HomeMy WebLinkAboutSWG2025-00053 - SWG As-Built - 8/22/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG Mit 00053 Parcel# ;-2-)-0 S/&)OO
Applicant Name Dial VIT1- (uki Thu-, Subdivision (Name/Div/Block/Lot)
Applicant Address 7/ $E ctivb/ 9YJmn / Se,/ Pail _'!
City, State, Zip fSej F-a-it, IAA 1$,fd-0 Installer Name /}-/Icon tkcp tic they-i.s
Site Address teff1 C__ Designer Name &l'cK ®.4y WC"r INSTALLATION CHECKLIST //
II System Installation 0 Tank(s)Only 0 Drainfeld Repair ❑Other
System Type ?'Q re_ C\---;(`Q J\f atment Type
>5 ft.from foundation? S" �1'" 0 NIA rifYEs ❑ NO
>50 ft.from wells? - t - - T`}.4 ---- - ❑ m 0 •
Z• >50 ft.from surface water? 0 - -- 0 0 •
✓ Cleanout between building and tank? --- -- - - - ID2r Litp Tank baffles present? - ❑ 21 ❑
a '3 24"access risers over each compartment?- ❑ ® ❑
rW Effluent filter installed?- - ---ffajp�d` - o-'n'Ac .- ❑ fa 0
Septic tank size /S) gal Manufacturer /NF/Tjetra.t.-
I
O D-box water level and speed levelers used? - e2(N/A ❑YES 0 NO
p0 Manifold/D-box accessible from surface?- - ❑ la1 0
GQCheck valves installed? - -` ❑ ❑
a Transport Line Size 2,I, Schedule/Class ach Flo
Bedrooms installed (check one) 0 2 0 3 �k4 ❑ 5 0 6 ❑Commercial/Other
>10 ft.from foundation?- , - ❑ NIA YES 0 NO
>100 ft.from wells?- 0 0
W >100 ft. from surface water? - - ❑ 0
u. >10 ft.from potable water lines? • ❑ 0 0
aZ > 5 ft.from property lines and easements?- 0 0 0
IR >30 ft.from downgradlent curtain/foundation drains? - 0 m ❑
Drainfeld level and observation ports present - - 0 0 •
*lean❑ Graveless chambers or lean gravel used? (check one)
Proper cover installed over drainfeld?- - 0 0
Pump tank setbacks OD
with septic tank? 0 WA acres [3 NO
`L Pump tank size I p D oat Manufacturer /A Pi T ,t-m_
< 24"access riser(s)and accessible from surface?- - 0 aQ 0
ILAlarm or Control Panel Installed? - - 0 4 ❑
2 Control Panel equipped with Timer/ETM/Counter- 1 .�t� �- CI �Gi ❑
0- Pump installed in ❑ ((Bucket or 9nn Block or 0 Othera.
'raaa"�.��-..',�����
• Pump Make/Model r--I berry a-8O 0 Floats or }yt Transducer
R Tank draw down ��11 I_____in1/min Pump capacity ,30Z gpm Squirt Height__ \\3y" ft
Pump on time a.S MaN Pump off time atip hil j Daily flow set at y4}n qpd
Updated A;21/2010
Mason County OSS Installation Report pg. 2 Parcel# ,:2 - ?-5-1 060 &
•
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - YES 0 NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - YES NO
RECORD DRAWING �,``''fit
This is a permanent record and must be accurate and descriptive enough to relocate In the rayed of marnt.nanco activities and future development. typical Record
Drawinga contain. Drainfield&manifold orrentat{ort&layout.Septietpuinp lank location.North arrow reserve drainl o!d,existing and proposed buildings.bcstten of wells.waterlines.
wells,observation pods.deanouts,and other maintenance access points. Incompble Record Drawings may create addtUonai delays:n fnallmterratim approval and relied permits.
rl
KRecord Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
1 certify that I installed the system in accordance with I certify that the system has been installed in actor-
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 ounty Codes. State and Mason County Codes
I further rtlfy that all i at' n contained on this 1 further certify that all Information contained on this
foram a attached r ing Is accurate. form and attached Record Drawing is accurate.
7-
Sig of�Installer
,, �Q�j/, Date :tell
ar' Of
40
Printed Name of Slgnee �' if
MASON COUNTY PUBLIC HEALTHI tlThe undersigned approves this Installation Report and -:1 pI.
fi r
Record Drawing on behalf of Mason County Public _ r . r�
Health: .� ��
Signature off Environmental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON TUC MASON COUNTY WEB SITE updated I3421/2018
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