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HomeMy WebLinkAboutSWG2023-00185 - SWG As-Built - 9/12/2025to c. CLEAIR FORM Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Perriit Number SWG 2023-00185 Parcel# 123194250030 App icant Name Gitlin Subdivision (Name/Div/Block/Lot) App icant Address 3459 W MARDAN DR LOT 3 OF LLS #95-14 -g City, State, Zip LONG GROVE IL 60047 Installer Name Jack Johnson co � aJ 1 161 Ridgetop Ct, Belfair WA Designer Name JIm Zimny Site Address 9 p r--- 7 INSTALLATION CHECKLIST tig w C=3 ® Full System Installation 0 Tank(s)Only 0 Drainfield Only 0 Repair ❑Other i____/.....; System Type Gravity Pretreatment Type 1 v >5 ft. from foundation? - - ❑ NIA ®YES NO C J >50 ft. from wells? - - 0 ® 0 >50 ft. from surface water? - - 0 III z 0 0 HCleanout between building and tank? - U Tank baffles present? 0 ® 0 H 24"access risers over each compartment?- - 0 ® ❑ a III ❑ Ili Effluent filter installed? 0 N Hagerman Septic tank capacity (working) 1250 gal Manufacturer C1 D-box water level and speed levelers used? - - 0 N/A ® YES ❑ NO �J O Manifold/D-box accessible from surface?- - IN 0 u. CO 2. Check valves installed? - - ® 0 ❑ th`Z 2 Transport Line Size 4" Schedule/Class 3034 Bedrooms installed (check one) 0 2 0 3 ❑4 0 5 ❑6 ❑Commercial/Other I >10 ft.from foundation?- - ❑ N/A li YES ❑ NO o >100 ft. from wells?- 0 II W >100 ft. from surface water? - - 0 IN 0 • • Er. >10 ft.from potable water lines?- - 0 ® ❑ Z > 5 ft. from property lines and easements?- - ❑ NE El d > 30 ft. from downgradient curtain/foundation drains? - - 0 II ❑ © Drainfield level and observation ports present - - ❑ 6 ❑ IR Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?- 0 II 0 Pump tank setbacks consistent with septic tank? - - ❑ N/A 0 YES 0 NO Y Pump tank capacity (flood) gal Manufacturer < 24" access riser(s) and accessible from surface?- - 0 0 0 t— a Alarm or Control Panel Installed? - - 0 0 0 m Control Panel equipped with Timer/ ETM/Counter- - ❑ 0 0 M a- Pump installed in 0 Bucket or 0 On Block or 0 Other a' Pump Make/Model ❑ Floats or 0 Transducer Q. a Tank draw down in/min Pump capacity gpm Squirt Height ft Pump on time Pump off time Daily flow set at gpd (Iodated 8121,231H Mason County OSS Installation Report pg. 2 Parcel# ABANDONMENT RECORD Were existing septic components abandoned as part of this project? 0 YES NO — If yes, please describe: __.---------___-. NO Were all components pumped out and property abandoned per WAC248-272A-0300?• - 0 YES RECORD DRAWING This.s a permanent record and must be eccurade and descriptive enough to re-locate In the need of maintsaance activities and future development. rypiad Record Drawings contain Drdn*enki b manifold oneMet,dt&layout.Sepecrprrrnp tank location.Noret arrow.reserve drarnrreki,existing and proposed buildings.location of wells.waloninec. µHIE,observation Cori s fiearntlts,anct other nra.n nklin a access mints Incomplete Record Drawings inlay create edddranal doiays In rm.d mstailatwn approval and misled pounds 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 ail State myself and Mason County Public Health and meet all and Mason County Codes. State and Masai County Codes I further certify that all information contained on this I further certify that all information contained on this 0fo • :nd aft herd Record Drawing is accurate. form and attached Record Drawing is accurate. ae a- )u -2 Si.si!Tfore of Installer Date I Printed Name of 5ignee ,�� r MASON COUNTY PUBLIC HEALTH %f /*} +r 44 'n+/ The undersigned approves this Installation Report aid iii # Record Drawing on behalf of Mason County Public .• ; LICENS•%DE,",'?_R Healthy s�x•:. .�� . , 9(411 4 c(747c--- Signature of Environment I Health Specialist Dale (stamp.signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Up".°a2"xna ..._...- A et � i ‘‘` 0 vi r(14'r \ (D N Cyr ' 6 p,\� 0 s-n t 3 ♦. y�TFR \ rr ao 7 ev t!t 0 d c J to rp = fD xi aC. r) -. m ro c fa. r — o z o . f w rn o 00 r j r -C W :;. x r l0 :ram '+ n N •� 0 z fD 0 to O to rt n W I -n O OD P. v O O rb Lc, . . ' Q. ,( 0 urn 0 . P pR �� ;' V� D SEP I Q� L MAS 2 ZD?5 ��� ; ro CN COUNTY Eh�R4NME r II o RE • T NTA�HEALTH �` 0 O O NJ • i t