HomeMy WebLinkAboutSWG2022-00530 - SWG As-Built - 12/26/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SIwI11G2022-y�Ob1s0 Parcel# 1gIn - 22- oom-o
Applicant Name Lh fir IA.0C.6LA& a. Subdivision (Name/DIvIElock/Lot)
Applicant Address (- %e /uW
City, State, Zip MlJta� (t QdnI Installer Name �1 \
Site Address ( Designer Name f-F fJa rr H-B 4r r
INSTALLATION CHECKLIST
[ Full System Installation ❑Tank(s)Only ❑ Drainfeld Only ❑Repair ❑Other
System Type Pretreatment Type
>5 ft.from foundation? --------- ------------ ---- -- ❑NIA YES NO
>50ft.from wells? --- ------------ - -- ---------- - ❑ ❑
Z >50ft.from surface water? - -- - ------ -- ---- - --- ---- ❑ IV ❑
H Cleanout between building and tank? -------- ----------- ❑ �', ❑
U Tank baffles present? - --- ----- ----- -- ----------- ❑ R]' ❑
d24"access risers over each compartment?---- - ------- --- - ❑ LT�r� ❑
rW Effluent filter installed?- - -------- ----- - ----------.. ❑ nYl ❑
Septic tank capacity(working) L11D oal Manufacturer
0 D-box water level and speed levelers used? -- ----------- - - 5N/A YES NO
QO Manifold/D-box accessible from surface?-- -- ------------ - ❑ ❑
fQZ Check valves installed? - --- - - -- - ---- - - - -- --- ----. ❑ ❑
O N
g Transport Line Size I Schedule/Class " 40
Bedrooms Installed(check one) ❑ 2 ❑4 ❑5 ❑6 ❑Commerclal101her
>10ft.from foundation?- ---- - -- - ---- - - - --- - -- ---- ❑ N/A Wr'Es NO
>100 ft.from wells?------- --- - ---- - - - ---- - ------ ❑ ❑
W >100 ft.from surface water? - ----- ----------- --- --- - ❑ ❑
LL >10ft.from potable water lines?------------------ - -- - ❑ ❑
Q2 >5ft. from property lines and easements?- -- -- ---- --- -- -- ❑ ❑
C > 30 ft,from downgredient curtaln/foundation drains?- - -- - -- - -- ❑ ❑
im Drainfield level and observation ports present ------ ❑ ❑
❑ Graveless chambers or Pg Clean gravel used? (check one)
Proper cover installed over drainfield?----- -------------- ❑ ❑
Pump tank setbacks consistentwlth septictank? ------------ - ❑ NI/A1 ( J7vas ❑ No
2 Pump tank capacity(flood) IW 9at Manufacturer
Q 24"access riser(s)and accessible from surface?------ ------- ❑ M) ❑
2 Alarm or Control Panel Installed? - ----- ------- ------- - ❑ ❑
Control Panel equipped with Timer l ETM/Counter - -- -- --- - - ❑ ❑
a Pump installed In ❑ Bucket or 410n Block or ❑ Other M
Pump Make/Modal kt r S ,ya bats or ty Transducer
a Tank draw down In/min Pump capacity LI O gpm Squirt Height /•A ft
Pump on time It{ Sex s*V-S Pump off time kD rh Lq Dally flow set at 276 gpd
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Mason County OSS Installation Report pg. 2 Parcel #
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - - -- - - - - -- ---- ❑ YES NO
If yes, please describe:
Were all components pumped out and property abandoned per WAC246-272A-0300? -- ---- -- ❑ YES NO
RECORD DRAWING
Thb le a pemulvnt.cola and mu.Ca accurate and aascrlPri na anoua n to labiate In Na-ad or mainbrunn atllmalas.lawn eewbp,mne Typbal Aeco.e
n'mirgcwmam 13—flao 6 anandoldoNnutian&layout.stau1,—main borgn.Nona.cola.aaemdninMb.exiYng BM Propma06ulenga.Wlwnmad,.waWMnea.
vast.Damn.ports.EM..a,are Mhn rnYmenarca across poina. IntonpM4 ReroN Dra.nae rnayGuu eddPinamdNays b final inY edam awm+al and imam permAs.
❑ 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 cleared/approved 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
form and attached Record Drawing is accurate. form end attached Rem wing is accurate.
I I A III
Signalitureofinstaller Date
J M n �72.
nr. ovSc,
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH /
The undersigned approves this Installation Report andiA
Record Drawing on behalf of Mason County Public
Health: -Ly
Signature of Environments ealth Specialist Data (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE wda'.eavaa+e
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