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Home My WebLink AboutSWG2025-00011 - SWG As-Built - 6/6/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 207,5 - UDC)‘1 Parcel # 521 12 - 3 L'1 -- 002.00 Applicant Name G))0,7.e Fame\q ca' rn Subdivision (Name/Div/Block/Lot) Applicant Address `J\0 6 r()0,_ WI 126 ' C City, State, Zip S Q,1)vr�w\oR G Y) M S Installer Name *`f\(A -Q M(a(�\e Site Address 510\ VI . S\�OY. ci Sh VG\ signer Name 1() f(A_ INSTALLATION CHECKLIST ❑ Full System Installation IZKank(s)Only ❑ Drainfield Only ❑ Repair ❑Other System Type (PAY ON\' Pretreatment Type >5 ft. from foundation? - ❑ N/A EYES ❑ NO >50 ft.from wells? - ❑ la r� ❑ Z >50 ft. from surface water? - - ❑ `r ❑ FQ- Cleanout between building and tank? - - ❑ Ef ❑ V Tank baffles present? - - ❑ d ❑ n.~ 24" access risers over each compartment?- - ❑ �,( ❑ W Effluent filter installed?- - ❑ LJ ❑ N Septic tank capacity (working) ICJ 09) gal Manufacturer \--V),( \Y c OX' 9`(e-(S .Sk L] D-box water level and speed levelers used? - - [ 'N/A ❑ YES ❑ NO J oO Manifold/D-box accessible from surface?- - ❑ ❑ mZ Check valves installed? - - ❑ ❑ ❑ Q Schedule/Class 2 Transport Line Size Bedrooms installed (check one) ❑ 2 0 3 ❑4 ❑ 5 ❑6�J ❑Commercial/Other >10 ft. from foundation?- - - - - - Y - - �_- ❑ N/A Di YES ❑ NO >100 ft. from wells?- �� - ❑ Qf ❑ W ❑ d >100 ft. from surface water? ❑(` {;, Er_ >10 ft. from potable water lines?- - ❑ d ❑� Z > 5 ft. from property lines and easements? El �� Q ❑ ❑ � ^' � > 30 ft.from downgradient curtain/foundation drains? - cti L] PM CI level and observation ports present ❑ ❑ ❑ Graveless chambers or ❑ Clean gravel used? (check one) t'4jA Proper cover installed over drainfield?- - d ❑ c m Pump tank setbacks consistent with septic tank? - - ❑ N/A ❑ YES No� • Pump tank capacity (flood) gal Manufacturer Z - ❑ ❑ ❑ < 24" access riser(s)and accessible from rface? I— a. Alarm or Control Panel Installed? - - ❑ ❑ ❑ 2 Control Panel equipped with Timer/ ETM /Co ter- ❑ ❑ ❑ - D C- Pump installed in ❑ Bucket or ❑ On Bloc or ❑ Other a'• Pump Make/Model ❑ Floats or ❑ Transducer a. a Tank draw down in/min ump capacity gpm Squirt Height ft Pump on time Pump off time Daily flow set at gpd Updated R!211201R Mason County OSS Installation Report pg. 2 Parcel# 52.1 i2 -2)`'I- 00200 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 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 n final installation approval and related permits. 4 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 and attached Record Drawing is accurate. form and attached Record Drawing is accurate. ��,z---- -- (1/le\ \1,C) Signature of Installer Date \c S Printed Name of Signee MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report and Record Drawing on behalf of Mason County Public Health: 5911/V (7c Signature of Environmental Heal 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 RECORD DRAWING (continued) 11\ N r v e 9 wJ A r B vJ d � r New o Hacjerman E. i60 ertcaSt- iCgme locafim to' ac rtiica -rArt I-1 O'tcc, APPROVED JUN 0 6 2025 MASON COUNTY ENVIRONMENTAL HEALTH RET PaACeI* 621I2-',4-8020e CGOnnmL(,lliM W4tCr)