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HomeMy WebLinkAboutSWG2023-00399 - SWG As-Built - 6/25/2025 Mason County OSS installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2023-00399 Parcel # 12205-21-90071 Applicant Name Kristopher&Terri Klusman Subdivision (Name/Div/Block/Lot) Applicant Address PO Box 2816 City, State, Zip Belfair, WA 98528 Installer Name Owner Install Site Address 450 NE Alder Creek Ln, Belfair Designer Name Arrow Septic Designs Inc INSTALLATION CHECKLIST © Full System Installation ❑Tank(s) Only ❑ Drainfield Only ❑ Repair ❑ Other System Type Gravity Bed Pretreatment Type >5 ft. from foundation? {�{]- - ❑ N/A 0 YES ❑ NO � ❑ El ❑ >50 ft. from wells? - � ❑ >50 ft. from surface water? - 1 6 2��5 - ❑ I ❑ z _ JUN ❑ <I— Cleanout between building and tank? , CI I I::U Tank baffles present? •• 1- 24" access risers over each compartm;in- - - -5v - - - - jib ❑ 0 ❑ W Effluent filter installed?- ❑ Cl) Hagerman Septic tank capacity (working) 1,000 gal Manufacturer YES NO 0 D-box water level and speed levelers used? - _ ❑ N/A ❑ O Manifold/D-box accessible from surface?- ❑ 0 mZ Check valves installed? - ❑ ❑ 6Q E Transport Line Size 4" Schedule/Class 3034 Bedrooms installed (check one) 0 2 ❑ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other N/A � YES ❑ NO >10 ft. from foundation? - ❑ CI >100 ft. from wells?- ❑ ID ❑ W >100 ft. from surface water? - El El DI El >10 ft.from potable water lines?- ❑ z Q > 5 ft. from property lines and easements?- - El . Cl CL > 30 ft. from downgradient curtain/foundation drains? - ❑ ©a CI level and observation ports present - - CI ❑ Graveless chambers or ® Clean gravel used? (check one) Proper cover installed over drainfield?- - ❑ 0 El .••. tank setbacks consistent with septic tank? - - El N/A ❑ YES % NO Pump tank cap. flood) gal Manufacturer z 24" access riser(s) and ac - '•le from surface?- - ■ ❑ ❑ I-- ❑ ❑ a. Alarm or Control Panel Installed? - - - ❑ ❑ ❑ 2 Control Panel equipped with Timer/ ETM /Coun - CI- Pump installed in ❑ Bucket or • • = ock • a Pump Make/Model ■ Floa or ❑ Transducer D • .. . ft a Tank draw •'-ump Pump off - Daily flow - updated 8f21 RO t 6 Mason County OSS Installation Report pg. 2 Parcel# - ABANta TOORD' YES NO Were existing septic components abandoned as part of this project? If yes, please describe: YES [] NO Were all components pumped out and properly abandoned per WAC246-272A-0300? SOP North arrow,reserve drainfield.existing and proposed buildings,location of wells.waterlines. 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 create additional delays proposed inbui dings approval and related permits. wells. o Drawings contain:ports. eld&man and t entati in&layout.Septic/pumpssoi is tank location. wells,observation ports.cieanouts,and other maintenance access points. Incomplete Record Drawings may ------------ Cp c,JV - -- S\cA.k(K) « z 2ge__ (2-vCl1C_A--Gx Record Drawing Attached CERTIFICATION OFINSTALLATiON INSTALLER DESIGNER/ ENGINEER 1 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 aso Countyouty Public ub i Health and meet all and Mason County Codes. s 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. s/ ,J- Sinature of Installer Date A Printed Name of Signee 1.°' ' ',' MASON COUNTY PUBLIC HEALT N. I-3 6 . .r' 10 The undersigned approves this Instaii n Repo�(�i d .Ci��` stoes.ts 't•�t'r 44-,� PAULA JOY JQHtvStl V' •� Record Drawing on behalf of Mason Cout' F lies ,'," L� A JOY JO tG� it•' ''1„ Health: /�j� �7 4 (c(77 S 201 S ��� ZS ,y/. 9`4,,, (stamp, signature and date) Signet r of Environmental Healt Specialist Date THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated&2tr2o1a • SCAuE, .1''=40' �'r�. -i t 40 �o e0 zo u E � cN_ 11C>.0 s M? _ 1-.4% P t \�. .0�2 'ac°=- �A.o' wee 'fit r� �ij.�� •nti 1 ) 7 J 49 i ���PAUIJaJJOY3JOHNSON' l G-(o-zs Li try, jq:i. \s *l s(oo-k'S 'ro boots. :- 0 "91 S w 1 v-00- 5 *0 ,c o M• 7 \; t'' �8' {- aLs H roots• / VA rr) , ` f j' `)S/''(.SSE ostd �. fYL2___-e9_____- ^emu ' Co! � vl 1� r ouS2 O :.\ 4f,. '\ ET?:Ac \Nd1kl / .9E55 .S LQPG Ai,0 0• i,rl V i..�v(,Cor CM' Lr ___(:):, .. .._.4..._..____ C (osi-- i E-kSe t 30, K_i. E� C , e c p�A� 0 C?ear_out _ rJ -- � seM5NT 3 1,000 Gallon Septic TanK 2-Compartment with Effluent FE t 0 D-Box with speed-levelers 11 -E= — and cover to surface — — — O VE JUN 2 5 2025 MASON COUNTY ENVIRONMENTAL HEALTH DJA