HomeMy WebLinkAboutSWG2025-00319 - SWG As-Built - 9/11/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2O7Sj� O0-3 Parcel # 322187500440
Applicant Name Kitsap Septic Pumping INC Subdivision (Name/Div/Block/Lot)
Applicant Address P.O Box 809
City, State, Zip Manchester WA 98353 Installer Name Darren Miller
Site Address 390 Ne Rendsland Creek Rd Designer Name
INSTALLATION CHECKLIST
0 Full System Installation ®Tank(s)Only ❑ Drainfield Only ❑ Repair ❑Other
System Type Pretreatment Type
>5 ft. from foundation? ---- - 1,1,,L-,� - -s,-,- - - - .- ❑ N/A EYES ❑ NO
>50 ft. from wells? - ��1 k., - - - - ❑ ❑
Z >50 ft. from surface water? - - -.., _ 1��6. J._ 5 ❑ ❑
HCleanout between building and tarli6 ____ __ ❑ 0
U Tank baffles present? - _ - Lig ❑
(Ell 0
a 24"access risers over each com ar Y•, ❑
W Effluent filter installed?- - 0 ❑ 01
Septic tank capacity(working) ilbei gal Manufacturer
9 D-box water level and speed levelers used? - - El N/A ❑YES ❑ NO
oO Manifold/D-box accessible from surface?- - CI ❑
m— Check valves installed? - ❑ 0 0
caQ
E Transport Line Size Schedule/Class
Bedrooms installed (check one) ❑ 2 KI.3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- •- ❑ N/A ❑ YES ❑ NO
0 >100 ft. from wells?- - ❑ ❑ ❑
W >100 ft.from surface water? - - ❑ ❑ ❑
>10 ft. from potable water lines?- - 0 ❑ ❑
Z > 5 ft.from property lines and easements? ❑ 0 ❑
> 30 ft.from downgradient curtain/foundation drains? -CI
- ❑ 0 0
Drainfield level and observation ports present - - ❑ 0 ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - 0 ❑ El
Pump tank setbacks consistent with septic tank? - - ❑ N/A Ei YES ❑ NO
• Pump tank capacity(flood) 1v06 gal Manufacturer
Z
< 24"access riser(s)and accessible from surface?- - !;� ❑ ❑
aAlarm or Control Panel Installed? - - ,►': ❑ ❑
2 Control Panel equipped with Timer/ ETM/Counter- - ❑ 0 RI
m
a Pump installed in ❑ Bucket or IN On Block or ❑ Other
a. Pump Make/Model L;bec k-i 7-a0 [ Floats or ElTransducer
d Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 8/21/2018
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Mason County OSS Installation Report pg. 2 Parcel# 322187500440
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - gj YES No
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - CO YES 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.
[KJ Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that I 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 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
l 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.
4i/ZZ(Z5r-
Signature of Installer Date
Darren Miller
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
Signature of Environme tal Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated W2tr2018
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