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HomeMy WebLinkAboutSWG2025-00086 - SWG As-Built - 4/16/2025 Docusign Envelope ID:E99DB8EE-CF07-4FF5-89C3-D98106348CC5 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG SWG2025-00086 Parcel # 319027790061 Applicant Name WILLIS DEAN A& JANIS E Subdivision (Name/Div/Block/Lot) Applicant Address 260 SE PAULCYN LN City, State, Zip Shelton, Wa 98584 Installer Name Micah HAlverson Site Address 260 SE PAULCYN LN Designer Name Jamie Workman INSTALLATION CHECKLIST ❑ Full System Installation El Tank(s)Only x❑ Drainfield Only El Repair ❑ Other System Type Gravity Trenches Pr eatment Type Septic Tank >5 ft. from foundation? - ❑ NIA x❑ YES ❑ NO >50 ft. from wells? iit9S-V- - - - ❑ x❑ ❑ >50 ft. from surface water? - x H Cleanout between building and tank? - - - PRa - ❑ E El Tank baffles present? - - -.- - - ❑ 0 ❑ a24" access risers over each compartment? Si - - - - - - - ❑ El W Effluent filter installed?- - El x❑ ❑ fn Septic tank capacity (working) Fxisting 1200 gal Manufacturer (Concrete) Unknown D-box water level and speed levelers used? - - ❑ N/A EYES ❑ NO J 5-"‹O Manifold/D-box accessible from surface?- - ❑ E ❑ LL mZ Check valves installed? - - El ❑ El 0Q E Transport Line Size 4" Schedule/Class ASTM3034 Bedrooms installed (check one) El 2 0 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft. from foundation?- - ❑ N/A ® YES ❑ NO >100 ft. from wells?- - El N] ❑ CI W >100 ft. from surface water? - - El 0 El u. >10 ft. from potable water lines?- - ❑ x❑ ❑ Z > 5 ft. from property lines and easements?- - ❑ I ❑ w > 30 ft.from downgradient curtain/foundation drains? - - ❑ ® El ca Drainfield level and observation ports present - - ❑ ® ❑ ❑ Graveless chambers or ® Clean gravel used? (check one) Proper cover installed over drainfield?- - El El ❑ Pump tank setbacks consistent with septic tank? - - x❑ N/A ❑ YES El NO • Pump tank capacity (flood) gal Manufacturer < 24" access riser(s) and accessible from surface?- - El ❑ ❑ H a Alarm or Control Panel Installed? - - ❑ ❑ CI 2 Control Panel equipped with Timer/ ETM /Counter- - El ❑ El m 0.. Pump installed in ❑ Bucket or ❑ On Block or ❑ Other a• Pump Make/Model El Floats or ❑ Transducer a. a Tank draw down in/min Pump capacity gpm Squirt Height ft Pump on time Pump off time Daily flow set at gpd Updated 8/21/2018 Docusign Envelope ID: E99DB8EE-CF07-4FF5-89C3-D9B106348CC5 Mason County OSS Installation Report pg. 2 Parcel # 319027790061 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - ® YES I=1 NO If yes, please describe:Failed Drain Field Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ® YES ❑ NO 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. Typical Record Drawings contain: Drainfield&manifold orientation&layout,Septic/pump tank location,North arrow,reserve drainfield,existing and proposed buildings,location of wells,waterlines, wells,observation ports,cleanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits. a See Approved Design I 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 1 further certify that all information contained on this I further certify that all information contained on this 4, t oched Record Drawing is accurate. form and attached Record Drawing is accurate. 4-15-25 '-tt41Ar3s1-4Ab4Ut Signature of Installer Date �i t+, Jamie Workman \ �f) Printed Name of Signee1� MASON COUNTY PUBLIC HEALTH art. ,9 The undersigned approves this Installation Report and ` �� Record Drawing on behalf of Mason County Public �� 61NanE ►tKverseoN �0400 1 Health: DESIGNER r 1� �` Silt) ink `,a 9" f- EXPIRES:09V1$I 1. - _ Signature of Environm4ntal Health Specialist tu Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8/21/2018 . 0 0 c copcoo3o —I ill E co • 0 0 _3- N < im Da N � a ° � � � D Allen Road(b • ot„ < -1 (Z 113 � CD u' co N n' N ] 3 S. o Q o o 0lC (U' il) - CD iii cn CO0 t; z tr n' fZ E•to C) rr 0 (0 SZ rt N r T 0 n -, (0 11 O N 3 • T O o (D (0 n U, LC 613 SZ (D N N N n N NO (0 3 fl Q w lfl (�0 a'� N . o IL_ l0 1 Q 4- vo A O ty X c• 73 n o_ 6 u, 75 N ff1 3 O ---1 --1 -1 O. (D rt N o .. N I I I II (0 W N O • _� N O III if (U 3 Qa �1 v OD N • N N � O O A ■ O C C n ' 0 0) Cn V) s: I, I♦ PI • IIII U1 .p. W V -,. x P.'"*kj c v N CCDD ^cn co C W x X tZ lCJ cn U1• � • N n > . W0 = 5 3 II i a a. < co 7 N) (D (D 0f gi p * °' o ° 0- N o DO (1) Etijai , o ao m Hco co a3 5 o, mD � � � r.s,n IP 0 (D n v co- m -, �t 4 m (D " o PIPN 3 =1 / (D a x- (D I aN 4 CD , o �,i,� ' in* ok cbo, (A co a j� • N ao I CJ7`_, " gi \_ z N (� ti © oPL o V r. VII- ,s..,a 7' , 3 \ i 11111' LI LC' / o rn O Z o / �� / NJ rn C. E. / -1 61 / r-- (P / r II _ •1i / , / O / V' v a k / ccoo / P "57 9' \ 1 ju, swe 'fi' N; ��� ��. I I 0 �, *-40.-...——� i � 11� 1� 3 jff i /1001--.' — t t \ cb /,,�. O I \ — . I E' I F I I r� . / / O i I . Co . - 'S I R y Abbreviated Description: TR 1 OF SP #1678 M.Halverson Design L L C Owner/Applicant. DEAN WILLIS Site Info. Parcel# 31902-77-90061 SHEET NUMBER PO Box 1519 Shelton Wa 98584 260 SE PAULCYN LN. 260 SE PAULCYN LN 1 HalversondesignlIcAoutlook.com SHELTON, WA. 98584 REVISION#: