HomeMy WebLinkAboutSWG2022-00519 - SWG As-Built - 4/17/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG Z.02,2—cos(q Parcel # 2.22237 790(2) 14-
Applicant Name Ecz.'‘ L VA i Cr H.v S Subdivision (Name/Div/Block/Lot)
Applicant Address 4 5 S v6-51-14.-r— 12.0 ?5 �
City, State, Zip t.�r.>v i V1�i l N `�L Installer Name L�..4.-k----(-fL,A.)C �Sc+^1
Site Address 4.2P, i24.so 2 'OD vJ Designer Name .571.3.w>:as 7 i t tv i Li
INSTALLATION CHECKLIST
afull System Installation 0 Tank(s)Only ❑Dratnfteld Only ❑Repair 0 Other
on
System Type `. b . Pretreatment Type
>5 ft. from foundation? - _ - ❑ N/A ['YES ❑ NO
>50 ft. from wells? - -� . - - - ❑ E ❑
Z >50 ft.from surface water? - APR 1 1 ❑ ® El
HCleanout between building and tank? - / 42o-?E- ❑ [� 0
0 Tank baffles present? - - Rk'Ek/� l - ❑ (I 0
d24" access risers over each compartment? - F� • ❑ [� ❑
W Effluent filter installed' - .- - - ❑ Llf 0
U)
Septic tank capacity(working) /2 S O gal Manufacturer (s 4(-7 IaR-.u•ale,/
0 D-box water level and speed levelers used? - - - [,NIA ❑ves ❑ NO
k0 Manifold/D-box accessible from surface?- - 0 Q/ l❑—t
OP Z Check valves installed? - - CI La
o< .►
2 Transport Line Size Z Schedule/Class 40
Bedrooms installed (check one) P '2 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft.from foundation?- - ❑ N/A aiTS ❑ NO
>100 ft. from wells?• - El 1117 ❑
-1 >100 ft.from surface water? - - ❑ [ ElLT. >10 ft. from potable water lines?- - Cl ,I/ ❑
z > 5 ft. from property lines and easements?- - ❑ [ ❑
Q
ID
CI CI> 30 ft-from downgradient curtain/foundation drains? • -
Dra field level and observation ports present - - 0 GT ❑
[ raveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?• - ❑ P- ❑
Pump tank setbacks consistent with septic tank? - - ❑ N/A Q YES ❑ NO
Pump tank capacity(flood) l" _W gal Manufacturer
Z
< 24 access risers)and accessible from surface?- - 0 QJ ,❑�/
d Alarm or Control Panel Installed? - - ❑ 0 L+
2 Control Panel equipped with Timer/ETM/Counter- - ❑ ID" ❑
D
0- Pump installed in EIBucket or ❑ On Block or ❑ Other
a. Pump Make/Model 1�nSQlt- Zt30 [/Floats or ❑ Transducer
tx Tank draw down ! r� in/min Pump cap p Squirt Height 5 . ft
a
Pump on time 1 - N^tt✓\ Pump off L Y l Diltlfy flow set at (� qpd
APR Jpdated<, r%1
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Ii�ASpN�� i 121?�� 1•:l,'
UNtY�NU!
Mason County OSS Installation Report pg. 2 Parcel# Z. 2 ZZ-S71C>C t i
ABANDONMENT RECORD
Wore existing septic components abandoned as part of this protect? - -- - 0 YES Er NO
If yes, please describe
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - - - - - - - ❑ YES aNO
RECORD DRAWING
This is a permanent record and must be accurate and descriptive enough to re-locate in the need of maintenance activities and future development. Typlcai Record
[Peewit/5 contain Dralnrtelo 6 mantokl nnenletion&layout Septic/pump tank location.North wow reserve dra,nfield,easing and proposed buiid,ngs location of welts.watenrnes
wens,obse satin portc rinnnouls awl ,lbw•"n.nlenancn aaAras pOmla Innvalplele Record Dritermos may create additional delays in final rnStaeatInn approval and related permits
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MASON COUNTY ENVIRONMENTAL HEALT-
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Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that I installed the system in accordance with l 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 ce ify,thal all information contained on this I further certify that all information contained on this
form and ached Record Drawing is accurate. form and attached Record Drawing isaccurate.
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Signature/f Installer Date
f i'r'
Printed Name of Signee i- t �� %
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MASON COUNTY PUBLIC HEALTH I, oi.I
The undersigned approves this Installation Report and a3fly `t;r
Record •yawing on behalf of Mason County Public LICE t 'DES1 DESIGNER ,�#
He. ... __ .m ..wl,
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Sign:ture ,onrnental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE uodersd eratrlole
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