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HomeMy WebLinkAboutSWG2024-00196 - SWG As-Built - 6/25/2025 Docusign Envelope ID: 129A2BF5-ECEF-429F-BFD7-6E4DF1214C23 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG SWG2024-00196 Parcel # 31902-41-90002 Applicant Name GORZYNSKI. RAYMOND Subdivision (Name/Div/Block/Lot) Applicant Address 6013 SILVER OAKS CT SE LOT: B OF SP#1946 City, State, Zip TUMWATER WA 98501 Installer Name Scott Johnson `'G, K > Site Address 41 SE WELLSWOOD WAY Designer Name Micah Halverson -p<< d INSTALLATION CHECKLIST 1 fi0 `3 x❑ Full System Installation ❑Tank(s) Only ❑ Drainfield Only ❑ Repair ❑ Other System Type Oscar X02 Pretreatment Type XO2 >5 ft. from foundation? - - ❑ N/A x❑ YES ❑ NO >50 ft. from wells? - - ❑ © ❑ Z >50 ft. from surface water? - - ❑ El HCleanout between building and tank? - - ❑ 00 O Tank baffles present? - - ❑ x❑ ❑ a24" access risers over each compartment? - - ❑ El W Effluent filter installed?- - x❑ ❑ ❑ u) Septic tank capacity (working) 100n gal Manufacturer Hagerman precast O D-box water level and speed levelers used? - - x❑ N/A ❑ YES ❑ NO DO Manifold/D-box accessible from surface?- - 00 El u. co 2- Check valves installed? - - x❑ ❑ ❑ OQ E Transport Line Size 4' Schedule/Class 3034 Bedrooms installed (check one) ❑ 2 x❑ 3 ❑4 LI 5 ❑6 ❑Commercial/Other >10 ft. from foundation? - - ❑ N/A X❑ YES ❑ NO o >100 ft. from wells? - - ❑ 0 ❑ W >100 ft. from surface water? - - El El ti >10 ft. from potable water lines?- - ❑ 0 ❑ Z > 5 ft. from property lines and easements?- - ❑ x❑ ❑ Q Q• > 30 ft. from downgradient curtain/foundation drains? - - El ® ❑ Drainfield level and observation ports present - - ® ❑ ❑ ❑ Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?- - 0 ❑ ❑ Pump tank setbacks consistent with septic tank? - - x❑ N/A ❑ YES ❑ NO ZPump tank capacity (flood) 1000 gal Manufacturer Hagerman precast < 24" access riser(s)and accessible from surface?- - ❑ ® ❑ ~ a Alarm or Control Panel Installed? - - ❑ El 2 Control Panel equipped with Timer/ ETM /Counter- - ❑ ® ❑ D a Pump installed in ❑ Bucket or ® On Block or ❑ Other Na O.• Pump Make/Model Oscar X02 ❑ Floats or ❑ Transducer a. Tank draw down Na in/min Pump capacity Na gpm Squirt Height Na ft a .360 Pump on time Na Pump off time Na Daily flow set at XO2 rate gpd Updated 8/21/2018 Docusign Envelope ID: 129A2BF5-ECEF-429F-BFD7-6E4DF1214C23 Mason County OSS Installation Report pg. 2 Parcel# 31902-41-90002 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? - - 0 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 in final installation approval and related permits. owners Initial : Initial gN6 ` X❑ Record DrawingAttached 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 farpopaq,apched Record Drawing is accurate. form and attached Record Drawing is accurate. 6/16/25 tl04913Fo �Z54 l Signature of Installer Datej $ � = del Scott Johnson `� Printed Name of Signee C, ��, MASON COUNTY PUBLIC HEALTH l ' e`bf '/ • The undersigned approves this Installation Report arld ' S100409 1+ Record Drawing on behalf of Mason County Public ® fr ; sc�►trf+a�eL LICE l�uvl�te DESIGNERow I �U ,e r NSED Health. ASpN(// iv� / 4 � 7 5 cXptnr..; r?nrt�r Signature of Environmental Health Specialist Date 1,7 Iff' (stamp, signature and date) ks,t,T�' Updated 8I2112018 THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLICWIEW ON THE MASON COUNTY WEB SITE Tabloid 11"X17" . v C) N ® DcoofkO-1 �' SU N m n 0 N N . 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C N ,-,- it M01 D O_ d m p n) 0 0 ` 0 ',- 0 CD I C) O r 3 0 r ; v I co o I Abbreviated Description: LOT: B OF SP #1946 Site Info' SHEET NUMBER M.Halverson Design LLC GORZYNSKI, RAYMOND Parcel# 31902-41-90002 n Wa 98584 y Mailing:6013 SILVER OAKS CT SE 41 SE WELLSWOOD WAY 1 PO Box 1519 Shelto n TUMWATER WA 98501 Halversondesignllc(C�outlook.com REVISION#: