HomeMy WebLinkAboutSWG2025-00209 - SWG As-Built - 8/25/2025 4
r CLEAR FORM (*I-NC
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG E,20 g`1 - QO .09 Parcel# 222181400100
Applicant Name ELIZABETH & DARELD JOLLIFFE Subdivision (Name/Div/Block/Lot)
Applicant Address 7354 BETHEL BURLEY RD SE
City, State, Zip PORT ORCHARD WA 98367 Installer Name Aaron Shoemaker
Site Address 8621 NorthShore RD, Belfair Designer Name Jim Zlmry
INSTALLATION CHECKLIST
111 Full System Installation ❑Tank(s)Only ❑ infield Only ❑Repair ❑Other
System Type Atu - Pressure distri retreatment Type BNR 500
1JT
>5 ft. from foundation? - - ❑ N/A ■YES ❑ NO
>50 ft. from wells? - -`��- - - - 0 is
>50 ft. from surface water? - A...Ts'-tz5- -Iii. r --- ❑ ❑ MI
Cleanout between building and tank? - - -/- -•E'- - � 4-- - - 0 II
Tank baffles present? tit
- -- (` — ——- 0
® 0
24" access risers over each compartmen . /�----- El MI El
Effluent fitter installed?- — ————- 0 ❑
NI
Septic tank capacity (working) 1 000 gal Ma wfacturer its.vi- M4,,L - C a R4
C3 D-box water level and speed levelers used? - - ElN/A ElYES ❑ NO
DO Manifold/D-box accessible from surface? - 0 IN 0
Qa Check valves installed? - - 0 ID
2 Transport Line Size 2" Schedule/Class Scxh 40
i
Bedrooms installed (check one) JP.", [ ❑Commercial/Other
>10 ft. from foundation?- - ` -,` -. ` ❑ N/A • YES ❑ NO
0 >100 ft. from wells? -
- , -- ' 0 ❑
- AU%-Z5�;.; III
W >100 ft. from surface water? ---- - - El El III
u >10 ft. from potable water lines?- MASON COUNTY ENVIRONM P; ❑ ■ ❑
31Y
z > 5 ft. from property lines and easements?- - --J3 - - o is IDd > 30 ft. from downgradient curtain/foundation drains? - - El IN ❑
Drainfield level and observation ports present - - ❑ ❑ ❑
❑ Graveless chambers or MI Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ SI ❑
Pump tank setbacks consistent with septic tank? - - 0 N/A ® YES El NO
zPump tank capacity (flood) 1000 gal Manufacturer v v o- , rvt aw C '..(_-c.Z,
< 24" access riser(s)and accessible from surface?- .- - ❑ II 0
a Alarm or Control Panel Installed? - - ❑ 0 ❑
2 Control Panel equipped with Timer/ ETM/Counter- - 0 U 0
D
a Pump installed in ❑ Bucket or Hi On Block or ❑ Other
a Pump Make/Model Liberty 280 Floats or� ❑ Transducer
d Tank draw down 2" in/min Pump capacity 40 gpm Squirt Height 10' ft
Pump on time 45 secs Pump off time 4 hrs Dai yflow set at 180 gpd
Updated 8/21/2018
Mason County OSS Installation Report pg. 2 Parcel# -2.7-2L `$ I 4 0 0 I00
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - Eit YES 0
If yes, please describe:
Were all components pumped out and properly abandoned per WAC248-272A-0300? - la YES El NO
RECORD DRAWING
This is a permanent record and must be accurate and descrlpttve enough to re-locate in the need of maintenance
Drawings contaur Dramfeld 8 manifold orrnntal on 8layout.Se tiUacti��and(ot4 i dawbpmao Typical Rene
p pump tank location.North arrow,reso�ve Mainftald.existing and proposed Oulptnga.Ideation off wells,waterlines.
wets.oOservabon ports,cleanouts,and other maintenance access pants. Incomplete Record()towels may create addt,onal delays in final n*alation approval and related perm Rs.
PPROVE
AUG 252025
MASON COUNTY ENVIRONMENTAL HEALTH
JBW
a R Ord Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER ,
I certify that I installed the system in accordance with I certify that the system has bee stalled in accor-
the septic design stamped"APPROVED"by Mason dance with the septic design sta ed"APPROVED"by
County Public Health and that any deviations shown Masbn County Public Health an t at any deviations
here have been cleared/approved by both the designer shorn here have been cleared/ roved by both
and Mason County Public Health and meet all State myself and Mason County Publi earth 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 inforrnatio ontained on this
form and attached eco rawing is accurate. form and attached Record Drawl 4 is accurate.
7///r 2a2 S-:
ignature of Installer i Date
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Printed Name of Signee :l fff
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MASON COUNTY PUBLIC HEALTH ......., ft
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason CountyPublic .? '•230 f •�►
Heart J uc n ; D e SIGNER f
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I e1 ''3 �= �z
Signet:.
ironmental H alth Specialist Date
(stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8R1,2018
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