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Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2025-00269 Parcel # 32027-31-90002
Applicant Name B-LINE CONST C/O LENOIR Subdivision (Name/Div/Block/Lot)
Applicant Address 2971 E PHILLIPS LK LP RD
City, State, Zip SHELTON, WA, 98584 Installer Name B-LINE CONST
Site Address 600 SE TJ LANE Designer Name CINDY WAITE
INSTALLATION CHECKLIST
❑ Full System Installation ❑Tank(s) Only 4 Drainfield Only ❑ Repair ❑Other
System Type GRAVITY Pretreatment Type
>5 ft. from foundation? - El N/A 0 LiYES ❑ NO
>50 ft. from wells? - - - � , _ - _ ❑ ❑ CI>50 ft. from surface water? - - - - - ,'1 .. CS
t
FQ- Cleanout between building and tank. -- (j.1.L L5_ - - - El ❑ ❑
V Tank baffles present? - - - - _ - ❑ 0 0
a24" access risers over each compartm-nt?- - - - - _ _ - 0 0 ❑
W Effluent filter installed?- By _ 0 ❑ 0
N
Septic tank capacity (working) 1200 gal Manufacturer
o D-box water level and speed levelers used? - - ❑ N/A 101 YES ❑ NO
oO Manifold/D-box accessible from surface?- - ❑ II ❑
Z Check valves installed? -
m - 0 ❑ ❑
OQ
2 Transport Line Size 4" Schedule/Class 3034
Bedrooms installed (check one) ❑ 2 ■❑ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation? - - ❑ N/A ® YES ❑ NO
>100 ft. from wells? ❑ ® ❑
W >100 ft. from surface water? - - 0 MI
!i >10 ft. from potable water lines?- - ❑ ® ❑
Z > 5 ft. from property lines and easements?- ❑ El ❑
li > 30 ft. from downgradient curtain/foundation drains? - ❑ inCI
Drainfield level and observation ports present - -
❑ U] ❑
II ❑ Graveless chambers or MI Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ II ❑
Pump tank setbacks consistent with septic tank? - - ❑ N/A ❑ YES ❑ NO
Pump tank capacity (flood) gal Manufacturer
I Z
< 24" access riser(s) and accessible from surface?- - CI CIa Alarm or Control Panel Installed? - - ❑ ❑ ❑
2 Control Panel equipped with Timer/ ETM /Counter- - ❑ ❑ ❑
m
n- Pump installed in ❑ Bucket or ❑ On Block or ❑ Other •
0.
2 Pump Make/Model ❑ Floats or ❑ Transducer
dTank 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# 32027-31-90002
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES is NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - 0 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.
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0 Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ ENGINEER
1 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
I 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.
73- z.5--
Sig ture of Installer Date
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Print&Name of Si ee pleA MASON COUNTY PUBLIC HEALTH -��' . • .'• 3�,y„z
The undersigned approves this Installation Report and o2 irai . a TE ��
Record Drawing on behalf of Mason County Public u. D uEstc;NER ��,
Health: ExeiRss.onto,
°4<<.!"h
Ulf\{wile*
Signature of Environmental Health Specialist Date
(stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated emizots
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