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HomeMy WebLinkAboutSWG2023-00389 - SWG As-Built - 6/27/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2023-00389 Parcel # 120195000005 Applicant Name Brett& Lori Vaughters Subdivision (Name/Div/Block/Lot) Applicant Address 10820 SW Stockholm Dr City, State, Zip Wilsonville, OR 97070 Installer Name Hansen Excavation - J. Hansen Site Address 81 E Smith Cove Way Designer Name Caliber Septic Design - Bazzell INSTALLATION CHECKLIST © Full System Installation ❑ Tank(s)Only ❑ Drainfield Only ❑ Repair ❑ Other BOA, System Type Standard Gravity Pretreatment Type 4' >5 ft. from foundation? - - ❑ N/A ❑■ YES >50 ft. from wells? - - ❑ 0 Y >50 ft. from surface water? - - ❑ 0 ❑ z I-- • Cleanout between building and tank? - - ❑ 0 ❑ ✓ Tank baffles present? - - ❑ 0 ❑ P.a 24" access risers over each compartment?- - ❑ 0 ❑ W Effluent filter installed?- - ❑ ■❑ ❑ co Septic tank capacity (working) 1250 gal Manufacturer Hagerman Pre Cast 0 D-box water level and speed levelers used? - - ❑ N/A ❑■ YES El NO �O Manifold/D-box accessible from surface?- - 0 ❑ ❑ 002 Check valves installed? - - 0 ❑ ❑ 0< 2 Transport Line Size 4" Schedule/Class SCH40/3034 Bedrooms installed (check one) ❑ 2 ❑■ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft. from foundation?- - ❑ N/A 0 YES ❑ NO Ca >100 ft. from wells?- - ❑ 0 ❑ W >100 ft. from surface water? - - ❑ 0 ❑ LL >10 ft. from potable water lines?- - ❑ 0 ❑ z > 5 ft. from property lines and easements?- - ❑ 0 ❑ Q cc > 30 ft. from downgradient curtain/foundation drains?- - ❑ ■❑ ❑ o Drainfield level and observation ports present - - ❑ II ❑ 0 Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?- - ❑ 0 ❑ Pump tank setbacks consistent with septic tank? - - ❑] N/A ❑ YES ❑ NO • Pump tank capacity (flood) N/A gal Manufacturer N/A < 24" access riser(s) and accessible from surface?- - 0 ❑ ❑ H a Alarm or Control Panel Installed? - - 0 ❑ ❑ 2 Control Panel equipped with Timer/ ETM /Counter- - ❑■ ❑ ❑ a- Pump installed in ❑ Bucket or ❑ On Block or ❑ Other N/A a• Pump Make/Model N/A ❑ Floats or ❑ Transducer a.a Tank draw down N/A in/min Pump capacity N/A gpm Squirt Height N/A ft Pump on time N/A Pump off time N/A Daily flow set at N/A gpd Updated 8I21/2018 Mason County OSS Installation Report pg. 2 Parcel# 120195000005 ABANDONMENT RECORD Were existing septic components abandoned as part of this project'? - - E YES Q NO If yes, please describe: Were all components pumped out and properly abandoned per WAC246-272A-0300? - - 0 YES 0 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 i 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 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 and attached Record Drawing is accurate. form and attached Record Drawing is accurate. 7/4ct-8 ' 6/23/2025 S. ature of Installer Date Jared Hanson i Printed Name of Signee4 pp ,,is, MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Repot;and "`� vp/� 21037126 ELL' Record Drawing on behalf of Mason ty Pub/i6/4/2 , �i LICENSED DESIGNER Health:1_1 COONTY�N °25 06/23/.25 677 ft u- H Signature of Environmental Health Specialist Date FA/7 / (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8/21/2018 r 0 coO ov om Co n m y mO OrY N -1 i com i -. m r o n D m o Z Z 3 O 2n . NJZ 0 m O N O ,Na T§ p 2 0 N O1 ti 55yy C1 O < O Mp M r mo O W / - \ a z O o0 Q . . . \ m m .b N Z \ . 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