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HomeMy WebLinkAboutSWG2019-00260 - SWG As-Built - 5/20/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2019-00260 Parcel # 42127-50-00008 Applicant Name JAMES FLETCHER Subdivision (Name/Div/Block/Lot) Applicant Address 872 LANE 6 City, State, Zip POWELL, WY Installer Name (kkie.j.c,,., Srj,e. Site Address 1010 W CALIFORNIA RD Designer Name PENINSULA SEPTIC DESIGN INSTALLATION CHECKLIST MI Full System Installation 0 Tank(s)Only 0 Drainfield Only ❑ Repair ❑Other System Type SAND LINED PRESSURE DIST Pretreatment Type >5 ft.from foundation? - - 0 N/A 0 YES ❑ NO >50 ft. from wells? - - 0 0 0 >50 ft. from surface water? - ❑ ® ❑ Z -Cleanout between building and tank? - - 0 El 0 U Tank baffles present? - - ❑ 0 0 a24" access risers over each compartment?- - El ® 0 `W Effluent filter installed?- - 0 0 0 Septic tank capacity (working) 1250 gal Manufacturer NOT KNOWN O D-box water level and speed levelers used? - - CgN/A 0 YES ❑ NO o O Manifold/D-box accessible from surface?- - 0 .g 0 . C Q Check valves installed? - - ❑ ❑ z Transport Line Size •� �� Schedule/Class Sel, c cs/aIr 1710 Bedrooms installed (check one) ❑ 2 N 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft.from foundation?- - ❑ N/A IN YES ❑ NO G >100 ft. from wells? 0 El —I >100 ft. from surface water? - ❑ El ❑ W Z >10 ft. from potable water lines?- - El .1 Eleg > 5 ft. from property lines and easements?- - 0 0 0 > 30 ft. from downgradient curtain/foundation drains? - - © ❑ 0 o Drainfield level and observation ports present - - ❑ ❑ al 0 Graveless chambers or 0 Clean gravel used? (check one) Proper cover installed over drainfield?- - ❑ 0 0 Pump tank setbacks consistent with septic tank? - - ❑ NIA 4 YES 0 NO Z Pump tank capacity (flood) 1000 gal Manufacturer NOT KNOWN Q 24"access riser(s)and accessible from surface?- - 0 ® ❑F- Alarm or Control Panel Installed? 0 0 0 a - 2 Control Panel equipped with Timer/ETM /Counter 0 II 0 D EL Pump installed in 0 Bucket or ® On Block or ❑ Other d Pump Make/Model PS540 � ® Floats or ID Transducer aTank draw down in/min Pump capacity gpm Squirt Height ft Pump on time /, Pump off time Daily flow set at 270 gpd l� w v a 1`\""�� 4-0 Updated,8/21/2018 Mason County OSS Installation Report pg. 2 Parcel# 42127-50-00008 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - El YES ❑� NO If yes, please describe: Were all components pumped out and properly abandoned per WAC246-272A-0300? - - 0 YES Ej 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. CD—FA/5- (S Gya evi/oe. 71- 14(4 ,c='Go C �/'4 1'J1 P QT./-r-reJ /'v ),."c.'cG 'pi/a' by 'fl'i r!e r, C) n! 0 J2 S'/d/,„tfCP .0 Ai S-,,l-G Q ? v Pac1 0A. il - `-" A` p 4b.s"P.t v t�io v P7r I n1 cl"w"v ie'� 6 Aif/ /41 ,PPS �C�-C /9/r/". pI6..11..' ® Record Drawing Attached CERTIFICATION OF INSTALLATION INSTALLER DESIGNER/ ENGINEER I certify that 1 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. 1 AVCit &fib(c Signature of Installer Date -.gel t4 0,-MA UV S641 o .- • Printed Name of Signee a.P�• .Ail o An . MASON COUNTY PUBLIC HEALTH $ Co V. N -,_ �y-+A1.- 2�J The undersigned approves this Installation Report and • • \ .7, �3�1Record Drawing on behalf of Mason County Public oo CINDY E WATE. 5',51 Health: i• LICENSED DESIGNER ie C/t/� . y� EXr>IRES OSitOi.)1NLA/lel) Signature of Environmental Health Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated an1/2018 /D/b IN 6 /,' Poem,/G.. 11 11 IP /7- ;�I- 'o A 1 e� 0 A 2 .• 1.jn 7 •r y 10041 fR`GA ij› ✓e. CIN YE. •E I, j.• .�LICEN ES��SSSTTTT((G ER� ' +/ LXPIRS t15,10, 11�� ' ' ! / I _i_ 1\ 1 11 :::: /OF 6rz, - , 1\ qi:i- ,-- A-V r v`' 0 RA/ GUV ryZ r s- fiL -0+v k Z..e ��� CD •I PU ' 4) TQW lc. 41) ....0 f."0#11142 4:-• 14 I..$i'ho,if& 0 r.:d.D . 10 0 0 VG lye a� • ZD xcau„,j i,e'f j 1 •'SE Q I C I)0 l Cf 1 ii", t-\► : N 1a LL i 'i:,JRr1 tv eic'r 1 LAW(,,,„ •N �,2• 9 J LA)- Ct'1.tI km Ise% .- :1icjc•L.1 e)N1,t c)A - fr r=tlzvtr tico 4U6► id r , Gyr` O? 4A It.,"- q c-ew a-'..& N U 4 �jy/1% ,j, ' -r. r`},,�-.d 1` :.0 I/P-- I hi,� Ns .n! 90jy +- . fit•t tl.;) ti r_ k• `'rap \is_ t slv fit PA JP r44, � �- ' " c. .r1 tea_ N__/5� f s/ � vo,."_.(.__./----------- -:., _Aor ,.•,.,::.A.--trzwed. i . 004. %.l. ---.... il \ \<' -' --- ..-- ice_zic.,,u3droc` •\ q " rr Aill \ \\ �y -1 res nt S f` 'l tit 1. leFL)2 s�jsr'd, I Titt-Es r `� �, - 3t V (Fe "D c.At�:s c 1 eti.) 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