HomeMy WebLinkAboutSWG2022-00418 - SWG As-Built - 1/22/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATION
Permit Number SWG 2022-00418 Parcel # 32335-50-00031
Applicant Name Marylynn Walbaum Subdivision (Name/Div/Block/Lot)
Applicant Address 11632 18th Ave SW Tee Lake Shore Acres Lot 31
City, State, Zip Buren,WA 98148 Installer Name South Shore Construction
Site Address 2391 NE Tee Lake Rd, Tahuya Designer Name Frank Marcinko
INSTALLATION CHECKLIST
Full System Installation ❑Tank(s)Only ❑ Drainfeld Only ❑Repair ❑Other
System Type Time Dosed Pump to Gravity atment Type
>5 ft.from foundation? ----- ❑ NA N YES ❑ No
>50 ft.from wells? -- - - - -- - -- - ---- - ❑ e ❑
Z >50 ft. from surface water! - ----- - ____-�� 'iQ�.11- - ❑ ❑
Cleanout between building and tank? -- VE�---- ❑ El_
tl Tank baffles present? - ---------- ----- ❑ 1-1a 24"access risers over each compartment? IM- ------ ❑ ElIM Effluent filter installed?-- -- --- --- -- - ----- -- --- -- ❑ ® El
Septic tank size 1250 gal Manufacturer Hagerman Pre Cast
o D-box water level and speed levelers used? - -- - ---------- - ❑ NIA ®YES ❑ NO
QOManifold/D-box accessible from surface?- - - - - - -- -------- - ❑ ® ❑
19Z Check valves installed? -------- - - ----- - ❑ ❑
0Q
E Transport Line Size 2" Schedule/Class Sch 40
Bedrooms installed (chat*one) ❑ 2 E 3 ❑4 ❑ 5 ❑6 ❑CommerciaVOther
>10ft.from foundation?- -- - - - ------- - - - - - - - - - - - - - ❑ NIA 0 Yes ❑ NO
13 >100 ft.from wells?--- -- - -- -- ------- - -- - - - - - - - - - ❑ ! ❑
W >100ft from surface water? -- --------- - --- ------- -- ❑ e ❑
EL >10ft.from potable water lines?-- ---- --- - ------------ El ® El
> 5ft.from property lines and easements?- ---- -------- --- ❑ e
> 30 ft.from downgradient curtain/foundation drains?--------- - ❑
Drainfield level and observation ports present - -- - --------- - ❑ e z
0 Graveless chambers or ❑ Clean gravel used? (check one) i
Proper cover installed over drainfeld?--- --- ---- --- ---- --
Pump tank setbacks consistent with septic tank?- - - - - - - --- --- ❑ NIA YES ] Now
Y Pump tank size 1000 gal Manufacturer Hagerman Pro Cast 1 :.
Q24"access riser(s)and accessible from surface?--------- ----
IL ❑ ❑
IL Alarm or Control Panel Installed? ----- -- ------------- - ❑ El
jControl Panel equipped with Timer/ETM/Counter--------- - - ❑ ❑
a Pump installed in ❑ Bucket or e On Block or ❑ Other
d Pump Make/Model Liberty 290 a Floats or
2 ❑ Transducer
a Tank draw down 1.1 irdmin Pump capacity 23 gpm Squirt Height NA ft
Pump on time 2 min Pump off time 4 hrs Daily flow set at 276 gpd
ursNe smimis
Mason County OSS Installation Report pg. 2 Parcel# 32335-50-00031
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-03007 - - - ---- - ❑ YES ❑ NO
RECORD DRAWING
lIW le a p..M nwN vq mwl W ec[unle end Gevlpllye mnuyll b nJwb In 1M mM 0.....nce ee1NMh end Mun d.Il pmeM. Trylml R.m
Dr .w W- Dr IMJ 6.e KMenletion 6ls u sepWpuM YM baWn,Nor error,reurva drs.OW,..tNeM pra% WlNirga,b Wn d.ft wet.N .
xatr,aMervaWnpale,AerwW,erq oNer meinbrercae®en polnh. NCompble RemN OnWrpe may oeele eddllbrel delay In flrallmYlMlbn epprdyeleM rebled permih.
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 infomtation contained on this
form a d atta hed Re Drawing is accurate. form and attached Record Ekwing is accurate.
01/15/25
Signature of Installer Date
Rich Moore
Printed Name of Signee W
IPA
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and 20100M
Record Drawing on behalf of Mason County Public Frank 0
LICENSEDD D DESIGESIGNER
Health:1�Q�� ( �, /
(6517,
Somhrre ofEnvinertmental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE upmYe erztrzme
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