HomeMy WebLinkAboutSWG2024-00224 - SWG As-Built - 8/25/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2024-00224 Parcel# 32021-58-04061
Applicant Name Empire Home Construction Subdivision (Name/Div/Block/Lot)
Applicant Address P.O. Box 241 SHORECREST BEACH ESTATES#1 BLK:4 LOT'.61
City, State, Zip Kelso,WA 98626 Installer Name Mason County Excavating
Site Address 90 E Kingston Way, Shelton,WA Designer Name Arrow Septic Designs
INSTALLATION CHECKLIST
• Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair 0 Other
System Type OSCAR Pretreatment Type NuWater BNR-500
>5 ft from foundation? 69 .�y ., - 0 N/A RYES ❑ NO
>50 ft. from wells? - 9p 'tt - - ❑ • ❑
Z• >50 ft. from surface water? - -
FCleanout between building an ? -- k ., - ❑ ® ❑
U Tank baffles present? --- --
AUG 75 20 5 0 ® 0
E.E. 24` access risers over each coh1wfi'arff rh7X- LLtu `_ "" • r • ❑ II CI
w Effluent filter installed? SWIM ❑ 0 0
GO Hagerman
Septic tank capacity(working) NuWater BNR gal Manufacturer
O D-box water level and speed levelers used? ❑ N/A ❑ YES ® NO
OO LL Manifold/D-bcx accessible from surface?- - - i�EAD L^Isigsr,`z - - - - ❑ U 0
£9 Check valves installed? - 0 MI ❑
c< 40
2 Transport Line Size 1 inch Schedule/Class
Bedrooms installed (check one) 0 2 0 3 0 4 0 5 El 6 0 Commercial/Other
>10 ft from foundation?- ❑ Nis In YES 0 NO
a >100 ft. from wells?- ❑ ® ❑
W >100 ft.from surface water?- ❑ IN 0
'CZ >10 ft from potable water lines? 0 0 ❑
Z > 5 ft. from property lines and easements? ❑ ® ❑
K > 30 ft. from downgradient curtain/foundation drains? ❑ IN ❑
• Drainfield level and observation ports present 0 a El
Proper cover installed over drainfield?- 0 ® 0
Pump tank setbacks consistent with septic tank? ❑ WA I YES 0 NO
• Pump tank capacity (flood) 1,000 gal Manufacturer Hagerman
Q 24" access riser(s) and accessible from surface? ❑ I] ❑
~ ILI
0 Alarm or Control Panel Installed? - 0 IN 2Control Panel equipped with Timer/ETM /Counter ❑ El 0
O. Pump installed in ❑ Bucket or ❑ On Block or p Other on bottom of tank
SPump Make/Model A.Y. McDonald E-30 Floats or ❑ Transducer
0.
o_ Tank draw down — in/min Pump capacity 9.20 gpm Squirt Height -- ft
Pump on time 22 seconds Pump off time 3 min,44 sec Daily flow set at 360 gpd
Updated a:'2016
Mason County OSS Installation Report pg. 2
Parcel# 320 2 —"' — 0+0 `
ABANDONMENT RECORD ���(((
YES �7{� NO
Were existing septic components abandoned as part of :his project? IT
If yes, please desulbe: YES NO
Were all components pumped out and properly abandoned per WAC246-272A-0300? -
RECORD DRAWING
enough to rcdotate in the need of malntenanee activities and future development Typ®I Recore
Th.
be
DrayIsn a permanent recordteldma doll ne accurate and aSeaavpum en reserve t et sang< dons and proposed dmlcings,locador.of wells,watedines,
w2wmeseU On oas.f ea8nanandhertmainenan layout. L•conk mea.ened DFwme addaonal delays in final icsuofllon approval and related permits.
wed.,od:ere van ports.a<anoon,and other maintenance aexss pores. Incomplete Record oarnns<may create
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AUG 25 2025
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Record Drawing Attached
1 .
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER(ENGINEER
I certify that I installed the system in accordance w 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 ail State myself and Mason County Public Health and meet all
and Mason County Codes. State and Mason County Codes
I further certify that ail information contained on this I further certify that ail information contained on this
form and attached Record Drawing is accurate, form and attached Record Drawing is accurate.
O
Veg.// 29
Signature of Installer pate
P t\ova, V1Y4 ��'�j,,_
Printed Name of Signee AE I
MASON COUNTY PUBLIC HEALTH ....
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The undersigned approves this Installation Report and 4` PAULA uor uo HN oN �
Record Drawing on behalf of Mason County Public LIC 4. Y JOHNS N 9
t
Haa iAlikilii^ 1-25-2-5 8 -I v LC
Sign.turtrvimnmental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEVW ON THE MASON COUNTYVEB SITE oxercanrzo,e
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