HomeMy WebLinkAboutSWG2023-00009 - SWG As-Built - 6/25/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2023-00009 Parcel # 320103150180
Applicant Name David Stolte Subdivision (Name/Div/Block/Lot)
Applicant Address 801 E Anchor View Ln LLS#21-04 lot 8
City, State, Zip Shelton WA Installer Name Andrew Lehman ,
Site Address 801 E Anchor View Ln Designer Name °kl +�.J✓vt fc;A
INSTALLATION CHECKLIST
0 Full System Installation ❑Tank(s)Only 0 Drainfield Only ❑Repair ❑Other
System Type gravity trench Pretreatment Type
>5 ft. from foundation? - •- ElN/A 0 YES El NO
>50 ft. from wells? RiEg- Efry - ® ❑
• >50 ft.from surface water? - ® ❑
Z
Q Cleanout between building and tank? -- f - AM-$ Th - 0 III ElU Tank baffles present? - �2 ❑ MI 0
a24" access risers over each compartme 43Y El MI 0
W Effluent filter installed?- - - - - - ❑ ® ❑
Septic tank capacity(working) 1200 gal Manufacturer Infiltrator
D-box water level and speed levelers used? - - ❑ N/A 0 YES 0 NO
J
OO Manifold/D-box accessible from surface?- - El II El
ME Check valves installed? - - 0 0 0
thQ
2 Transport Line Size 4 inch Schedule/Class SDR35
Bedrooms installed (check one) 0 2 0 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A If YES ❑ NO
• >100 ft.from wells?- - 0 ® 0
W >100 ft. from surface water? - - 0 In El
ti >10 ft.from potable water lines?- - 0 0 0
Z > 5 ft.from property lines and easements?- - 0 0 0
Q
> 30 ft.from downgradient curtain/foundation drains? - - El 0 El• Drainfield level and observation ports present 0 0 ❑
UI Graveless chambers or 0 Clean gravel used? (check one)
Proper cover installed over drainfield?- - 0 0 0
Pump tank setbacks consistent with septic tank? - - I N/A 0 YES 0 NO
• Pump tank capacity(flood) gal Manufacturer
< 24"access riser(s)and accessible from surface?- - 0 0 0
1—
a. Alarm or Control Panel Installed? - - El 0
2 Control Panel equipped with Timer/ ETM/Counter- - 0 0 ❑
D
a Pump installed in 0 Bucket or 0 On Block or 0 Other
a• Pump Make/Model ❑ Floats or 0 Transducer
a
Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 8/21 2018
Mason County OSS Installation Report pg. 2 Parcel # 320103150180
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES ■❑ NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ 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
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.
0 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.
6/9/25 )
Signature of Installer Date ill �`
Andrew Lehman n i �1• I I u 2
Printed Name of Signee /ar4• \C..
MASON COUNTY PUBLIC HEALTH j,S%:•-,r w.r e,, „11
/v
The undersigned approves this Installation Rep / ; ;a: •,i.1
Record Drawing on behalf of Mason County Public r Ote i 0a,2 30/11
Health: �fqs� i(/4/0 /�/ •$ . ADAM J.HUNTER ':i5nzNtA ,' t1
6� is/ o zs yFN� I.Y.I'.KES 07/17) ..4
Sign Lure of Environmental Health Specialist D 4 t'h1FVT (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR Ptre§tX VIEW ON THE MASON COUNTY WEB SITE Updated 8/21/2018
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