HomeMy WebLinkAboutSWG2025-00233 - SWG As-Built - 9/12/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPUCANTI PERMIT INFORMATION
Permit Number SWG 'ZD ZS— 0023 3 Parcel# Z2.Zoc)y-H 11'o e 3 l
Applicant Name f ifi•Keect. 7-Son n r/ P,4,tt-4(41/subdivision (Name/Div/Block/Lot)
Applicant Address Z?O3 F_ lO1 c K8rf n II
City, State, Zip (k-e k tO r (1O4 Cr(4 q Installer Name Toy IA\ C- L 5 k
Site Address 290 t ts [161c-will Designer Name (),..1 K/40,3 Y\
INSTALLATION CHECKUST
❑ Full System Installation It: ank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type £9 / 'Vt retreatment Type N 0 e-
>5 ft.from foundation? - --- 0 NIA [YES 0 NO
>50 ft.from wells? - 0%1 -_ ❑ �V ❑
Z >50 ft.from surface water? ----- _ ❑ ❑
Q Cleanout between building and tank? ,-I-----t-V-- - ❑ S CI
✓ Tank baffles present? - \ $.- �`-;trit--- - ❑ _74 ❑d24'access risers over each compartment?,' Sri.--- ❑ ❑
W Effluent filter installed?- . � - 0 (�'' IDu) r"
Septic tank size 250 gal Manufacturer T N L4--r6I{11)
9 D-box water level and speed levelers used? - - ❑ N/A 0 YES ❑ NO
OLL Manifold/D-box accessible from surface?-- -- -ici ❑ El El
mz Check valves installed? - -- ---- - ❑ ❑ ❑
(aQ
2 Transport Line Size Schedule/Class
Bedrooms installed (check one) ❑ 2 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A YES ❑ NO
0 >100itt from wells?- - ❑ ❑
W >100 ft.from surface water? - - ElElu. >10 ft.from potable water lines?- �-}/� - 0 El
>5ft.from property lines and easements?----- ��" � El (� ❑
>30 ft.from downgradient curtain/foundation drains? - g-- kiElDrainfield level and observation ports present - - ❑ 0
0 Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - 0 ❑
Pump tank setbacks consistent with septic tank?- - ❑ NIA 0 YES ❑ NO
Z• Pump tank size gal Manufacturer
< 24"access riser(s)and accessible from ce?- - ❑ 0 ❑
a Alarm or Control Panel Installed? -- -- - -- - ❑ ❑ ❑
j Control Panel equipped with Ti /Coun - - El El ID
a Pump installed in 0 Bucket o ❑ On Block or 0 Other
a• Pump Make/Model ❑ Floats or ❑ Transducer
d Tank draw down in/min Pump capacity qpm Squirt Height ft
Pump on time Pump off time Daily flow set at qpd
Updated 9¢1QO18
Mason County OSS Installation Report pg. 2 Parcel# 2 Z (4 E,R oo 3 (
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - try= NO
If yes, please describe: C v v S H fL U F/Ll.E>fJ
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - BYES NO
RECORD DRAWING
This Is a permanent record and must be accurate and descriptive enough to re.loca1e la the need of raalakenance activities and whin dwMop.. e. Typical Record
Drawings carain: Drainneld&nw Id aiedakan&layout.Septic/pump tank krcalion,North arrow,reserve draintield,existing and proposed tnildlrgs.location dwells,nesberirnes,
weds,observation ports,deanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in tine)installation approval and added perm.
.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 deared/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
1 fu tin all information contained on this I further certify that all information contained on this
fo and Drawing is accurate. form and attached Record Drawing is accurate.
0 2-
Signs of 1 leer Date
1 1N
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
"by' I Ct1\2f2
Signature of Environmen Health Specialist Date
(stamp, signature and date)
THIS FORM MAY BE S=A m en AND AVAILABLE FOR PUBLIC VfEWdal TIE MASON COUNTY WEB SITE uPdm"aa+ame
RECORD IN
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