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HomeMy WebLinkAboutSWG2023-00256 - SWG As-Built - 4/16/2025 Docusign Envelope ID:F1 NOE9F-ODD4 E45-13C9C-530CD687021A Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG SWG2023-00256 Parcel# 120311290040 Applicant Name Mark smith Subdivision (Name/Div/Block/Lot) Applicant Address 741 E CAMDEN WAY Tract 4 of Govt lot 1 Lot A of SP#1104 City, State, Zip Shelton We 98584 Installer Name Travis Villines Site Address NIA Designer Name Micah Halverson INSTALLATION CHECKLIST ® Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other System Type retreatment Type Septic Tank >5 ft. from foundation? - ---- --- - ---- -- ❑ NIA %❑YES ❑ NO >50 ft. from wells? -- - - -- - - - - - - - - - - ❑ ® ❑ Y >50 ft. from surface water? - - - - - - - ---Q.Lt3 - - ❑ x❑ ❑ 2 F Cleanout between building and tank? - -- - - -- - ❑ x❑ ❑ V Tank baffles present? -- - - - - - - - - �- - - ❑ x❑ ❑ a24"access risers over each compartmen ❑ ® ❑ y Effluent filter installed?- - - - - - - - - - - - - - - - - - - - - - - - ❑ x❑ ❑ 00 Septic tank size 1971 gal anufacturer Infiltrator IM1250 0 D-box water level and speed levelers used? - -- - - - - - - -- - - - - ❑ NIA x❑YES ❑ NO 0O Manifold/D-box accessible from surface?-- - - - - - - ❑ x❑ ❑ g°Z Check valves installed? ❑ ❑ x❑ oa 2 Transport Line Size 4" Schedule/Class ASTM 3034 Bedrooms installed (check one) ❑ 2 ®3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10ft. from foundation?-- - - --- - - - - - - --- -e�- -- -w- --- - ❑ NIA © YES ❑ NO 0 >100 ft. from wells? - - " �/ `DE ®>too ft. from surface water? - -- - ---- -�- -----`- ❑ ® ❑ Z >10ft. frompotablewaterlines?- - -- -APR-}638rJ-- ❑ ® ❑ > 5 ft. from property lines and ease` ? El ID ❑ �ft�V CcuAT4 ENVIR6NR1EMfAl NEALThi > 30 ft from downgradient curtain/foundation drai"^'w - -- - --- El El ❑ Drainfield level and observation ports present --- - - - - - --- - - - ❑ ® ❑ ❑ Graveless chambers or ® Clean gravel used? (check one) Proper cover installed over drainfield? ❑ ® ❑ Pump tank setbacks consistent with septic tank?-- - - - -- --- - - - x❑ NIA ❑ YES ❑ NO Y Pump tank size at Manufacturer Q24"access dser(s)and accessible from surface? - ❑ El El~ Alarm or Control Panel Installed? ❑ ❑ ❑ Control Panel equipped with Timer I ETM/Counter- - ❑ ❑ ❑ 7 S Pump installed in ❑ Bucket or ❑ On Block or ❑ Other Pump Make/Model ❑ Floats or ❑ Transducer a Tank draw down in/min Pump capacity Dpm Squirt Height ft Pump on time Pump off time Daily flow set at apd Docusgn Envelope ID F1 B40E8F-01) 4 E45-13C9C-530CD597021A lWason County OSS Installation Report pg. 2 Parcel# 120311290040 ABANDONMENTRECORD Were existing septic components abandoned as part of this project? - ❑ YES © NO If yes, please describe: Were all components pumped out and property abandoned per WAC246-272A-0300? - - -- - - - - ❑ YES ❑ NO RECORD DRAWING This Is a permamnt mom!and must he SttWam and descriptive enough In no-lout,In NS MM of mtlmoremo ac&vltles and Noun development Typkel ReWN Omwings conhrr'. Dmlesep&manhid oumhdo ,&IeyM,SepalWmpoank loutbn,NwN arrow,rc.+erve drenfield,eak0p and propound Widings,buWn ol"Is we inaa. wells.ohaeraloa pals,laxone,and olher meintmanu a'RSS unis Inmmplele humid Dawings may Coals Wdilbnal delays In anal irosenalkn appoval and needed permM. APPROVE APR 16 2025 MASON COUNTY ENVIRONMENTAL HEALTH J13 W © Record Drawing Attached CERTIFICATION OF INSTALLATION INSTALLER DESIGNER/ENGINEER 1 certify that I 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 deviations shown Mason County Public Health and that any deviations here have been cleared/approved 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 chad Record Drawing is accurate. form and attached Record Drawing is accurate. � 2/2612F Signature of Installer Date &WWWWWWBOW, Trav'c V'IrnnePrinted Name of Signee MASON COUNTY PUBLIC HEALTHThe undersigned approves this Installation Report andRecord Drawing on behalf of Mason County Public 1 I �^W f4 ` -1(0- �fiflfiBidiltlii kado"cidlfe Data (8t8No; Wdtuf8 Ind dote) tH19 F817M MA BE$@ANNE6 Ah5MfttlLAI1I P rd§PHBU@ bIENd bN THE MAS®N COUNfi1 Vi WE aratrmle 0 arm N 3 < C m N m 3nsm ac3D $` 3N 3m N10 � 6 � $ u+ N 5 N 3 C In d N s 3 � p .. `• r d M 3 to N SY a \ d 0 3 3 m O' O' � N � d " 3 a P � n N ME Q N py p - � A a N O F1 N O a (^ R f0 V � N N � � l93N mO0O0 ➢ N 3 N T c j a p O S N � O� 0 SN �N > > N N 8 c _ '55 0 I S N F R 36 � S A F- - - - - - - - - I a I I o I I � I I p I I m I n I I � I I > m I - - - - - - - - N bPy o N A fl v' v � r s z o m I s a �- I I o g I o a ° I In I In I I 4 I oa g I = v r IL m a _C Z _ I � 1 � Abbreviated description: TRACT 4 OF GOVT LOT 1 LOT: A OF SP #1104 M.Halverson Design LLC ownPr/Anmfir�nr Mark D Smith sir Inf, Parcel#12031-12-90040 SNEE NUMBER PO Box 1519 Shelton Wa 9858411 741 EAST CAMDEN WAY Undevelo ed Land 1 Halversondesi nIIC outlook.com SHELTON,WA 98584 P RWWNt