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HomeMy WebLinkAboutSWG2021-00351 - SWG As-Built - 4/29/2025 CLEAR FORM -10 (-- v)SP Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2021-00351 Parcel # 222125400005 Applicant Name Jerry Howard Subdivision (Name/Div/Block/Lot) /� Applicant Address 17951 E St RTE 106 .4 .. `, City, State, Zip Belfair WA 98528 Installer Name Shae Den R� 1, . Site Address Designer Name Jimn Zimny ''. ./4) INSTALLATION CHECKLIST ❑ Full System Installation ®Tank(s)Only ❑ Drainfield Only 0 Repair ❑Other System Type Pressure Distribution Pretreatment Type >5 ft. from foundation? - - ❑ N/A ®YES ❑ NO >50 ft. from wells? - - ❑ © ❑ Z >50 ft. from surface water? - - 0 ® 0 H Cleanout between building and tank? - - ❑ LI ❑ U Tank baffles present? - - ❑ LI El a CI ® CI access risers over each compartment?- - W Effluent filter installed?- - ❑ ❑ ❑ cn Septic tank capacity (working) 1500 gal Manufacturer 0 D-box water level and speed levelers used? - - ElN/A ❑ YES ❑ NO 02 Manifold/D-box accessible from surface?- - 0 ❑ ❑ mZ Check valves installed? - - 0 It ❑ OQ z Transport Line Size Schedule/Class Bedrooms installed (check one) ❑ 2 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft.from foundation?- - 0 N/A ❑ YES ❑ NO CI >100 ft. from wells?- - ❑ ❑ ❑ W >100 ft.from surface water? - - ❑ ❑ 0 LT >10 ft. from potable water lines?- - ❑ ❑ ❑ Z > 5 ft from property lines and easements?- - ❑ ❑ ❑ > 30 ft. from downgradient curtain/foundation drains?- - ❑ 0 0 tp Drainfield level and observation ports present - - 0 ❑ ❑ ❑ Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?- - ❑ ❑ 0 it Pump tank setbacks consistent with septic tank?- - 0 N/A ® YES ❑ NO • Pump tank capacity (flood) 1500 gal Manufacturer Infiltrator M 1530 < 24" access riser(s)and accessible from surface?- - ❑ IN ❑ t— a Alarm or Control Panel Installed? - - CI 0 ❑ E Control Panel equipped with Timer/ETM/Counter- - ❑ ❑ N] D d Pump installed in ❑ Bucket or ® On Block or 0 Other n'• Pump Make/Model Liberty ❑ Floats or ❑ Transducer 0- a Tank draw down 2" in/min Pump capacity 50 gpm Squirt Height N/A ft Pump on time N/A Pump off time n/A Daily flow set at N/A gpd Updated 8/21/2018 mommommor • CLEAR FORM -El:fl ( ('--At,) '- Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2021-00351 Parcel # 222125400005 Applicant Name Jerry Howard Subdivision (Name/Div/Block/Lot) Applicant Address 17951 E St RTE 106 City, State, Zip Belfair WA 98528 Installer Name Shae Olen Site Address Designer Name Jimn Zimny INSTALLATION CHECKLIST ❑ Full System Installation ®Tank(s)Only ❑ Drainfield Only ❑ Repair ❑Other System Type Pressure Distribution Pretreatment Type >5 ft. from foundation? - - ❑ N/A YES ❑ NO >50 ft. from wells? - - ❑ ❑ Z >50 ft. from surface water? - - 0 I Tr • Cleanout between building and tank? - ❑ I0 U Tank baffles present? ❑ ❑ a24" access risers over each compartment?- - 0 'r 0 W Effluent fitter installed?- - ❑ ❑ i N Septic tank capacity (working) 1500 gal Manufacturer Infiltrator M 1530 0 D-box water level and speed levelers used? - - ❑ N/A El YES ❑ NO DO Manifold/D-box accessible from surface?- - ❑ ❑ ❑ co Check valves installed? - - ❑ IN 0 oQ Transport Line Size 2" Schedule/Class Sch 40 Bedrooms installed (check one) ❑ 2 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft.from foundation?- - ❑ N/A ❑ YES ❑ NO 13 >100 ft. from wells?- - ❑ ❑ ❑ W >100 ft. from surface water? - - ❑ 0 ❑ ti >10 ft.from potable water lines?- - ❑ 0 ❑ z > 5 ft. from property lines and easements?- - ❑ ❑ ❑ d > 30 ft.from downgradient curtain/foundation drains? - - ❑ ❑ ❑ o Drainfield level and observation ports present - - ❑ 0 ❑ 0 Graveless chambers or ❑ Clean gravel used? (check one) ill Proper cover installed over drainfield?- - ❑ 0 ❑ Pump tank setbacks consistent with septic tank?- - 0 N/A il YES ❑ NO i Y Pump tank capacity (flood) ,$-C) _gal Manufacturer 0<—vet o '' < 24" access riser(s)and accessible from surface?- - 0 NE 0 1-- Alarm or Control Panel Installed? - - ❑ IN 0 fa- 2 Control Panel equipped with Timer/ETM/Counter- - 0 0 II D a Pump installed in ❑ Bucket or x On Block or Other_ a'• Pump Make/Model L.\o -A d- -tftlr L- II Floater or ❑ Transducer p_ a Tank draw down 2" in/min Pump capacity (3 O gpm Squirt Height NIA ft Pump on time N/A Pump off time n/A Daily flow set at N/A gpd Updated 8/21/2018 maw Mason County OSS Installation Report pg. 2 Parcel#7 7 •�( L —S Li- Go0(3 J ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - TiES [ NO If yes, please describe: Were all components pumped out and properly abandoned per WAC246-272A-O30O? - .YES NO RECORD DRAWING This Is a permanent record and must be accurate end descriptive enough to re-locate In the need of maintenance activities and future development Types!Record Drawings conlo n. Drainfietd d marulofd orientation 8 layout.Septic/pump tank location,North arrow reserve dranteld,existing and proposed buildings,location o1 well$.waleimes. wells,observation pals,cleanouts,and ouar maintenance access pants. Incomplete Record Drawings may create additional delays in final instaltat on approsal and related permits. '!SI Record Drawing Attached CERTIFICATION OF INSTALLATION INSTALLER DESIGNER/ENGINEER 1 certify that!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 WI and Mason County Codes. State and Mason County Codes 1 further certify that all information contained on this I further certify that all information contained on this form end attached Record Drawing is accurate. form and attached Record Drawing is accurate. )Vf 4,‘ 4A c VA/ Signature of Installer Date C1 �f► Printed Name of Signee MASON COUNTY PUBLIC HEALTH :.k t' ++ The undersigned approves this installation Report and / �so. M Record Drawing on behalf of Mason County Public � �; E DESIGNER + Health: y�7 (Th9-11 Signature of Environm ntal Health Specialist Date (stamp.signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE updataa 8'21'2018 150' APPROVEC' 292025 N �` f vsiing Axo CPO M ON COUNTYAPR ENVIRONMENTAL HEALTH • • Orainficld RET ``�.z Olkisting punp tail, �(ATti i I 1- -40' �__ ....] - I *locate all utliities -T� _ I before digging WATT R is t i I 1 tlik, Std. R, `'•� �. . 2 -4----:-.74. -- ' mo ti - cvsti 2"pump�liite►-.,___ I I I iz1:z , i ( •i lir%50' lI Fes. " - -L ♦c Curtain • rain l ! MAIN 1101.Sf '3 1 , l ( -_ _--+ t Esc existing pump and --`Pc" . controls \I__ I 1 ‘,. I 1 1 1 -•. Ne.• 1A00 Ciall n Septic and t pum1 tank(in iltrator rn - 15- 0 110 ' ..., t , 2'Pump line I •.— 24'>t A'(>rcnco pump basin 1 L. I , - - w•o nioorc grinder pump for 1 cabins -isik.._ -A. 1xistinp tanks 1 so• _ 20•25'cabin :! q / • ` VbI abandoned litand,It i! r ] .ft f ~� ' LICE .=,o ••• ♦ 'I q 2 1-? j""- lum limn) Jerry and t ana Howard Ad.antagc Pcrc L Dcsign 179511 St Ric 106 i 31+0t 5 t6•?2R? Not A Sunny ROM.WA..98524 P.ARCI I W 222 125400005