HomeMy WebLinkAboutSWG2025-00081 - SWG As-Built - 4/29/2025 Mason County OSS Ins-.allation Report pg. 1 ` ' MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2a.5 - 6ao9J Parcel # 32127- 5Z- 0002'f
Applicant Name - (.410-JC5 Le-Vi N-ie- Subdivision (Name/Div/Block/Lot)
Applicant Address 851 a so-Am aoU. DR-.
City, State. Zip Sb i3i_fe J 1 WA '$c f Installer Name-BAi'4Aa O Sl?&3L I- #341-1S CLC-
. Site Address SA in(' Designer Name Coleti WARE
INSTALLATION CHECKLIST
Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair ❑ Other
System Type IVOAJ GoN67-02 1/4/G f2 itg9 L ZOPl ntment Type
>5 ft. from foundation? - ❑ N/A TE1YES ❑ NO
>50 ft. from wells? - ❑
El
z >50 ft. from surface water? - I
� W_ _�F - El ❑❑Cleanout between building and tank? - -U Tank baffles present? - _MAY_1 2 ZQ25_ _� _ E El
9 d 24" access risers over each compartment?- _ _ _ _ - ❑
i!
LU Effluent filter installed?- -ay- - - - - ❑ E]El ❑
CO
Septic tank capacity (working) 1'QSt O gal Manufacturer•I+' a2,
5 D-box water level and speed levelers used? - - �N,'A ❑ YES ❑ NO
OO Manifold/D-box accessible from surface?- ❑ Er ❑
mZ Check valves installed? - El
.
Q 2 v
o
2 Transport Line Size Schedule/Class 1110
Bedrooms installed (check one) (r 2 ❑ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation? - -_ ❑ N/A YES ❑ NO
>100 ft. from wells?- AePPROVE
-E _ _ - I: g ❑
--I >100 ft. from surface water? - -
. F. II 0 Al
ti >10 ft. from potable water lines - -M�� i_-T _ _ - - - ❑ IN -
z > 5 ft. from property lines and ents?- - - - - ❑
\TY E\i 0--1v1ENTAt IlEAL4i+ +- ID 24' ❑
Q > 30 ft. from downgradient curtail �lp�tntt�iIon dr�• {�9.�- - ❑
Drainfield level and observation ports present . - ❑
,� Graveless chambers or ❑ Clean gravel used? (check one) ❑ ❑
Proper cover installed over drainfield?- - ❑ ❑
Pump tank setbacks consistent with septic tank? -
�-7 ❑ N/A YES ❑ NO
Z Pump tank capacity (flood) I2.p � gal Manufacturer 4 PP6a I► nil 3't-Pr14 ,
L- --
24" access riser(s) and accessible from surface?- - ❑ ❑
0. Alarm or Control Panel Installed? - ❑ ON ❑
E Control Panel equipped with Timer/ ETM/Counter- - - - ❑
z ❑ �syit
d Pump installed in IDBucket or it`On Block or ElOther t i v
2 d Pump Make/Model QC.L 12- /v- /F2---
W ❑ Floats or XTrangducer
a Tank draw down 2 in/min Pump capacity_50_ 4
Q /� _gpm Squirt Height Z- ft
• Pump on time_ 4 ! nn/1 Pump off time�O ,,
Daily flow s emuV et � gpd
Ca, j o
Mason County CSS Installation Report pg. 2 Parcel # 32.
127 dG162Y
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - YES 0 NO
If yes, please describe:
Were all components Pumped'out and properly abandoned per WAC246-272A-0300? - - YES 0 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 Draintield A manifold orientation A layout.Sept:dpump tank location.North arrow,reserve drainfield existing and proposed buildings location of wells.waterline.;
wells.observation ports.cleanouts.and other maintenance access points. Incomplete Record Drawings tray create additional delays in final installation approval and related permits
APPROVES
MAY 15
o`•7.
MASON
tieRecord 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 attache Record Drawing is accurate. form and attached Record wing is accurate.
lei )2o. "
Signature of installer Date
r 'y�7 ./ .
c A yam i 4 � pF riAS �>;A
Printed Name of Signee P . �,
l
MASON COUNTY PUBLIC HEALTH • 510 to
O CI Y WAITE
The undersigned approves this Installation Report and LAC SE ESIGNER
Record Drawing on behalf of Mason County Public ter n f s °boo,
Health:
V�`l
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 Updeted&21i2dift
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MAY 15 21'25 HEALTH APPROVED '
%SON CC �g L as k./ D - 1,, MAR 17 2025 •
'LA MASON COUNTY ENVIRONMENTAL HEALTH
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