HomeMy WebLinkAboutSWG2022-00614 - SWG As-Built - 2/21/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2022.-6bUILI Parcel# R19 UU-S3- (�(IUtS
Applicant Name Ft " \T\ 1P,1 n N Subdivision (Name/Div/Block/Lot)
Applicant Address QW? Ova eM 8k.W
City, State,Zip l� Pit I I&B 9R 14U1I Installer Name r��No') . &-Ol.
Site Address llgk� CcP\tt>Y4F [�C- Designer Name hf .rtbr
INSTALLATION CHECKLIST
00ruli System InstallaUyn ❑Tank(s)Only ❑Drainfield Only ❑Repair ❑Other
System Type (0\Qr)CW Pretreatment Type
>S It.from foundation? .-------------------------- ❑WA FIYES ❑ NO
>50 ft. from wells? -- - -- ----- ---- - ------------- - ❑ ❑
Y >50ft.from surface water? -______ _________________ ❑ ❑ 0)
Z
Qr Cieanout between building and tank? ------------------
❑ ❑
U Tank baffles present? - - --- -- -------------------- ❑ c
d 24-access nsers over each compartment?--------------- - ❑ [l
lu Effluent filter installed?-- --- ------ --------- -- - --- - ❑ A '
Septic tank capacity(working) II -Q gal Manufacturer t
l
O D-box water level and speed levelers used? -- ------------ - We/A ❑ YES qNO
OIO� Manifold/D-box accessible from surface?-- -- ------------ - El
rt ka�, 1ry3 t�
nlZ Check valves installed? -- --- - -- ----------------- ❑ pr CLE,
OQ I
f Transport Line Size k SchedJe/CMss Si� )N'U I7
Bedrooms installed (check Y ❑6 ❑Commerclal/Oeter
>10 ft.from foundation? --�EC [-yJ-- ---- ❑WA QjVYEs ❑ ao
>100 IL from wells?-_ _ _ _____________ ___ ❑ ❑
W
>100 ft.from surface wateWSQN"WW HU&AWM6NT4 HEALTH___ . ❑ DD
M >10 ft from potable water Imes?-----JBW----------- - ❑ ❑
Z >5ft.Aran property lines and easements?---------------- ❑ ❑
Q
K >30 R from downgradient curtain/foundation drains?- --------- ❑ ❑
Drainfield level and observation ports present ---- ---------- ❑ ❑ ❑
❑ Gmveless chambers or QZ Clean gravel used? (check one)
Proper cover installed over drainfield?-- - - --------------- ❑ ❑ ❑
Pump tank setbacks consistent with septic tank?------------ - ❑ WA toYES ❑ NO
Y Pump tank capacity(flood) 17AD at Manufacturer NA YfP(lwdi-
Z ❑ ❑
F24'access nser(s)and accessible from surface?-- -- - ---- --—— rryr
d Alarm or Control Panel Installed? - ----------- -- ---- - ❑ ❑
rd Control Panel equipped with Timer/ETM/Counter--------- - - ❑ ❑
9 a Pump installed in ❑ Bucket or nUOn Block or ❑ Other
7 a Pump Make/Model r fQ V ❑ Floats or ❑Transducer
Tank draw down in/min Pump capacity�1- D pm Squirt Height
IL ft
Pump on time A &L. Pump off time IO Mln. Daily flow set at 2y h gpd
{bdl d 6211M18
Mason County OSS Installation Report pg. 2
ABANDONMENT RECORD
Were existing septic components abandoned as pan of this project? - -- -- --- --- -- -- YES NO
If yes, please describe:
Were all wmponents pumped out and properly abandoned per WAC24&272A-0300? - --- -- -- ❑ YES ❑ NO
RECORD DRAWING
TI is Ia --i,r to n+«ah in IM—d W—Itxe anu anlvpMa aM I..eawbpmaiu rryiW A.,,
O'anraa wn'an ]ra.n*xia a v.+'oa orienaaan 8 3(r.'.SeYvea.m.�m^.�LCa:G.1.Y ^.arc..'.."a u'."I.olopasec w.tl,roe.C:aaon vwma.veurrren.
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APPROVE
FES MASONCOON YE Z 4 Z01�
ENVIRONMENTAL HEALTH
Jaw
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 clearedlapproved by both the designer shown hen;have been clearettlapproved 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 andattached Record Drawing is accurate. form and attached Record Drawing is accurate.
V6t ��i�✓
Si nature of Installer Date
do, .
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH `
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public N ENT J011W
H t : ' I NSED OE iGNER
& netu Environmental Heattn Specialist Date (stamp, signature and date)
TMS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE u�pe blr^nsa
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