HomeMy WebLinkAboutSWG2022-00405 - SWG As-Built - 8/6/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2022-00405 Parcel# 12105-51-17009
Applicant Name Tim Macdonald Subdivision (Name/Div/Block/Lot)
Applicant Address 5440 E Grapeview Loop Rd
City, State, Zip Allyn WA 98524 Installer Name Keith Chamberlain
Site Address 5"0 E Grapeview Loon Rd Designer Name Lawrence Purdum
INSTALLATION CHECKLIST
❑ Full System Installation ❑Tank(s)Only ® Drainfeld Only ❑ Repair ❑Other
System Type Pressure Distribution Pretreatment Type N/A
>5 ft. from foundation? - - -- - - - - - - - -- - - - - - - E] MIA ❑YES NO
>50 ft.from wells? - - - - -- - - - - - - -- - - - - - - ❑ ❑ ❑
Z >50ft.from surface water? . - - - - - - -- - - - - - - - - - - - - - - - ❑ El ❑
F Cleanout between building and tank? -- - - -- - - - - - - - -- - -- -
❑ ❑ ❑
U Tank baffles present? - - ❑ ❑ ❑
IL
24' access risers over each compartment?- - - - - - - -- - - - - - - - ❑ ❑ ❑
W Effluent filter installed?- - - - -- - - - - - - - - ❑ ❑ ❑
rn
Septic tank size Existing 1,500 gal Manufacturer Infiltrator
O D-box water level and speed levelers used? - - - - -- - -- - - - - - - NIA ❑ YES ❑ NO
00 Manifold/D-box accessible from surface?- - - - - - - - - - - - -- - --
❑ ® ❑
faZ Check valves installed? - - - - - - -- - - - - - - - - - - - ❑ ® ❑
O<
2 Transport Line Size 2^ Schedule/Class 40
Bedrooms installed (check one) ❑ 2 03 ❑4 ❑ 5 [:1 6 ❑Commercial/Other
>10ft. from foundation?- - - - - - - - - - - - - - - - - - - - - - -- - - ❑ MIA Q] YES NO
O >100 ft. from wells?- -- -- -- --- -- - - - ❑ ® ❑
W >100 ft. from surface wateO— -- - - - - - - - El ® ❑
LL >10ft.from potable water lines?- - - - - - - - - - - - - - - -- - - -- -
❑ ❑
Q? > 5ft. from property lines and easements?-- - - - -- -- - - - - - - -
❑ ❑
K >30 ft. from downgradient curtain/foundation drains? - - - - - - -- - - ❑ ® ❑
O
Drainfeld level and observation ports present - - - - - - - - - - - - - - ❑ ® ❑
® Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfeld?--- - - - - -- - - - --- - -- - ❑ [Z ❑
Pump tank setbacks consistent with septic tank?- - --- ❑ WA ❑ YES ❑ NO
Y Pump tank size Existing 1,250 gal Manufacturer Infiltrator
Q24"access riser(s)and accessible from surface?- - - - - - - -- - - -- ❑ ❑ ❑
~ Alarm or Control Panel Installed? - - - - - - - - - ❑ ❑ ❑
Control Panel equipped with Timer if ETM/Counter- - - - - - - - - - - ❑ ❑ ❑
7
a Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
Pump Make/Model Existing Pump ❑ Floats or ❑ Transducer
a
Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
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Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENTRECORD
:Vera e.Isnng sepbc compnnents abandoned as pan <J this projeOl - - - - - - - - -- - -- - - ❑ YES ® NO
It yes please desadbe _ _ — —
Were all components pumped out and properly abandoned per WAG246-272A-03001 - - "' - - - ❑ YFS ❑ NO
RECORD DRAWING
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® Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER!ENGINEER
I certify that 1 installed the system in accordance with 1 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 aR
and Mason County Codes. Stale and Mason County Codes
I further certify that all information contained on this l further certify that all information ro. lainad on this
form and attached Record Drawing is accurate form and attached Record Drawing is accurate.
Signature of lmdeller De e
Printed Name of Signee A ��Fass ••
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and .. ........
'Lwr�fl�/MF Pprtlum
........ . .
Record Drawing on behalf of Mason County Public L
Health' EXPIRES pf$12025
����
e/l/2024
Signature of Envuonme al Health Speplahst Date (stamp, signature Ond date)
ter.i.:rra
MIS FORM MAY SE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTV WEB SITE
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