part of this project? - ------ -- ------ ypp 13 tip
if yes, please describe: �\
Were all components pumped out and properly abandoned per WAC24&272A-0300? - - - - - - - - ❑ YIM No
RECORD DRAWING
The Is a pmunant ncoN and must pe aaunb and aeinx-li a enough to reA«ate In Me need or malnhvnce eNvl4es and Nmre development Tynlsal Remrod
CICMngs mnlaT: Dnpnrrea E mennoM onente.s IeyoN.seprdpump tank location,rvwM arrow,reserve n2mneld existing and proposed bmmmgs.ocaticn of wens.waletlines,
all obselMlbn pMs.deanows.and other maintenance aIXess pools mcOTolete Record Dcroogs may create addnonal delayx,n final mstare-on Snore-I andrelale!ceonns
f}5 Per [7�sr7h
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 cleare"Dogroved 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 I further certify that all information contained on this
fomr end a ttec�h Record Drawing is accurate. form and attached Record Drawing is accurate.
TI A to-t,g -2IF
Si uA D
Printed Name of Sign" G
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 opnnedemnom
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