HomeMy WebLinkAboutSWG2024-00103 - SWG As-Built - 5/22/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
• Permit Number WIG 262`j OPIO3 Parcel # [2105— 5Z-- ate'91
Applicant Name Cfq e 5 CI'i A v>~ Subdivision (Name/Div/Block/Lot)
Applicant Address t Z512 I 1(iP A4v
•
City, State, Zip Y4v1C00Je/ 14...A 1 ?S Installer Nametnlyd S f1C C 1tC
Site Address 6 D E 77'eolSc.4C isisw,t Jgner Name Crnfl kJ Pri it
INSTALLATION CHECKLIST
%Full System installation ❑ rank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type •OSCA/L Pretreatment Type Y v Z_.
>5 ft.from foundation? - N/A 181 YES ❑ NO
>50 ft. from wells? lECE0
\ - _ t ❑Z >50 ft.from surface water? - ❑ td ❑H Cleanout between building and tank? - - - -MAY-- 1 -2_2025- - _- D �F 0
v Tank baffles present? - - ❑ g ❑
d24"access risers over each compartmertgy- - - - ❑ N. 0
la Effluent filter installed?- .- .- - ❑
cn
Septic tank capacity(working) }4..00 gal Manufacturer seS 1 >ffi e—P444
o D-box water level and speed levelers used? - ❑ YES ❑ NO
DO Manifold/D-box accessible from surface?- - gNIA0 0
CQCheck •valves installed? •f -. - 0 ,LI 0
I _ 1
2 Transport Line Size Schedule/Class
Bedrooms installed (check one) ❑ 2 e3 ❑4 G 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?• - 0 N/A [YfES ❑ NO
CI >100 ft. from wells?- - • 0 gl 0
W >100 ft. from surface water? - ❑ M 0
Z >10 ft. from potable water lines?_ 0
L^J 0
Q >5 ft. from property lines and easements?• 0 K 0
Q >30 ft.from downgradient curtain/foundation drains?- - X ❑
Drainfield level and observation ports present - - - ❑ 0
0 Graveless chambers or 0 Clean gravel used? (check one)
Proper cover installed over drainfield?- - 0 0
Pump tank setbacks consistent with septic tank? • - ❑ N/A ES ❑ NO
Pumptank capacity(flood) t2A'� 05E yes -T/'a.. VA-
P y gal Manufacturer
H24"access riser(s)and accessible from surface?- - 0 or
a Alarm or Control Panel Installed? - • ❑ 0
2 Control Panel equipped with Timer i ETM/Counter- ❑ ❑
a Pump installed in ❑ Bucket or 'On Block or f❑ Other
a Pump Make/Model ii�� 1\5
'-� iZ 1fP 12AV P� Floats , or
0 Tran ducer
n, Tank draw down in/Min Pump capacity gpm Squirt Height ft
Pump on time 0a=/4i2-- Pump off time 0 5C.A-r2, Daily flow set at
gpd
Joaatad 8:2?'2019
Mason County OSS Installation Report pg. 2 Parcel 1210 5—52- pot,9 /
ABANDONMENT RECORD
Were existing septic components abandoned as part of this protect? - - - -- -. - - -- - - _ _ - YES Ei NO
If yes, please describe: -
Were all components pumped out and broperly abandoned per W C241i-272A-0300? - - OYES 0 NO
RECORD DRAWING
This Is a permanent record and must be accurate:,.id descriptive enough to ra-locate in the need of maintenance activities and future development. Typical Record
Drawings contain': Drain/laid&manifold orientation&layout.Septic/pimp tans location.North arrow,reserve charnfield.existing and proposed buildings.location of wells,waterlines.
,veils,observation ports,cieattouts.arc a- mairterance access points. incomplete Record Drawings ma)create add tional delays in final installation approval and related permits.
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--ral4d1c Jo c'f a ch a,►,re ezai /At sc..
}a 4,r•J
ji 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 Ccdes State and Mason County Codes
i further certify that all information contained on this I furtner certify that all information contained on this
rm and attached Record Drawing is accurate. fOrrn and attached Record Gr 'rig is accurate.
Signature of Installer Date r�
ec.tVs,,,. A la
Printed Name of Siyre2
•
44/
MASON COUNTY PUBLIC HEALTH • 00
O� CINDY E WAITE`
The undersigned approves this installation Report arc LICENSED DESIGNER
Record Drawing on behalf of Mason County Public
EXPIRES U&tOr •
Health:
‘ iy.V2it/11\10(6111 1W7 ( •
Signature of Environmental Healtn Specialist Cars
(stamp. signature and date)
THIS FORM P.tA'r SE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE
UpdatOC 8/:U2018
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