HomeMy WebLinkAboutSWG2024-00119 - SWG As-Built - 8/22/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2024-00119 Parcel# 22127-76-00070
Applicant Name Rachel Clark Subdivision (Name/Div/Block/Lot)
Applicant Address 5115 Andrew St SE
City. State. Zip Lacey,WA 98503 Installer Name Maples Excavating
Site Address 121 E Passage View Rd, Shelton Designer Name Arrow Septic Designs Inc.
INSTALLATION CHECKLIST
• Full System Installation ❑Tank(s)Only ❑ Drainfi�. Only ❑ Repair ❑ Other
System Type Shallow Pressure - n Pretreatment Type
>5 ft from foundation? ^�\iF - "` - - - - ❑ N'A IN YES ❑ NO
>50 ft. from wells? - - - - . �(` V -��- -\\\���JJJIII ❑ 0 ❑
Z >50 ft.from surface water? - - - -\�_ - - `-0,% - El 0 ❑
<
Cleanout between building and to• -- Pd�' 0
❑
U
Tank baffles present? - - - - ❑ El
El
F 24" access risers over each compart`u El"- ❑ ❑
W Effluent filter installed? - - ❑ 0 ❑
u) IA Hagerman
Septic tank capacity (working) 1,20, gal Manufacturer
O D-box water level and speed levelers used? - - ❑ N/A ❑ YES 0 NO
>CO Manifold/D-box accessible from surface? ❑
m2 Check valves installed? -- - ❑ 0 ❑
O¢ p" Schedule/Class 40
2 Transport Line Size
Bedrooms installed (check one) ❑ 2 I0 3 ❑4 0 5 ❑6 ❑Commercial/Other
>10 ft. from foundation? - - ❑ N/A O YES ❑ NO
Q >100 ft.from wells? - ❑ ❑� ❑
W >100 ft. from surface water? - - ❑ I] ❑
IT >10 ft.from potable water lines? ❑ 0 ❑
> 5 ft from property lines and easements? - ❑ 0 ❑
K > 30 ft. from downgradient curtainifoundation drains? ❑ 0 ❑
o
Drainfield level and observation ports present - ❑ • ❑
❑ Graveless chambers or • Clean gravel used? (check one)
Proper cover installed over drainfield? ❑ 0 ❑
Pump tank setbacks consistent with septic tank? - ❑ N/A . YES ❑ NO
Y Pump tank capacity(flood) 1,000 gal Manufacturer Hagerman
< 24' access riser(s) and accessible trona surface? ❑ . U
Alarm or Control Panel Installed? --- ❑ 0 ❑
a ❑ • ❑
2 Control Panel equipped with Timer/ ETM/Counter-
m
a Pump installed in ❑ Bucket or • On Block or ❑ Other
a• Pump Make/Model Zoeller N152 ❑� Floats or ❑ Transducer
a
• Tank draw down 2.5 in/min Pump capacity 46 gpm Squirt Height 5 ft
Pump on time 1.8 min Pump off time 6 hr Daly flow set at 360 gpd
•
Mason County OSS Installation Report pg. 2
Parcel# Z2121 -110— 0001 D
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project?
0 YES NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC24E-272A-0300? 0 YES ❑ NO
RECORD DRAWING
and e pa enough re-locate theea of R 'loth/din d futuredevelopment. Typical R re
Th
orpe aaanr record and must bereserve field 's] a and proposed a , ca wells,
w2wn55mnaan: r.fitlefln5, on tal enn '.5s 9 p k l ^'e 5z may Peal and related peens.
wells.observation ports.avnvvu,and other maintenance access points. Incomplete Record pawn au aaaco,a delays in anal asraaauvn approval
odd.„)(, i ,
P( 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
1 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.
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-"Signature of Installer Date - A
Printed Name of Si nee rA .3.d,l
MASON COUNTY PUBLIC HEALTH .eat 4 Cr""''
The undersigned approves this Installation Report and
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Record Drawing on behalf of Mason County Public PAULn jOY JOHNSON '. \V
Health: BC $EtipTS'i NE
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17kl�YINVO 1 B 1Z-zs
Signature of Environmental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNEC AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Upaaee arzrrzme
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° =°-� APPROVED
AS kLT t AUG 2! 2025
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