HomeMy WebLinkAboutBLD2024-01455 - SWG As-Built - 12/10/2024 AM TtiC- YY�ff- ItA)f C T4���aoay� p lycj: 5
,Masoh County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG Parcel# 32006-50-02073 E
Applicant Name TRAVIS/DAWN TWIDDY Subdivision (Name/gKi &tl\ H Fy"T't'V AL
Applicant Address 121 N ENATAI CT H
City, State, Zip SHELTON,WA- 98584 Installer Name �E
of
Site Address 1910 E.7--slR �a�DR Designer Name _jr . A
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INSTALLATION CHECKLIST
❑ Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type Pretreatment Type
>5ft.from foundation? --------------------------- ❑wA 0YES ❑ NO
>50 ft.from wells? --------- ---- ---------------- ❑ e ❑
Z >50 ft.from surface water? - ------------- ---------- ❑ ❑
HCleanout between building and tank? ---- --------------- ❑ ❑ ❑
U TankbaTFlespresent? -- - ------------------------ ❑ ❑ ❑
IL 24"access risers over each compartment?---------------- ❑ ❑ ❑
W Effluent filter installed?------- -------------------- ❑ ❑ ❑
Septic tank capacity(working) 750 gal Manufacturer D(IST1N0
0 D-box water level and speed levelers used? --------------- VA ❑yEe � No
p0 Man'rfold/D-box accessible from surface?------- ---------- ❑ ❑ ❑
C< Check valves installed? ------------------- ❑ ❑ ❑
2 Transport Line Size Schedula/Class
Bedrooms installed(check one) ® 2 ❑3 ❑4 ❑5 ❑6 ❑CommerC121/Other
>10 ft from foundation?--- - ---------------------- ❑ WA D YES ❑ NO
!. G >100 ft.from wells?--- - ------------------------- ❑ ❑ 0
W >100 ft.from surface water? --- - -------------------- ❑ ❑
W >10ft.from potable water lines?- - - ------------------• ❑ 11 ❑
aaZ >5 ft.from property lines and easemenis?------- --------- ❑ 19 ❑
K >30 ft.from downgradient curtain/foundation drains?---------- 0 ❑ ❑
Drainfield level and observation ports present - ------ ❑ ❑ ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- -- --------- ------- ❑ ❑ ❑
Pump tank setbacks consistent with septic tank?------------- ❑ WA ❑ YES ❑i NO
Z Pump tank capacity(flood) gal Manufacturer
H24"access riser(s)and accessible from surface?------------- ❑ ❑ ❑
a Alarm or Control Panel Installed? -- -- -- -- ------------- ❑ ❑ ❑
Control Panel equipped with Timer/ETM/Counter- -- -- ------ ❑ ❑ ❑
it Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
IL Pump Make/Model ❑ Floats or ❑ Transducer
IL
aTank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily Flow,set at gpd
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"ason'County OSS Installation Report pg. 2 Parcel it 32006-50-02073
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? ------ --- ---- - - ❑ YES ❑ No
If yes, please describe:
Were all components pumped out and propedy abandoned per WAC249-272A-0300? - ---- --- ❑ YES ❑ NO
RECORD DRAWING
Thar,Is a temunaht recom and mug Oa accurate and deecdpdve enough w M4x oe In the need of mslnranano agNtera and rulum da rewpment. Typical Record
02wmgs mntaln: gtinhew&mended onan eron&layout,Septic rhp tank location,North.1.,,reeerve dainrreld,anisdng and prop.tarh irys,I..h aaen,waterlines,
xens,oMnvaton poN,deYpW,and other mawenaMe a¢ess mn6. In Wmpble RemN ix.ono tNy IX6rd.additional dewy.in final inslaNlwn a,no.1 and related 1.1te.
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0 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 I further certify that all information contained on this
form and attached Record Drawing is accurate. forth and attached Record Drawing is accurate.
Signature Of Installer Date _
�9
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
a
The undersigned a roves this Installation Report and y I t a tick
KJ PP P p' liN WAIT
Record Drawing on behalf of Mason County Public r]cENSEp DestcNEti
Health: E.m.S dsmt - ..
5L A-TVM/ 1
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 uneewd minodle
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