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Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATION
Permit Number SWG ZoZI —ovT6f Parcel#
Applicant Name K, DFc� Subdivision(Name/Div/Block/Lot)
Applicant Address c//90 ' 414. PA
City, State,Zip S�i��-r &Aj Installer Name
Site Address 36 F Vi6o Auer Designer Name
INSTALLATION CHECKLIST
Full System In&dletlon ❑Tank(e)ody ❑OreNaeks Ony ❑Repair ❑Other
System Type Pretreatment Type
>5ft.from foundation? -------_--------- ------ ❑WA (6rl vee ❑No
>50ft.from wells? . ----------------------------- ❑ 0 ❑
Yz >50 ft.from surface water? -- ---------------------- ❑ 0 ❑
F Cleanout between building and tank? ------------------- ❑ ® ❑
tl Tank baffles present? - --- - - - - - ----------------- ❑ m ❑
a24'access risers over each compartment?---------------- ❑ [� ❑
LLI Effluent filter installed?--------------------------•- ❑ �( ❑
0)
Septic tank capacity(Working) /SVO gal M8111118ch)nir
J0J [),box water level and speed levelers used? -------------- - M�IdsA El YES I]No
BOLL Manifoltl/D-box accessible from surface?---------------- - ❑ ❑
f44 Check valves Installed? - - ----------------------- ❑ ❑
of Transport Line Size 2 [/ adtd laea Yy
Bedrooms installed(check one) 02 *13 ❑4 ❑5 ❑5 ❑Commercial/Omn
>loft.from foundation?-------------------------- ❑WA 'ayae ❑ No
C >100 ft.from wells?----------------------------- ❑ .® ❑
W >100Rfrom surface water? .----------------------- ❑ N ❑
LL >10ft.from potable water lines?.--------------------• ❑ ❑
_Q >5ft.from property lines and easements?---- ------------ ❑ ❑
C >30 ft.from downgradient curraintroundation drains?---------- ❑ ❑
0 Dralnfield level and observation ports present ---- ---------• ❑ ❑
Ig Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfleW--------- ---------- ❑ ❑ ❑
Pump tank setbacks consistent with septic tank?----------- - ❑ WA YES ❑ No
be Pump tank capacity(flood) /ede at Manufacturer
24'ecro9s risers)andewuibla imam wrboa?------------ ❑ ❑
11 Alam)or Control Panel Installed? -------------------- - ❑ ❑
S Control Panel equipped with Timer/ETM/Counter----------- ❑ ❑
d Pump installed in la Bucket or ❑ On Block M ❑ Other
fPump Make/Model fh t 7 Ab WiFlosts or ❑ Transducer
y Tank draw down 31
_Wmin Pump capadly yl�aPm Squirt Heigh fl
Pump on time /:`/O Pump off time `+, PS Daily flow set at pd
wa.se exrasre
Mason County OSS Installation Report pg. 2 Parcel It
ABANDONMENTRECORD
Were a°isting septic components abandoned as part of this project? --------------- C] YES �No
If yes, please describe:
Were all components pumped out and property abandoned per WAC249472A-03OD?-------- El YES NO
RECORD DRAWING
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Or�Y'rirss O�aYall�wYa4wrahw+4MwriwrANrrwN....a�enmw..:wm sm w.w.b wwmw aum�.a.+w.aww..
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A
PPROVED
MAR 31 2025
MASON COUNTY ENVIRONMENTAL HEALTH
JBW
❑ Record Drawing Attached
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 Scour-
the septic design stamped"APPROVED"by Mason dance with the septic design stamped-APPROVED-by
County Public Health and that any devWatlpna shown Mason County Public Health and that any deviations
here have been clearedrapproved by both the designer shown hem 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 Meson County Codes
I further oerily that all information contained on this I further certify that all information contained on this
form and ette I�ad Record Drawing is accurate form and attached Record Drawing is accurate.
Yfi aY
a ofinsteller O.M
Printed Name of SWISS ..a•,'•,�.'.1
t.
MASON GOunTY PMelrc nenLm , SN
The undersigned approves this Installation Report and r? s1 a
Record Drawing on behalf of Mason County Public Becky J.Rieger -
tiDEI N
Health: ery
I 0 _ 03.26.2025
Sign rreMS/Heat6swierfat Dote 0(sgmpoa/gnature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC NEW ON THE MASON COUNTY WEB SITE Wie"'f�R01°
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Environmental Design, LLC.
Septic Designs Wetlands*Site Planning ilExcavatlon
2041 Ia"ule Hanoford Road, Cenmlia, WA 98531 Phase:(360)219-3345
March 26,2025
Dear Delany Family,
Congratulations on the completion of your On-Site Waste Water System. Environmental Design,LLC is
pleased to present you with the Record Drawings of your system and some general information about
your new system. Enclosed in this packet you will find the following:
o General Information About Your System
o Septic System Maintenance&Recommendations
o Contact Information for you Designer,Installer and Local Health Jurisdiction
o Record Drawings
o Pictures of Before, During and After Installation
We have also included an insert from the Department of Health about your system.
A copy of your Record Drawings have been submitted to Mason County fortheir records and a copy has
been given to your installer as well.
It has been a pleasure working with you and we hope this information finds you well. If questions or
concerns arise please do not hesitate to contact us.
Sincerely,���
-0el" D
Licensed Designer
Wetland Specialist
References:
Washington State Department of Health Website.
htto://www.doh.wa.aov/eho/ts/ww/pubs-ww-toolc.htmaHome Owner. 2014.
Lewis County Environmental Health Website.
htto://lewiscountvwa.eov/environmental-health/perm its-forms. 2014.
Thurston County Environmental Health Website.
htto://www.m.thurston.wa.us/health/ehoss/dos donts.html. 2014.
Cowlltz County Environmental Health Website.
htto://www.co.cowlltz.wa.us 2014.
Mason County Environmental Health Website.
https:Hmasoncountywa.gm/health/environmental/index.php
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