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Home My WebLink Aboutswg2025-00139 - SWG As-Built - 5/27/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 7 1 5 DO 13 q Parcel # 32.1 V1 300104 Applicant Name bal._cus t,t.C. Subdivision (Name/Div/Block/Lot) Applicant Address /6-ttS Psow ►2-b SuJ 3 City, State, Zip rENINO�uv1A i 98_sgci Installer Name TEss 1 40(r n -' rn ` Site Address `I -0 E + -t-rYiooi2 2 Z Designer Name p; D. INSTALLATION CHECKLIST ❑ Full System Installation Rcnk(s) Only ❑ Drainfield Only ❑ Repair ❑Other System Type ext—eakwYL-e Pretreatment Type >5 ft. from foundation? - - ❑ N/A EKES ❑ NO >50 ft. from wells? - - ❑ (] / ❑ Z >50 ft.from surface water? - - ❑ Er- ❑ HCleanout between building and tank? - - Er . ❑ ❑ U Tank baffles present? - - ❑ Q' ❑ a24"access risers over each compartment?- - ❑ 1-3 - ❑ W 'Effluent filter installed?- - ❑ g ❑ Septic tank capacity (working) a 2 SO gal Manufacturer ((JF t LlYLpr1OM. D-box water level and speed levelers used? - - ❑ N/A El YES El NO xJ O Manifold/D-box accessible from surface? - ❑ ❑ ❑ o0Z Check valves installed? ❑ ❑ ❑ CIQ 2 Transport Line Size Schedule/Class Bedrooms installed (check one) [t ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft. from foundation?- - LI N/A ❑ YES ❑ NO 0 >100 ft. from wells?- - ❑ ❑ ❑ W >100 ft. from surface water? - - El ❑ s. Z >10 ft.from potable water lines?- - CI ❑ N\ > 5 ft. from property lines and easements?- - ❑ El �C d > 30 ft.from downgradient curtain/foundation drains? ❑ ❑ ❑ 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?- - ❑ N/A ❑ YES ❑ NO Pump tank capacity (flood) gal Manufacturer < 24"access riser(s)and accessible from surface?- - ❑ ❑ ❑ H a Alarm or Control Panel Installed? - - ❑ ❑ ❑ j Control Panel equipped with Timer/ETM/Counter- - El El _\\k" a- Pump installed in ❑ Bucket or ❑ On Block or ❑ Other a Pump Make/Model ❑ Floats or ❑ Transducer a. a Tank draw down in/min Pump capacity qpm Squirt Height ft Pump on time Pump off time Daily flow set at qpd Updated 8/21/2018 Mason County OSS Installation Report pg. 2 Parcel# - ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - �ES ❑ NO If yes, please describe:fit-0M1'&% %ICoNEb /'tPU(._ j OFF S(7E. Were all components pumped out and properly abandoned per WAC246-272A-0300? - - IEs ❑ 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,deanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits. ❑ 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 I further certify that all information contained on this I further certify that all information contained on this form .nd attached Record Drawl is accurate. form and attached Record Drawing is accurate. .5%/2'ZS ature .f In t Iler Date Printed Name of Signee MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report and Record Drawing on behalf of Mason County Public Health: LL (UWiAryi)(C`114\ h7 17—c 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 8/21/2018 i _ tank. exIstirlg _ Replace with 1,200- gailon infiltrator tank Ns Conned from e>dstin9 stub out to pump O.- 1 Iti 4 1 le tillr— i`1J`7L ri { 3 tr-- IQ • APPROVED APR 2 2 2025 MASON COUNTY ENVIRONMENTAL HEALTH RET . ( E� MAY 2 7 z025 MASON COONTYENVIRONMENTAL H RET �a�rh