HomeMy WebLinkAboutSWG2021-00175 - SWG As-Built - 6/25/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2021-00175 Parcel # 61904-32-00120
Applicant Name JOHN CARPENTER Subdivision (Name/Div/Block/Lot)
Applicant Address 1982 W FORD LOOP RD
City, State, Zip ELMA,WA. 98541 Installer Name HOUSE BROTHERS
Site Address 1982 W FORD LOOP RD Designer Name CINDY WAITE
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type GRAVITY treatment Type
>5 ft.from foundation? - st-V-- L' - - ❑ N/A ®YES ElNO
>50 ft. from wells? ❑
Z >50 ft. from surface water? - _ _ _ 03' - ❑
H Cleanout between building and tank? -�uN _ El ® El
Tank baffles present?
-...5.-- ❑-...5.-- ❑ II
d24"access risers over each compartme t%y--- - - ❑ ® 0
I Effluent filter installed?- - ❑ II
Septic tank capacity(working)X i'2,o gal Manufacturer 1 Q rec.cd\-
9 D-box water level and speed levelers used? - - ❑ N/A ® YES ❑ NO
G0 Manifold/D-box accessible from surface?- III El- ❑
OQCheck valves installed? - - 0 El ❑
2 Transport Line Size 4 Schedule/Class 3034
Bedrooms installed (check one) 0 2 0 3 ®4 0 5 0 6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A ® YES ❑ NO
G >100 ft. from wells?- - ❑ ® ❑
W >100 ft. from surface water? 0 NI 0
Z >10 ft.from potable water lines?- - 0 III
a > 5 ft.from property lines and easements?- - IN ❑ ❑
te C > 30 ft. from downgradient curtain/foundation drains? - - 0 PI 0
Drainfield level and observation ports present - - 0 0 ❑
0 Graveless chambers or 4 Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ ® 0
Pump tank setbacks consistent with septic tank? - - ❑ N/A ❑ YES IN NO
Y Pump tank capacity (flood) gal Manufacturer
Z
H24" access riser(s)and accessible from surface?- - El El
a Alarm or Control Panel Installed? - - 0 0 0
f Control Panel equipped with Timer/ ETM/Counter- - 0 0 0
D
a Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
a PumpMake/Model
g ❑ Floats or 0 Transducer
a. Tank draw down in/min Pumpcapacity a p ty qpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 8r21n018
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Mason County OSS Installation Report pg. 2 Parcel# 61904-32-00120
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - 0 YES [/NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ YES F2rNO
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 onentaton&layout,Septtclpumo tank location.North arrow,reserve drainfield,existing and proposed Du,ldings,location of wells,watentnes,
wells,observation ports.deanous.and other maintenance access points Incomplete Record Drawings may create additional delays in final installation approval and related permits.
ecord 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
1 furtr7er 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.
1 .."' --t (93(1.�
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nature Installer Date
Printed Name of Signee % 4 -
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation,s sport arg � '�
V 1 fi,js� o
Record Drawing on behalf of Mason County J4 N?S �a. `? ', •�, •
Health: .,/� ryFy cO25 51004.18 `�
e(r5(w /� O�A� �N LICENSED DESIGNER
�ITE ;
Signature of Environmental Health Specialist Date tiF4(r� (stamp, sigrii iure3 and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated eatr2018
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1. Proposed residence 4.4, t.-., 9 ti
2. 1200 gallon double chamber
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septic tank1
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3. Transport line re CINDYE WAtTE
LICENSED DESIGNER �I
4. D-Box am. ". s o i �....v/,
I ExP,RES 0511W
5. Primary drainfield(4-3'x50)
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3 6. Reserve area will need
s to go over repair system if needed. ! ��EtwALDTH
. A 7. Clean out
' 8. Proposed well 71:0PyRamitoisztax29 2021
9. Waterline
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