HomeMy WebLinkAboutSWG2024-00438 - SWG As-Built - 6/25/2025 Docusign Envelope ID:5417C178-B341-47FF-8710-452C2EE8D7E4
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG SWG2024-00438 Parcel # 52001-77-00020
Applicant Name DAMMANN. DAVID &VERITY Subdivision (Name/Div/Block/Lot)
Applicant Address PO BOX 3155 TR 2 OF SURVEY 6/41
City, State, Zip Shelton Wa 98584 Installer Name Jamie Workman
Site Address 480 W SIMPSON RD Designer Name Micah Halverson
INSTALLATION CHECKLIST
El Full System Installation ❑Tank(s) Only ❑ Drainfield Only ❑ Repair ❑ Other
System Type ATU to Pressure Bed Pretreatment Type Nuwater BNR-500
r
>5 ft. from foundation? - "
:, - ❑ N/A X❑ YES ❑ NO
>50 ft. from wells? �_ '- - - _ \ El El ❑
Z �N>50 ft. from surface water? 7 O 1,� j- - ' 1 ❑ x❑ ❑
Cleanout between building and tank? - - _ _ ' ❑ 0 ❑
U Tank baffles present? - - - ---_i ❑ x❑ ❑
a24" access risers over each compartment. - -.--- - ❑ 0 ❑
W Effluent filter installed?- - ❑ ❑ x❑
N
Septic tank capacity (working) 50n + NuwatPr gal Manufacturer Sound Placement
0 D-box water level and speed levelers used? - - x❑ N/A ❑ YES ❑ NO
XO Manifold/D-box accessible from surface?- - ❑ ❑ 0
u.
mZ Check valves installed? - - ❑ ❑ x❑
6Q
Transport Line Size 2" Schedule/Class 40
Bedrooms installed (check one) ❑ 2 0 3 ❑4 ❑ 5 1116 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A x❑ YES ❑ NO
O >100 ft. from wells? - - ❑ x❑ ❑
W >100 ft. from surface water? - - ❑ 0 ❑
u. >10 ft. from potable water lines?- - ❑ x❑ ❑
z > 5 ft. from property lines and easements?- - ❑ El El
ii > 30 ft. from downgradient curtain/foundation drains? - - ❑ ® ❑
• Drainfield level and observation ports present - - ❑ 0 ❑
❑ Graveless chambers or ® Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ 0 ❑
4 Pump tank setbacks consistent with septic tank? - - ❑ N/A Q YES ❑ NO
`1 Pump tank capacity (flood) 1223 gal Manufacturer Sound Placement
< 24" access riser(s)and accessible from surface?- - ❑ 0 ❑
F- Alarm or Control Panel Installed? - - ❑ 0 IIIi a
Control Panel equipped with Timer/ ETM / Counter- - ❑ 0 ❑
D
C- Pump installed in 0 Bucket or ❑ On Block or ❑ Other
a'g Pump Make/Model Zoeller 153 x❑ Floats or ❑ Transducer
a.
a Tank draw down 2.5 in/min Pump capacity 50 gpm Squirt Height 8 ft
Pump on time 1 min Pump off time 4 hrs Daily flow set at 300 gpd
Updated 8/2112018
Docusign Envelope ID: 5417C178-B341-47FF-8710-452C2EE8D7E4
Mason County OSS Installation Report pg. 2 Parcel# 52001-77-00020
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES x❑ NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ YES X❑ 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.cieanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
rIf niti�al
">C%�� El Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ ENGINEER
I certify that 1 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
forra,A14,AtOched Record Drawing is accurate. form and attached Record Drawing is accurate.
6-4-2025
``—tt4rArsJ1-4vt541_,t.
Signature of Installer Date Ai
t.tow aril
V.Jamie Wnrkman i I/
Printed Name of Signee 41 \��r Fi:
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MASON COUNTY PUBLIC HEALTH ofz :, (Cif tY 0 IIN.,
The undersigned approves this InstfJation Report and''''' �$•
Record Drawing on behalf of Mason P�,�(�,, �„" 5100409
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Health: '-'&, <7,j ;; 4 ', , Liu DESIGNER 11
6( 5/ oc o�,�o4�, EXPIRES! •
Signa re of Environmental Health Specialist Date Fti1g2, (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8/21/2018
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— Abbreviated Description: TR 2 OF SURVEY 6/41
/
M.Halverson Design LLC Applicant/Owner Site Info. Parcel# 52001-77-00020 v''`"`°'`'u._`
PO Box 1519 Shelton Wa 98584 Dave & Verity Dammann
480 W SIMPSON RD
Halversondesignllc@outlook.com Mailing: PO BOX 3155 Shelton WA 98584 RE:1510N