HomeMy WebLinkAboutSWG2025-00210 - SWG As-Built - 8/29/2025 Docusign Envelope ID:B37DF94B-FA34-41D5-9CA0-97F3EC642C83
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG SWG2025-00210 Parcel # 520013490081
Applicant Name ANDFRSC)N., noun] AS .l Subdivision (Name/Div/Block/Lot)
Applicant Address 50 W SIMPSON Rn
City, State, Zip Shelton Wa 98584 Installer Name Jamie Worman
Site Address Same as Mailing Designer Name Micah Halverson
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair ❑ Other
System Type ATU to Pressure Bed Pretreatment Type RNR-500
>5 ft.from foundation? - _..-•� Y�1-;--% ? -- ❑ N/A ® YES ❑ NO
>50 ft. from wells? - �';�;-,:=.-�r�= -•4 =,•
>50 ft.from surface water? - �,� ❑ ® ❑
z 1`t AUG n U25 —
Cleanout between building and tank? - �-i'� - _ - ❑ ® ❑
U Tank baffles present? - - - - ❑ ® ❑
F- 24" access risers over each compartmen 1,.,- - - - - - - - - ❑ Ni El
a
W Effluent filter installed?- - ❑ ❑
N
Septic tank capacity (working) gal Manufacturer Sound Placement
0 D-box water level and speed levelers used? - - ❑ N/A ElYES ® NO
00 Manifold/D-box accessible from surface?- - CI CI
002 Check valves installed? - - ❑ ❑
❑Q
2 Transport Line Size 2'' Schedule/Class 40
Bedrooms installed (check one) ❑ 2 2 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- -- ❑ N/A ElYES ElNO
>100 ft. from wells? S <}' ;.. El ® ❑
--1 >100 ft. from surface water? - 14 lilik. El Ni ❑
ti >10 ft. from potable water lines?- c3 `1 E 1N CI ® ❑
z > 5 ft. from property lines and ease ?- - P- - 7\\s\t" - -- ❑ Ni CId > 30 ft.from downgradient curtain/f 'on ckIl�. 1K - CI 00
Drainfield level and observation ports`` - - - �i�' - ❑ Ni ❑
❑ Graveless chambers or ® Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ Ni ❑
IPump tank setbacks consistent with septic tank? - - ❑ N/A ® YES ❑ NO
ZPump tank capacity (flood) 1 223 gal Manufacturer Sound Placement
< 24" access riser(s)and accessible from surface?- - ❑ ® ❑
H
cc_
Alarm or Control Panel Installed? - - CI ® El
2 Control Panel equipped with Timer/ ETM /Counter- - ❑ Ni ❑
a Pump installed in ❑ Bucket or X❑ On Block or El Other
a Pump Make/Model 7ollar 1.69- 161 Ni Floats or ❑ Transducer
a_
a Tank draw down 2" in/min Pump capacity 45 gpm Squirt Height 3' ft
Pump on time 1 min Pump off time 4hrs Daily flow set at 270 gpd
Updated 8/21/2018
Docusign Envelope ID:B37DF94B-FA34-41 D5-9CA0-97F3EC642C83
Mason County OSS Installation Report pg. 2 Parcel# 520013490081
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ® YES ❑ NO
If yes, please describe:OH gravity system on neighbors property
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ® YES El NO
RECORD DRAWING
This is a permanent record and must be accurate and descriptive enough to re-locate In the need of maintenance activities and future development. Typical Record
Drawings contain: Drainfield&manifold orientation&layout,Septic/pump tank location,North arrow,reserve drainfield,existing and proposed buildings,location of wells,waterlines,
wells,observation ports,cleanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
APP9
0NOO 2 S 2„,
tUr 15NyENON4/1EJ NTq Initial
Owners Initial:
e''''97
® 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
I further certify that all information contained on this I further certify that all information contained on this
fg, ,ggoched Record Drawing is accurate. form and attached Record Drawing is accurate.
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`-etat Al-ssranua1.t. r
Signature of Installer Date �!1i
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_i rpie workman :z 1
Printed Name of Signee Or . I
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MASON COUNTY PUBLIC HEALTH \ i yid' g +11
The undersigned approves this Installation Report and �' S100408 ` �f
Record Drawing on behalf of Mason County Public 0! ii�iwn�wEtw.v�soN'y
Health: , UCENSED DESIGNER 1
liti s ...eD— EXPIRES:oar's/.t5
Signatur o E vi nmental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8/21/2018
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Abbreviated Description: LOT A OF SP #1229 AF#411489
M.Halverson Desi n LLC Owner/Applicant.
Site Info Parcel# 52001-34-90081
SHEEI NUNBCR
g ANDERSON, DOUGLAS J
PO Box 1519 Shelton Wa 98584 Mailing: 50 W SIMPSON RD Site Address Same as Mailing
Halversondesignllc(a�outlook.com SHELTON WA 98584 -,EVSIONr