HomeMy WebLinkAboutSWG2023-00484 - SWG As-Built - 8/27/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG ZUZZS 0 OL{3L. Parcel# ZZZI 4 j 00oo0c
Applicant Name (,4u.._ 6 1 Subdivision (Name/Div/Block/Lot)
Applicant Address Z6'L O ,. -
City, State, Zip •= t- W14\_ Installer Name J€--0r•4 14 N►.-,c-
Site Address /6571 E- 4::z-r .Z..-i /OL Designer Name btcxaiT 'etn,y-"i r
INSTALLATION CHECKLIST
Full System Installation 0 Tank(s)Only 0 Drainfield Only ❑Repair ❑Other
System Type Pretreatment Type ,..��
>5 ft. from foundation? - r�..-. n r �:�-t' ❑ N/A L�Y ❑ NO
>50 ft.from wells? ;-- i FY I i.s 1. 4'- - ` 0 ❑
2• >50 ft. from surface water? - 1-ti
❑ / ❑Q I t etween buildin and tank? - - UG-� 4-2-Q25--
C eanou h g �- , ❑ � ❑
y-- ; LI Li
O Tank baffles present? - 0 Cl24"access risers over each compartme �y - -• CIa. V
Effluent filter installed?- /l^DI ❑
Septic tank size /COO gal Manufacturer ff*
O D-box water level and speed levelers used? - - ❑ N/A ❑ YES ❑ NO
oO Manifold/D-box accassible from surface?. _ - - - - - ._ - ❑ ❑ El
mi Check valves installed? - - 0 ❑ ❑
Transport Line Size Schedule/Class
Bedrooms installed (check one) 2 []3 ❑4 0 5 ❑6 ❑Commercial/Oth
>10 ft. from foundation?- - ❑ N/A Y ❑ NO
0 >100 ft.from wells?- - 0 0
iL >100 ft, from surface water? - ❑ 0
Li >10 ft.from potable water lines?- - 0 0
> 5 ft. from property lines and easements?- - 0 ge2/: 0
12 > 30 ft.from downgradient curtain/foundation drains? • - ❑
ca
Drainfield level and observation ports present - - 0 ❑
❑ Graveless chambers or 0 Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ ❑
Pump tank setbacks consistent with septic tank?- - 0 N/A YES ❑ No
Pump tank size fOC`ti9 gal Manufacturer 4 f - N)v-
.4 24"access riser(s)and accessible from surface?- - ❑ 0
F-
a Alarm or Control Panel Installe ? - - ❑ 1/ 0
2 Control Panel equipped • Timer/ETM/Counter- • ❑ ❑
M
a- Pump installed in Bucket or 0 On Block or ❑ Other
a. Pump Make/Model r•tPs J Floats or 0 Transducer
a,
4 Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at qpd
• Updats 8/2112018
Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? • • 2/::ES 0 NO
If yes, please describe.
Were all components pumped out and properly abandoned per WAC246-272A-0300? • - YES [] NO
IRECORD DRAWING
This Is a permanent record and must be accurate and descriptive enough to re•Iocate In the need of maintenance activhles and future development. Typical Record
Orowings contain: Drainkeid 5 manifold orientation&layout.Septic/pump lank location.North arrow.reserve drolnfleld.existing end proposed buildings.location of wells.viptertines,
wells.observation ports,cieenouts,and other maintenance accoss points. Incomplete Record Drawings may create additional delays in final ineta/ebon approval and related permits.
Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ ENGINEER
I certify that 1 installed the system in accordance with 1 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 cleated/approved by troth
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 fu.e- certify that all information contained on this I further certify that all information contained on this
form an. attac ed R rd D wing Is accurate. form and attached Record Drawing is accurate.
r
13—zil : ' �,
Signature rf Installer Date �� $
Oa ri ) iTI w1/4\`<-1 Pri"..?th
Printed Nttele of Signee ;!��'�� e y� 1
MASON COUNTY PUBLIC HEALTH ;:lt.t:' \:'' 7a 0'
fir, le. '% I
The undersigned approves this Installation Report and,'4' bi��.:9 r4
Record Drawing on behalf of Mason County Public a' \l
Health:
5/717/0 7..p/00/,:.7 ,.. 1),
Signature of Environmental Health Specialist Date ccti, a (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILA$LE"f> 2 r R'V VIEW ON THE MASON COUNTY WE9 SITE Updated Be`note
TANK PUMPING REPORT
Site Name:
Location:16571E STATE ROUTE 106 Service Company:
Belfair p y�
Tax ID:222145000005 KITSAP SEPTIC PUMPING
u.. 5201 E.Hillcrest Dr.
Port Orchard,WA 98366
360.871.5258
Serviced:07/31/2024 by:Trenton Miller Submitted 0610512024 by:Darren Miller
Dump Loc.tlon:Bio•Rscyc ng Jurisdiction ID:222145000005
COMMENTS
Pumped for demo
TANK'Septic Tank-Z Compartment
Tank Pumped: YES
Tank Size(Gallons)(Number only,no text): 1000
Effluent level within operational limits(if NO explain in comments): YES
Total Gallons pumped from tank(Number only,no text): 1000
Effluent returning back into tank after pumping: NO
Tank depth below grade(inches): 10
Access Risers installed to grade(N/A if not present): N!A
Tank Construction Material: Concrete
Tank Condition Good: YES
Baffles in good condition(N/A if not present): YES
Effluent screen cleaned(N/A if not present): NIA
Effluent surfacing around site components(N/A if not checked): NO
Tank abandoned after pumping: YES
Were repairs made to the Tank or Tank Components?(if YES explain in comments): NO
Compartment 1 Scum accumulation(Inches,if other specify):
Compartment 1 Sludge accumulation(Inches,if other specify):
Compartment 2 Scum accumulation(Inches,if other specify):
Compartment 2 Sludge accumulation(Inches,if other specify):
r
,. 2?20?0
`IV�gL/NMF�
AeS sport inoicales cod eon o'raradonsrics Cl rho onsdu sow000 systum or Me Nov of v,s0.m no ways this report o yutWanteo or opera4ar or fofwe ponormanco.
Reportl0:743987 View pump reports online at www.onlinerme.com Page 1 of 1
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