HomeMy WebLinkAboutSWG2024-00292 - SWG As-Built - 2/24/2025 ,Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATION
Permit Number SWG 2oZN-0%192 Parcel # 22Z02_ - VQ- n ZO(1 i
Applicant Name �� DCA&I Subdivision (Name/Div/Block/Lot)
Applicant Address (
City, State, Zip . Pak4,LJA 9&199 Installer Name .
Site Address 1 Designer Name
INSTALLATION CHECKLIST
[] Full System Installation ❑Tank(s)Only ❑DraiMeld Only Repair ❑Other
System Type NIn C.! YOL Pretreatment Type
>5 ft.from foundation? ------------------- - ❑WA ®YES ❑ NO
>50 ft.from wells? --------------- ,prrn(�� El
Z >50 ft.from surface water? ------- LI-�+—� ❑ ❑
H Cleanout between building and tank? -- -1 ❑ ® ❑
V Tank baffles present? ------- ---- -�Efl_ _ ___-- IR ❑
t- 24"access risers over each compartment? ---- - ---- - ® ❑
rW Effluent filter installed?------------ Y-- - -- - ❑ ® ❑
Septic tank capacity(working) 1 I U0 at Manufacturer �� �M PMA
O D-box water level and speed levelers used? -------------- - ® NIA ❑ YES ❑ NO
CLL Manifold/D-box accessible from surface?---------------- - ❑ ® ❑
mZ Check valves installed? - ------------------ ------- ❑ ® ❑
OQ n
f Transport Line Size ) Schedule/Class ScM 11r�
Bedrooms installed(check one) W 2 ❑3 ❑4 ❑ 5 ❑6 ❑CommerciaVOther
>10 ft,from foundation?--- --- ----- -�� ❑ NIA YES ONO
G >100 ft.from wells?--- ---------- � O-F/-E W
W >100 ft.from surface water? ------- -- --- r_ ❑
M >10ft.from potable water lines?------
- -_EL .1Jf ® ❑
nd MMnn 2015
X 30 ft.from dow 9 am property ld ennes tcurtain/fo curtain/foundation JB ONMEryjgl"yE4a ® ❑
Drainfeld level and observation ports present - - -- -- ---- ---- ❑ ® ❑
❑ Graveless chambers or C1 Clean gravel used? (check one)
Proper cover installed over drainfield?---- --------------- ❑ ❑
Pump tank setbacks consistent with septic tank?----------- - - ❑ wA ® YES ❑ NO
!d Pump tank capacity(flood) 12-00 oat Manufacturer IM
z
F24"access risers)and accessible from surface?-------- ----- ❑ ® ❑
IL Alarm or Control Panel Installed? -------------------- - ❑ ® ❑
Control Panel equipped with Timer/ETM/Counter-- ------- -- ❑ ❑
a Pump installed in ❑ Bucket or ® On Block or ❑ Other
u Pump 118ke/Model Adrenrn ® Floats or ❑ Transducer
a Tank draw down NIA in/min Pump capacity Sh apm Squirt Height N P �7p7�
Pump on time N I� nSrrJ Pump off time - s( Daily flow set at ft�__gpd
vwr..e smace
Mason County OSS Installation Report pg. 2 Parcel
ABANDONMENT RECORD
Were existing septic components abandoned as pan of this project? ---- - - -- -- -- - -- YES NO
If yes, please describe:Rowcra 'SA at.•ty-
Were all components pumped out and property abandoned per WAC246-272A-0300? ---- ---- YES ❑ NO
RECORD DRAWING
This u a pam4naM neeN and must of aecunala and Mwepuv.enough to o4aea a In the note of nwho nanu atlHiM1a and INun eevalop—L TMiul RaI
awirys mn0in. Dran3gc 8 man"p'9 p'Nnp:M 8!apd Sgapunp:ank bWbp Npd arrow.maerve dra:nhek.earvory eM pmWseO Eultl,rps krJl nn o'welq,walerunez
ual6.pMerva:an[arts ueannu3 a.p plMr manlenan<e acceu pdr:s. Irrwmpk<Rem'C D.aw:rpa nay create add:eorul dWyt n ruu!malgton eppvnl ana n!a:ee cermns.
® Record Drawing Attachec
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that 1 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 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. form and attached Record Drawing is accurate.
Q4
Si nature of Installer Date
:p
1K_ ,l-r
Printed Name of Signee ,,
MASON COUNTY PUBLIC HEALTH `•' �- i
The undersigned approves this Installation Report andh • s m •s�
Record Drawing on behalf of Mason County Public A D UNTER .y
'15i"P�J51!0'U@S1GNgR'r'
H the
YY p;azr u
Si of ERWron ta/Health Specialist 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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