HomeMy WebLinkAboutSWG2022-00195 - SWG As-Built - 2/10/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATION
Permit Number SWG 2022-00195 Parcel# 12329-13-00000
Applicant Name HOLUE MCOUILLAN Subdivision (Name/Div/Block/Lot)
Applicant Address PO BOX 2763
City, State, Zip BELFAIR WA. 98528 Installer Name SOUTH SHORE
Site Address 150 NE FOSTER DR Designer Name CINDY WAITE
INSTALLATION CHECKLIST
21 Full System Installation ❑Tank(s)Only ❑ Dminfield Only ❑Repair ❑Other
System Type Alu r-..J,. -I-. o, Ur- Pretreatment Type
>5 ft.from wells?
-------_ MOTE-1 ❑ N/A Ea ❑ NO
>50 ft.from wells? ------ -____ llv ❑ ❑
Z >50 ft from surface water? --- ---_ TIB ❑ ❑
F Cleanout between building and tank? - _ -0 ���- - ❑
C.1 Tank baffles present? -- - -___ _ _ ❑ ,-,- Ela 24'access risers over each compartme _ El
yIQ�'�
NEffluent filter installed?-______________ __________ _ - ❑ O
Se tic tank ca acit workin 1,000 Trash P capacity(working) Manufacturer g HAGERMAN
O D-box water level and speed levelers used? -_____________- dwA ❑ No
DO Manifold/D-box accessible from surface?-_______________- �' ❑
mOQ Check valves installed? - _ ___________________ _____ ❑ 0 ❑
f Transport Line Size .y Schedufe/Class
Bedrooms installed(check one) ❑ 2 8 ❑CommerciaVOther
>10 ft.from foundation?-- --- -- ❑ wA wEs ❑ NO
G >100 ft.from wells?-- ------ - . _7_ __ - ❑ ❑
W >100ft.from surfacewatert--- p
LL >10 ft.from potable water lines?- _FCB t% -- UH ❑ ❑
az NNRONNIEN�t�' ❑ B' ❑
K >5 ft. from property lines and as. ___- ❑ Gr ❑
>30 ft. from downgradient curtai undation draitw- --_____- ❑ ❑
Drainfield level and observation ports present ------ ❑ g
❑ Greveless chambers or ❑ Clean gravel used? (check one) ❑
Proper cover installed over drainfield?------------------- ❑ E ❑
Pump tank setbacks consistent with septic tank?------------- ❑ wA O'yES NO
Z Pump tank capacity(flood)rx 1250 gal Manufacturer I( HAGERMAN
Q 24"access riser(s)and accessible from surface?------------. ® ❑
yAlarm or Control Panel Installed? --------------------- ❑ ❑ ❑
Control Panel equipped with Timer/ETM/Counter---------- . ❑ ❑ ❑
7
IL Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
Pump Make/Model ❑ Floats or \�❑ Transducer
a Tank draw down—. irdmin Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
P4...p awr. /a-A Ofto. p�a.ar rysi'p m,a
Mason County OSS Installation Report pg. 2 Parcel x 52004-50-00037
ABANDONMENTRECORD
Were existing septic components abandoned as part of this project? -- -- -- -- --- --- . YES NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? ----- --- YES NO
RECORD DRAWING
lab Is a gmuront rapatl sed mutt W accurM and tl HAMNn anoupll to Moufe In Me need of malntenanca rNvlaas and future WvabpmaM. Typical ReraM
emnngs oonuM'. enin0ep a nlenilold giMtaLcn 61rywt,Sep4GWmp for, tfa,,NaM arrmv,nsena dremMla,eclnng and pmpoxd puYd"A noun.d.11A wabdinaa.
"I aGwmtlm potY,cadri Are—a annneMe acusa polnn. Ir.ple RemN Dra.1,may wade AW..rrM dela,i In final Inela'l xon eppmvel and nation: rods
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PPROVE ®
FEB 1 0 2025
MASON COUNTY ENVIRONMENTAL HEALTH
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Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
l 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 I further certify that all information contained on this
form and Y
ached cord Drawing is accurate. form and attached Record D awing is accurate.
� 10/3/24
Signatum oflnstaller Date
Richard Moore $�iP red
Printed Name of Signee 33 w+J g
MASON COUNTY PUBLIC HEALTH cI s f ITS
The undersigned approves this Installation Report and LICE DESIGNER
R rd Dnewmg on behagof Mason County Public EwrRES os,ry
�3
d �-IO'ZS
Sig atu f vimnmental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COU NTV WEB SITE updalad"'co'e
A
PPROVED
FEB 10 ?02j
MASON COUNTY ENVIRONMENTAL NF4TH
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