HomeMy WebLinkAboutSWG2023-00325 - SWG As-Built - 7/11/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2023-00325 Parcel # 22003-50-00007
Applicant Name Exodus Acres LLC Subdivision (Name/Div/Block/Lot)
Applicant Address PO Box 76 HARTSTENE RETREAT#1 LOT: 7
City, State, Zip Allyn, WA 98524 Installer Name South Shore Construction
Site Address 21 E Fox Ln, Shelton WA 98584 Designer Name Arrow Septic Designs, Inc.
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair OE Other 500 Pre-trash
System Type Shallgw Pressure YE
Pretreatment Type NuWater BNR-500
>5 ft. from foundation? - + jf { iJ - - - ❑ N/A 0 YES ElNO
>50 ft. from wells? - MI - - ❑ UI ❑
Z >50 ft. from surface water? - - - - - - JUL 21., - J - - ❑ CI ❑
H Cleanout between building and tank - - - ❑ ❑■ ❑
U Tank baffles present? - _y- - - - - - - - - ❑ ❑■ ❑
a24" access risers over each compa m- ' - - - - - - - - - - ❑ CI ❑
W Effluent filter installed?- - ❑ ❑ ili
Septic tank capacity (working) NuWater 500 gal Manufacturer Infiltrator
C] D-box water level and speed levelers used? - - ElN/A ❑ YES 0NO
oO Manifold/D-box accessible from surface?- - ❑ ❑■ ❑
oQCheck valves installed? - - - - a* V''"N* .- 41 "`" - ❑ 00
Transport Line Size 2" Schedule/Class 40
Bedrooms installed (check one) ❑ 2 ❑■ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A 0 YES ❑ NO
O >100 ft. from wells?- - ❑ ❑■ ❑
W >100 ft. from surface water? - - El0 ❑
ti >10 ft. from potable water lines?- - ❑ El ❑
Z > 5 ft. from property lines and easements?- - ❑ I ❑
Q
IX > 30 ft. from downgradient curtain/foundation drains? - - ❑ ® ❑
0
Drainfield level and observation ports present - - ❑ • ❑
• Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ X ❑
Pump tank setbacks consistent with septic tank? - - ❑ N/A 0 YES ❑ NO
• Pump tank capacity (flood) 1,060 gal Manufacturer Infiltrator
Z
Q 24" access riser(s) and accessible from surface?- - E . O
N
a Alarm or Control Panel Installed? - - ❑ II
E Control Panel equipped with Timer/ETM/Counter- - ❑ 0 ❑
D
a. Pump installed in ❑ Bucket or 0 On Block or ❑ Other
a-• Pump Make/Model Liberty 280 0 Floats or ❑ Transducer
a Tank draw down 2 in/min Pump capacity 50 gpm Squirt Height 3 ft
Pump on time 1.8 min Pump off time 6 hr Daily flow set at 360 gpd
Ua:ated 8:71'2C'a
Mason County OSS Installation Report pg. 2
Parcel# 22 D- D _ C��
ABANDONMENT RECORD
Were existing septic components,abandoned as part of this project? -
If yes, please describe: - NO
Were all components pumped out and properly abandoned per W - 0 YES
AC246-272A-0300? - 0 YE' � 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
and proposed b:,lid-•w s.location of weals,waterlines,
�� Dna9r>sdd&manifold orientation&layout,$epticlpump tank location.Northanvw.reserve dramrield.existing approval and related Permits.
observationi ps.uGenouis,and other maintenance a pants. Incomplete Record Drawings may create additional delays In trial lnstatlIItion
•
. • r
• •
. . .
. .
• .
..
• . . *Record Drawing Attached
-.CERTIFICATION OF INSTALLATION y.•ry,..,`,'=:`.•c`:^:?',,:'_
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
fo n alto eel R rowing is a rate. form and attached Record Drawing is accurate.
5-8-LE
Signature of Installer Date
-9-1\--0'^4X-41K V\-KIVI-Q-- Ak 4
, ..4%
•
Printed Name of Signee a t>`�
MASON COUNTY PUBUC HEALTH ;j°r` �T .4`' ' ";
The undersigned approves this Installation Report and sf',r.
Record Drawing on behalf of Mason County Public J''Q� PAULA JOY JOHNSON '��'
Health: �S71(( (-? �ls�iGN
Pts
•7- 2— LS—
�rr (stamp,signature and date)
Signature of Emironment2l Health Specialist Date
• This FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE upaasw 81214018
r — 30 45 wo
.....2:-._ 65 _hug k.
I
...._____ .. \•• . '--- v A jc.:(e.-5, L-4-\--
• 2'° ° / ► �v'- �CX LA;`c
— -- �" i I
87 s
. (a). 6%Z51 1 \ ,
• ' v A i
t Znv\res •
1/4, ,. J C ; ,e,
5 JG. w:T.'v"i
Zoo. Iielea,1 _ k.
leek of Rievve ' '
. --- s 3 pP
RovEn
•
Ze
4-15 --,' Nt vc,, ,; t'.�t irtd MASONJ UL > > Z015
ip Ii� ! COUNnENPRONMENTgC
REr HEALTH
000 f 4
4
I \ K
- . _ 50G C-sflas Pze-Trash s
,9 {
\ \uWat �NR-500 17.= K
1 i nc.-: 1 s ("7-•-.. _a Ov -ram:.= ;-. Ch2 :�C,+
•
(.C-1 i i Valve CJrr`DS Box- 7i eA.
x stii-t..kri- i
L v s2 `• I• j, ����
CO�5LL!-F1V•15 i
iIrl
1 ..
1
L i • .
H••• 5100349 '
tea` PAULA JOY JOHNSON..•.