HomeMy WebLinkAboutSWG2025-00194 - SWG As-Built - 6/25/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2025-00194 Parcel# 319065000015
Applicant Name Marty Lindholm Subdivision (Name/Div/Block/Lot)
Applicant Address 790 W Golden Pheasant RD SOMERS HIGHWAY TRACTS TR 6-A ✓G
City, State, Zip Shelton WA 98584 Installer Name Mike R Fesenbek <c�
Site Address 790 W Golden Pheasant RD Designer Name Justin Russell �/4 CO
INSTALLATION CHECKLIST
❑ Full System Installation 0 Tank(s)Only ❑ Drainfield Only ❑ Repair ❑ Other
System Type Gravity Pretreatment Type
>5 ft. from foundation? - - ❑ N/A 0 YES ❑ NO
>50 ft. from wells? - -- - ❑ 1=11 ❑
Y >50 ft. from surface water? - - ❑ 0 ❑
Z
I--
Cleanout between building and tank? - - ❑ 00
U Tank baffles present? - - ❑ 0 ❑
a 24" access risers over each compartment?- - ❑ 0 ❑
w Effluent filter installed?- - ❑ 0 ❑
cn
Septic tank capacity (working) 1250 gal Manufacturer infiltrator
D-box water level and speed levelers used? NSA ❑ YES ❑ NO
pm 0 Manifold/D-box accessible from surface?- - ❑ ❑ ❑■
Z Check valves installed? ❑ ❑
0<
2 Transport Line Size 4" Schedule/Class
Bedrooms installed (check one) ❑ 2 0 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation? - -- - ❑ NIA El YES ❑ NO
>100 ft. from wells? ❑ 0 ❑
W >100 ft. from surface water? - - - ❑ 0 CI
u.. >10 ft. from potable water lines?- - ❑ 0 ❑
Z > 5 ft. from property lines and easements? ❑ 0 ❑
4 62 > 30 ft. from downgradient curtain/foundation drains? - - - - - - - - - - Li El ❑
Drainfield level and observation ports present - - ❑ LI Pi
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - CI CI ❑
Pump tank setbacks consistent with septic tank? - - 0 N/A ❑ YES ❑ NO
• Pump tank capacity (flood) gal Manufacturer
< 24" access riser(s) and accessible from surface?- - 0 ❑ ❑
~ Alarm or Control Panel Installed? - - ■❑ ❑ ❑
EL
2 Control Panel equipped with Timer/ ETM /Counter- - 0 ❑ ❑
D
n- Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
a. Pump Make/Model CIFloats or CITransducer
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# 319065000015
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - Q YES ❑ NO
If yes, please describe:existing 300gallon ball tank pumped and removed
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - Ill 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 lank location,North arrow,reserve drainrield,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.
A/t-4e a
❑ Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ ENGINEER
I certify that!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.
� %?L AV—Rf p. 6/19/25
Signature o Installer / Date �.i1
i'•,,I.
Mike R Fesenbek �d
Printed Name of Signee /, �� /'
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MASON COUNTY PUBLIC HEALTH /ff W.c•� c. v_ `� �,
The undersigned approves this InstallatiorN ort ant/4i 6� 22030834 �f.
/ IUS E 5 DESIGUSSELLNER
�••Record Drawing on behalf of Mason County Pt�9 ` ,j 0 ,, / LICENSED DESIGNER I
Health: FNf'/�' 1jr
G(io5
%�i,/F4/7
e
Signatu of Environmental Health Specialist Date '476, (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8n1/2018
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