HomeMy WebLinkAboutSWG2023-00262 - SWG As-Built - 2/21/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATION
Permit Number Bwc 20T%- CZ1Q2 Parcel a qlq 04- S3- Lp
Applicant Name phtW jR-•V,.t�e,-ekrap Y\\1 Subdivision (Name/Div/Block/Lot)
Applicant Address uJ6l k1e-" YAkX6jk
City, State, Zip 011,\�nY7altb A �tArr �' tll�elnstaller Name l
Site Address 114 rn St On
INSTALLATION dt'. Designer Name
INSTALLATION CHECKLIST
*WI System Installation ❑Tank(s)Only ❑ Dralnfieid Only ❑Repair ❑Other
System Type 610fiew Pretreatment Type
>5 ft.from foundation? --- --- - -- -- -- ❑ NIA arEs NO
>50ft.from wells? - ___ _ __ ____ __ ___ _ _ __ _ ___ _ ____ ❑ ❑
zY >50ft.from surface water? - - - - - ------------------- ❑
FCleanout between building and tank? ------------------- ❑ ❑
Tank bellies present? -_ ___ ________ __ _ __________- ❑ ❑ _
24'access risers over each compartment?--------------- - ❑ ❑
W Effluent filter installed?----------- -- ---- --- -- ---- -
fT�11n (1 l ❑t
Septic tank rapacity(working) Won gal Manufacturer
O D-box water level and speed levelers used? -------------- - OWA ❑YES ❑�O b
AO8 Manifold/D-box accessible from surface?---------------- - ❑ ❑j
@= Check valves installed? ---- - - -------------------- ❑ �7 ❑t EA
tj I 11'91
n c �- ul7 t Transport Line Size I SGredulelClass
Bedrooms installed(check one) P ❑3 ❑4 ❑5 ❑6 ❑CommerostrOlher
>10ft.from foundation?--- -- -- --- -- ---- ❑WA ItYEe ❑ NO
G >l00fLfrcmwa1l0-----_____j_ 77//��� � __. ❑
W >100 R.from surface water?-_ �_Y______��___ . ❑ ❑ �1
Z >10R from potable waterlines -_ rn_2.q-AUT------ - ❑ pl ❑
>5 ft.ft"property lines and 4&ntsSu?___,_a Yn^:,',�,.-... ❑G >30 ft.from downgradient curt MF p� OFdih t•'-------- • ❑ IT El
Drairdield level and observation ports present -i a'-`-,... .... .. ❑ ❑
❑ Graveless chambers or Clean gravel used? (check me)
Proper cover installed over drainfield?-- - - --------------- ❑ ❑
Pump tank setbacks consistent with septictank?------------ - ❑ WA YES ❑ NO
Y Pump tank capacity(flood) (2-00 gal Manufacturer 40, PireMtd�
f24'access riser(s)and accessible from surface?-- --- -------- ❑ ❑
6 Alarm or Control Panel Installed? -- - - - -- --- ---------- - ❑ ❑
Control Panel equipped with Timer/ETM I Counter ---------- ❑ ❑
IL Pump installed in ❑ Bucket or �/IVOn Block or ❑ Other
n' Pump Make/Model�If hU l� ❑ Floats or Transducer
a. Tank drew down�Q_iNmin Pump capacity U� pm Squirt Height d2,� ft
Pump on time Pump oft time !D Olin. Daily flow set at ZyL_gpd
V�k4 B1v$16
r
Mason County OSS Installation Report pg. 2 Parcel It �9� —CJOCIL
ABANDONMENT RECORD
Were mating septic components abandoned as pan of this project? - - - --- -------- YES N. NO
If yes. please describe.
Were all components pumped out and properly abandoned per WAC24&272A-0300? ---- ---- YES NO
RECORD DRAWING
TM.Is.perm -I..rota.M nu.r W a.cunN end daaerlpti...n...,ro n1ec.1.In ev rcea ar ....tuwr.Yev.Mmeni,
Daxira.wnun Dn- .&"e-:':p oxmuc,8 ry :.3el. 'i" :,.r+c ,.e:oa r."aryn'e,..urci-,"in aec WiW`1A brawn aRans,wak.'enes
x.fs,a.Lerva_ipn Prra nx ,e Re.0—..,,me,:n.1.satl:;.nvl Rear,m keel.W:•.an appxre'ari!rcyYy pane^.a
APPROVE
FEB 2 4 2025 Lf
MASON COUNTY ENVIRONMENTAL HEAL-P
JBW
pRecord Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that)installed the system in accordance with 1 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 devladons shown Mason County Public Health and that any deviations
here have been clearectapproved by both the designer shown here have been clearediappmved 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
to=and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
Si rtatura of Installer Date
Printed Name of Signee Q'
MASON COUNTY PUBLIC HEALTHc�Rr
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public s+
Healh: ,y PA ERT BONES;;.
I .� )A i SED- E N� R
�A.t) J 2 Ib
Signature o(Erxv' tel He,Nlth Span.ah,rf Date
(Stamp.Signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE
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