HomeMy WebLinkAboutSWG2025-00071 - SWG As-Built - 9/15/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2025-00071 Parcel # 32224-51-02022
Applicant Name LYNDEN COTHARY Subdivision (Name/Div/Block/Lot)
Applicant Address 9991 NE NORTH SHORE RD
City, State, Zip BELFAIR, WA 98528 Installer Name LOGAN SPEARS
Site Address 9991 NE NORTH SHORE RD Designer Name ALEX PAYSSE
INSTALLATION CHECKLIST
0 Full System Installation E Tank(s)Only ❑ Drainfield Only ❑ Repair ❑ Other
System Type PUMP TO GRAVITY Pretreatment Type
>5 ft. from foundation? - - ❑ N/A ■❑ YES ❑ NO
>50 ft. from wells? - - ❑ El ❑
Z >50 ft. from surface water? - - ❑ 00
HCleanout between building and tank? - - ❑ 0 ❑
o Tank baffles present? - - ❑■ �( VA\l1/r ❑
H 24" access risers over each compartment?- - ❑ ❑
a �1
W Effluent filter installed?- - ❑ ❑■ ❑
u)
Septic tank capacity (working) 1500 gal Manufacturer ROTH
0 D-box water level and speed levelers used? - - ElN/A 11 YES ❑ NO
><O Manifold/D-box accessible from surface?- - ❑ IN ❑ al o
m- Check valves installed? - - ❑■ ❑ ❑ "C m
DQ
2 Transport Line Size 4" Schedule/Class 3034
o N
Bedrooms installed (check one) 0 2 ❑ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other co
>10 ft. from foundation?- - ❑ N/A 0 YES E N4 o
0 >100 ft. from wells?- - ❑ ❑■ ❑ j
—1 >100 ft. from surface water? - - ❑ El ❑ I : z" C` 7
W
LI >10 ft. from potable water lines?- - ❑ ❑I 0
Q Z > 5 ft. from property lines and easements?- - ❑ 0 0
Q > 30 ft. from downgradient curtain/foundation drains?- - ❑ In
Drainfield level and observation ports present - - ❑ II 0
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ 0 ❑
Pump tank setbacks consistent with septic tank? - - 0 N/A ❑ YES ❑ NO
Pump tank capacity (flood) gal Manufacturer EXISTING SOLIDS HANDLING PUMP
< 24" access riser(s) and accessible from surface?- - 0 ❑ ❑
F-
a Alarm or Control Panel Installed? - - ❑ ❑ ❑
2 Control Panel equipped with Timer/ETM /Counter- - ❑ ❑ ❑
D
a Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
a Pump Make/Model ❑ Floats or ❑ Transducer
ii
a 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
Parcel # 32224-51-02022
Mason County OSS Installation Report pg. 2
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - [] YES 0 NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - YES El 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.deanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
Q Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ ENGINEER
1 certify that 1 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 all State myself and Mason County Public Health and meet all
and Mason County Codes. State and Mason County Codes
1 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.
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i n tune of Inst !IS er Date 7(7/( A. I f
L. v c art 5p.ea kf 1
Printed Name of Signee '''^'."' 1
MASON COUNTY PUBLIC HEALTH % n: 41,
The undersigned approves this Installation Report and ,; '+` Ez Lt)llS pA •,/1
Record Drawing on behalf of Mason County Public r '
Health: q�r� F"� a.
kErl,billl WI
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 Upnatec a:2t'2tti,
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TRANSPORT LINE \\ NO
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AS PER DESIGN \ 11 f ♦S AS PER DESIGN
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SEP 15 2025 •
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RECORD DRAWING ��.4. . �� ` �`
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`\ CUSTOMER: LYN COTHARY TEST HOLE 1: TEST HOLE 2: TEST HOLE 3: N
�: 1 0-19 gls 0-24 gls 0-12 gls A \1
I I PARCEL:32224-51-02022 30*m otu 24+comp 12-30 gms
ALPINE SEPTIC 0 roots 2a 30r mot30omp
—DESIGN. LLC—
SITE:9991 NORTH SHORE RD roots 3D Dots @ 30
ALEX L PAYSSE,DESIGNER SHEET:ASBUILT SCALE: 1"=30' DISCLAIMER: THIS 13 NOT A SURVEY. REFERENCES INCLUDE.APPLICANT/COUNTY PROVIDED PLATS OR
3089 E MASON BENSON RD SURVEYS,FIELD MEASUREMENTS AND COUNTY GIS. DESIGN INTENDED FOR SEPTIC PURPOSES ONLY.
GRAPEVIEW WA 98548 PROPOSED DEVELOPMENT MAY BE SUBJECT TO OTHER DEPARTMENT/AGENCY REVIEW. DESIGNER NOT
380 507.1546 IO 10 5 I RESPONSIBLE FOR SETBACKS UNRELATED TO SEPTIC COMPONENTS