HomeMy WebLinkAboutSWG2021-00318 - SWG As-Built - 4/15/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATION
Permit Number SWG '7 O-1 - ua 19) Parcel# LAIT09 - 5 N - QW5I
Applicant Name V1-'W .P, 1wSh Subdivision (Name/Div/Block/Lot)
Applicant Address �qt)5 qq4"" AW. SE'
City, State, Zip IttYg, S42 .nS W h Q��� Installer Name
ppU1 .DY rName
Site Address �\. M61111�(AI'h v'DeslgnerName
INSTALLATION CHECKLIST
16 Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑other
System Type WC.5uyePr ant Type
>5 ft.from foundation? -------------- p\\Q� NIA ❑YES ❑ NO
>50 ft.from wells? -------------- '^--' ❑ ❑
hd >50 ft.from surface water? --- ------ � 4� - ❑ ❑
fCleanout between building and tank? -- ❑ �
V Tank baffles present? - - -- -- ------- --
a El
24"access risers over each compartment?--- ---- ❑ ❑
W Effluent filter Installed?-- -- - - - - - - - ---- ❑ ❑
125 Septic tank capacity(working) bgal - rer
0 D-box water level and speed levelers used? - r - ---- .-- , .B NIA ❑YES ❑ No
5_/_',,_
Ou Manifold/D-box accessible from surface?-----~ --- 1c a ❑ Ja ❑
--- ----OQ Check valves installed? 'tr y '3gl EV1Fv'� F ❑ ❑
Transport Line Size 2 1n• Saitd,'le/12411 W 'I n
Bedrooms installed(check one) ❑ 2 V3 ❑4 ❑ 5 ❑6 ❑CommerciallOther
>10ft.from foundation?- -------- -- ------- -------- OWA ❑ YES No
>100 ft.from wells?------------- ------------ ---- 0 ❑ ❑
W >100 ft.from surface water?----------------------- - B ❑ ❑
LL >10ft.from potable water lines?--- ------------------ - ❑ ❑
QZ >5ft.from property lines and easements?---------------- ❑ 0 ❑
K >30 ft.from downgradient curtain/foundation drains?---------- .0 ❑ ❑
Drainfield level and observation ports present -- --- -- ----- -- ❑ 0 ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?------------------- ❑ W ❑
Pump tank setbacks consistent with Septic tank?------------ - ❑ NIA YEEs���(L ❑ No
11 Pump tank capacty(flood) I 1n 50 gal Manufacturer
Q24"access riser(s)and accessible from surface?-- --- -------- ❑ V ❑
aAlarm or Control Panel Installed? - ---- - --- ----------- '- ❑ ❑
5 Control Panel equipped with Timer I ETM/Counter-- ------- - - ❑ `� ❑
a Pump installed in ❑ Bucket or 16 On Block or El Other
Pump Make/Model N�JZ f I('' ty_J Floats or ❑ Transducer
a
Tank draw down Z II in/min Pump capacity`gpm Squirt Height (a
Pump on time Pump off time ('1 - Daily flow set at pot
uoe.ee enino�e
Mason County OSS Installation Report pg. 2 Parcel a
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - --- - -- - --- - --- ❑ YES ❑ NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - ---- --- ❑ YES ❑ No
RECORD DRAWING
➢tie he a permanent mcmtl and must be accurate end tns rdlOve enough to moot,In the nwtl of maintenance adivltles ant IUWre development Typical RenoN
D.Iscontam Ualnlieltl6manlldd vlenlalionalayout,$eplidpump lank lou4on.Nontl Bnow.mserve tlralnliNd eustinB end proposed Euielnpa,kcalion o(wellf.welerines,
sell;oEfervarlm purls,dvanwla,aN Wermalnrenar¢a eccpss points. Mwmplde Pacatl DrawinBe may creole edtlllionel Jelaye'm Oral iru4Wtlpn approval anti related permi4.
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Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that I 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 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
form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
Signature of Installer Date
Shc��o wan
Printed Name of Signee r '..."r•r,,�ct
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and J n
Record Drawing on behaHofMason County Public � _ ADAM .HDNTER 'y
Lit.SH H NITER
CA"'
Health: nl.cd o:,12i
� d
Signature ofEn iron a/Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE upe.w en+rm+e
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