HomeMy WebLinkAboutSWG2022-00012 - SWG As-Built - 4/16/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/.PERMIT INFORMATION
Permit Number SwG 2022-00012 Parcel# 12221-75-00100
Applicant Name Wendy&Todd Leven seller Subdivision(Name/Div/Block/Lot)
Applicant Address 916 Division St
City, State, Zip Port Orchard,WA,SEWS Installer Name Bill Bumbalough
Site Address 101 E Corbin Ln Designer Name Rod Left
INSTALLATION CHECKLIST
Q Full System Installation ❑Tank(s)Only [IDrainfeld Only ❑Repair ❑Other
System Type `p(4 lAt ment Type
>5 ft.from foundation? --------- ❑N/A EYES NO
>50 ft.from wells? ---------- B 1y_______ _ ❑ ❑
z >50 ft.from surface water? ------- - - ®���- ❑ ® ❑
Q Cleanout between building and tank? -- ------
Tank baffies present? ----------- ______ ® ❑
2 24"access risers over each compartment. $Y ------ ❑ ® ❑
w. Effluent filter installed?--------------------------- ❑ ® ❑
0
Septic tank size 1250 gal Manufacturer Hagerman Pre Cast
❑: D-box water level and speed levelers used? --------------- ® WA ❑Yes NO
-_1
00 Manifold/D-box accessible from surface?----------------- ❑ ® ❑
mZ Check valves installed? -------------------------- ❑. ® ❑
❑Q^
2 Transport Line Size 2" Schedule/Class SCH 40
Bedrooms installed(check one) W 2 ❑3 ❑4 ❑5 ❑6 ❑Commercial/Other
>10 ft.from foundation?-------------------------- ❑ NIA QYES ❑ NO
0 '.>100 ft.from wells?---------- _^_________- ❑ N ❑
w >100 ft.from surface water9- a "� ^vw-� ❑ ❑
tl >10 ft.from potable water lines? --- - -a •; '-;• [] ® ❑
Q >5 ft.from property lines and easamen -- -f �fn---L ❑ ® ❑
O >30 ft.from downgradient curtain/found�{jg�r�irT7'V r- `h ,L�- /❑ ❑
Drainfeld level and observation ports present ---=--a Ir%n,'M,'tiTa.hc�T ❑ El® Greveless chambers or ❑ Clean gravel used? (dt{pdryne) H
- Proper cover installed over dreinfield?------------------- ❑ ❑ ❑
Pump tank setbacks consistant with septic tank?------------- ❑ wA YES ❑ NO
Y Pump tank size 1250 at Manufacturer Hagerman
QF 24'access risers)and accessible from surface?------------- ❑ ❑
a2,Alarm or Control Panel Installed? --------------------- ❑
Control Panel equipped with Timer/ETM/Counter----------- ❑ ❑
a Pump installed in ® Bucket or ❑ On Block or ❑ Other
a Pump Make/Model Liberty ❑ Floats or ❑Transducer
a.:.Tank draw down 2" intmin Pump capacity 44 apm Squirt Height +8 ft
Pump on time 27 sec Pump off time 2 his Daily flow act at 237.6 gpd
uoem arzirzoia
Muson County.OSS Installation Report pg. 2 Parcel# �Z22\� -15-60\0�
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? -------------.-- ❑ YES NO j
If yes,please describe:
Were all components pumped out and properly abandoned per WAC246-272A.0300?-------- ❑ YES ❑ NO
RECORD DRAWING,
Tnia H a wrmanenl re<aN and must be accurate and aea<flpllve enough to rvl«ate In the nova of malnlenenu activUles and Nwn aevvlopmmst rypkal accord
DraMng,conbin:.OreNfieWfimanfoW gienlelkn6NyoW,9eplklwmplank A%atim.NcAM1 Mw/.seservearaFaeW,ezYlNp entl popovM WlMtg,,b<ellon of vrel6,waleNnes, j
vela;obWVN1M pM,,clew«le,aM oNermelnknena eccesapoM,.Mcemplele ae«ra DnMnge mey vecle etltlabnelaNeye F rnelFNalhgop eppmvel eM mVletl pemds.
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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 urate. form and attached Record Drawing is accurate.
Gl7/;f
Signatureofinssttaller )) /I Date
D"11 B(rrn5a fbu<Hl
Printed Name ofSignee p
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and *6XM" 121161
.Record Drawing on behalf of Mason County Public
a h:
(/ w�o ZS
i /Environmental Health Specialist Date (stamp,signature and date)
THIS FORM MAY BE SCANNEDANDAVAILABLE FOR PUBLICVIEWON THE MASON COUNTYMB SITE upmaaenfaofa
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