HomeMy WebLinkAboutSWG2023-00374 - SWG As-Built - 1/29/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number S 1WG IL\I\-P,� - (Qj7ut Parcel# _?2L 09- T1 - /ml U
Applicant Name _p{_ t ��u Subdivision (Name/Div/B(ock/Lot)
Applicant Address Qn Rx"Y If-W
City, State, Zip _klLe UkAh4 , k,DA 9&&-7 Installer Name lk!y{, An)�h ors,
Site Address Designer Name Q8jaM lAur r
INSTALLATION CHECKLIST
A System Installation ❑Tank(s)Only ❑Drainfeld Only ❑Repair ❑Other
System Type Pretreatment Type
>5 ft.from foundation? -_________________________- ❑WA ❑ NO
>50 ft.from wells? - ____________ y-�A�� ❑
Z >50 ft.from surface wateR -------- IL�+ryry991♦:S5 {��II ❑ ❑
F Clearout between building and tank? --- iiijlltJJJ''II ❑ ❑
V Tank baffles present? -- ---- j'4NLy2O25 ❑ ❑_ __ __ _________
a24"access users over each compartmen .____ /_ ____ - ❑ ❑
NW Effluent filter installed?---________ - __ ❑
Septic tank capacity(working) 11hn at Manufacturer ❑
D-box water level and speed levelers used? -_____________ . ❑ NIA YES ❑ No
Ou0- Manifold/D-box accessible from sudace?-_______________ . ❑ ❑
6z Check valves installed? ----- -- --- ❑ El2 Transport Line Size U LY�P A-\ Schedule/Chm U&4A I-)y
Bedrooms installed(check one) 02 ❑3 ❑4 ❑5 ❑6 ❑CommerciallOther
>10ft. from foundation?------------------------
- ❑ WA Yes
❑ NO
� >100 ft.from wells?-- - ------------------------__ ❑ ❑
W >100 ft.from surface water? ----------------------- - ❑ ❑
N. >10ft.from potable water lines?--------------------- - ❑ El>6ft.from Property v._ __ ____________
p perry lines and easements. ❑ ❑
>30 ft.from downgradient curtaintroundation drains?-----____- ❑
Drainfield level and observation orls present - ----_______ 13 ❑
❑ Greveless chambers or Clean gravel used? (check one)
Proper cover installed over drainfield?----------- --- -- --- ❑ Rai ❑
Pump tank setbacks consistent with se tictank?_______ _____ _ ❑ WA �Y
❑ YES ❑ NO
Y Pump tank capacity%Installed?
aal Manufacturer Z
F24"access ricers) from sudaw?--- ________ ❑ ❑
a Alarm or Control Pa ------ -______ ❑ ❑ ❑Control Panel equip /ETM/Counter------a Pump installed in ❑ On Block or Other
oPump Make/Model
Tank draw downin ump capacity opm Squi fight ft
Pump on lime Pump off time Daily flow set at opd
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Mason County OSS Installation Report pg. 2 Parcel u
ARANDONMENTRECORD
Were existing septic components abandoned as part ofpthis roject? -- -- - - --------- YES N
If yes. please describe.
Were all components pumped out and properly abandoned—per WAC246-272A-0300? -------- YES E] NO
RECORD DRAWING
Tim is a gm4nent YceM aM mug Ce NcunY aM dewrbew enough Y mA gs In Hs q d ar mslMemw setYltiea and hMre deveio,t. T,a'.Rem-
Pawiyzconym O in3alCb mcldN oeien•,at nIkia sl elpo ,,,IsnI.,na�n errda.Nue,N"nf , vs:,3v:orse -3,_ e<..
eof.dMerva:M pdrlicllaruW.s'(OJCl/n�n munYru/e¢aTc[�ce[s/s/p�}/n/U/N/WppmvdM/DY Re[T:C'biny MY %eaY add'cc .._ :_. —.-
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Record Drawing Attaches
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 clearedyapproved 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 /further certify that all information contained on this
for and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
Si nature of Installer Date
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6; • ..•,,,, ,
Printed Name ofSignee
i •.u,
MASON COUNTY PUBLIC HEAL'• ✓ ',+y y - J N�,q 9,.N r AOA rly HUNTER '>
The undersigned approves this Installat�gpod a.V
Record Drawing on behalf of Mason County/� "a,, 'NSFb'B@SiCNE'R'`
Health: "` '
z z °
y� as
S/grrature 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 uVdaad g:" "
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