HomeMy WebLinkAboutSWG2023-00520 - SWG As-Built - 4/10/2025 Mason County OSS Installation Report pg. t MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SYVG Z0Z3 +00<'L0 Parcel # 7 ZZO/ - Z5 — Q9130
Applicant Name 54 cL � Subdivision (Name/Div/Block/Lot)
Applicant Address yam--mot , y$I..��'�' Ed -
city, State. Zip Installer Name In4Z 1
r
Site Address /YO r er Name
INSTALLATION CHECKLIST
([�I Fvll system Installatun, ❑Tahk(sl Only ❑ DrainLeld Only ❑Repair ❑other.
!� System Type Pretreatment Type-
-5 ft.from foundation? - - - -- -- - --- - ------ -- ------- ❑NIA WYES ❑ NO
>50ft.from wells? -- - - - - - - - - - - - --- - - -- - - - - - -- -- ❑ 0- ❑
>50ft.from surface water? - - - - - - - --- - - - - - -- -- --- -- El18 El
N
Cleanout between building and tank? --- -- -- - - - - -- ❑ ® ❑
V Tank baffles Present? - - - - - - - - - - - - - - - - - - - - - - - -- -' ❑ 9
11
24-access risers over each compartment?-- - - - - - - - - - - -- - EltL ❑
W Effluent filter installed?- - - - - - -- - -- - - - - - -- - - -- - ---- ❑
cc
Septic tank capacity (working)jo�gal Manufacturer K
O D-box water level and speed levelers used? - - - - -- -- - - - - - -- ❑ NIA WYES ❑ NO
��J Manifold/D-box accessible m efro surface?�- - - - - - --- ------- ❑
9z Check valves installed? - - - - - - - - - - - - - - - - - - - - - - ---- ❑ ❑
C<2Transport Line Size Schedule/Class
Bedrooms installed (check one) M2 ❑3 ❑4 ❑5 ❑6 ❑Commercial/Other
>10ft.from foundation?- - - - - - - - - - - - - - - - - - - -- - - - -- ❑ NIA [3JES ❑ NO
>100 ft.fro mwells?- -- ----- D `w` - ❑ � ❑
W >100 ft.from surface water? -- - T -Y ❑
a >10 ft.from potable water lines.- - - - - - — - ❑ 3
Z >5 ft.thorn property lines and a is- } g -2D2� - - ❑ �. ILLl
>30 ft. them downgradient LW ®. ❑�fitI
Drainfleld level and observation ports present ., ed? ( ❑ A
❑ Graveless chambers or Clean gravel uscheck one)
Proper cover installed over dramfield?- --- ---- -- ------ - -
-- ❑ M+ I Idyl
Pump tank setbacks consistent with septic tank?-- - - - - - - -- - - - X NIA ❑ YES o
X Pump tank capacity(flood) at Manufacturer
Q24"access riser(s)and accessible from surface?- ------ --- -- - ❑ ❑ ❑
r ❑
a Alarm or Control Panel Installed? - - - - - -- - -- - - -- - -- '-- ❑ ❑
f Control Panel equipped with Timor I ETM I Counter - - --- - - - - - ❑ ❑ ❑
S Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
It- Pump MakelModel ❑ Floats or ❑ Transducer
IL
Tank draw down m1min Pump capacity qpm Squirt Height ft
Pump on time Pump oft time Daily flow set at gpd
b[CarcO6iA:PB
Mason County OSS Installation Report pg. 2 Parcel tt
ABANDONMENT RECORD
,re exisung septic componeas abandoned as pan cf this project? - ---- - - - ❑ YES NO
If yes, please describe'.
Were all Components pumped out and properly abandonen per WAC246i2724-0300V ' - -- - ❑ YES NO
RECORD DRAWING
tnb n a perm+nerM1 nem0,.a mu,t M ueuoa.me a„enpne moupn m rsiwrc in Inn need a mtlm.nanee,.INnes,w mNm aewlepm.nt 'YP�I nee u'�
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E Record Drawing Attached
CERTIFICATION OF INSTALLATION
rmfasonCounty
In
R/ENGINEER
I installed the system in accordance withat the system has been installed in accor-
esign stamped`APPROVED.by Masonh the septic design stamped"APPROVED"by
lic Health and that any deviations shownounty Public Health and that any deviations
een cleamd/approved by both the designerre have been cleared/approved by both
County Public Health and meet all Stated Mason County Public Health and meet aftand Mason County Codes. 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 torn and afteched Record Drawing is accurate.
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- Data
Slgnelure a'Insfe::er
Printed Nifree of Signed
F
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and SIGNEa
Record Drawing on behalf of Mason County Public
H � z
st u o/ nomn,m,mal Health Slfeciallsf Date fstamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUSUG NEW ON THE MASON COUNTY WEB SITE °w"°°ex¢�•,e
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