HomeMy WebLinkAboutSWG2022-00105 - SWG As-Built - 11/27/2025 gimmisor
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWC/96a, 0 CP tC Parcel# ZZ 3\ 0`C 37
Applicant Name Scots. t;,yw`}t. Subdivision (Name/Div/Block/Lot)
Applicant Address `1\ Nr C441- `
City, State, Zip AG.Lc c, \1V4' Installer Name ,c?oN 1..0.4e3 gyp}{_
Site Address 1031 ( Lt ,{,tr/S L iL_ (DesignerName -15 Q-A L, <-1".44
INSTALLATION CHECKLIST
al Full System Installation ❑Tank(s)Only El Drainfield Only ❑Repair ❑Other
System Type 1)tl`le Pretreatment Type M S
>5 ft. from foundation? - - ❑ N/A Dill YES ❑ NO
>50 ft. from wells? - - ❑ (] ❑
Z >50 ft. from surface water? - - El CK El
I--
Cleanout between building and tank? - - ❑ V. ❑
O Tank baffles present? - - 0 0711 0
d24" access risers over each compartment?- - El (il ❑
N Effluent filter installed?-
liFr
Septic tank size gal Manufacturer ( ,e/V MIMI Q ikb-T CI .1
M 1
C 1
0 D-box water level and speed levelers used? - - ❑ N/A ❑ YES ❑ o 1
DO Manifold/D-box accessible from surface?- - ❑ KI El `" 1
9 Check valves installed? - - ❑ ❑ ❑
04
Transport Line Size Schedule/Class tC.) . 1
t
Bedrooms installed(check one) ❑ 2 10 3 ❑4 ❑ 5 El 6 El Commercial/Other $:
CO
>10 ft. from foundation?- - ❑ N/A E] YES ❑ cJa ��
0 >100 ft.from wells? - ❑ ® ❑
W >100 ft. from surface water? - - El tls ❑
u,. >10 ft. from potable water lines?- - El ® ❑
Z >5 ft. from property lines and easements?- ❑ iCi Elle > 30 ft. from downgradient curtain/foundation drains? - - ❑ KI El
Drainfield level and observation ports present - - El ❑ ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ I] ❑
Pump tank setbacks consistant with septic tank?- - ❑ N/A 93 YES ❑ NO
Z Pump tank size \tom gal Manufacturer ead`. tC't�C
. ON+< 24"access riser(s) and accessible from surface?- - ❑ tl CId Alarm or Control Panel Installed? - - ❑ El
2 Control Panel equipped with Timer/ ETM/Counter- - ❑ ❑
n- Pump installed in 0 Bucket or ❑ On Block or It Other P ✓ ;er
mPump Make/Model Q CO li Floats or ❑ Transducer
0_• Tank draw down in/min Pumpcap
acity aci p ty --SD gpm Squirt Height fAok ft
Pump on time_ 5-M-Y1 Pump off time \ let( Daily flow set at /l j 0 gpd
Updated 8mn01e
Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES ❑ NO
if yes, please describe:
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 end future development. Typical Record
Drawings contain: grainfield&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 creole 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 1 further certify that all information contained on this
fo a d attache Rec d Drawing is accurate. form and attached Record Drawing is accurate.
7--6= 22
Signatu of Installer Date Ab
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Da tmtc� _""":-i\ji
Printed N�fffe of Signee ,c y1`
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MASON COUNTY PUBLIC HEALTH �`4r,'4 f :t) g.':t:$$
The undersigned approves this Installation Report and ;� . �'a:.� j
�. Etoo2:1
Record Drawing on behalf of Mason County Public , BRADFORD F SSsrl;r{';
Health: L1t 1;^�'i 5e.?"Gf f ..__�, ,
(...:jc -.0\1111ily\occyv)
71
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Signature of Environmental lth Specialist Date ea (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updatede2V2ote
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