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Home My WebLink AboutSWG2023-00363 - SWG As-Built - 9/16/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2023-00363 Parcel# 222125800034 Applicant Name Stephens Cynthia P&Jeffery Subdivision (Name/Div/Block/Lot) Applicant Address 3911 N25th St,Apt 204 City, State, Zip Tacoma Wa 98406 Installer Name Aaron Shumaker Construction Site Address n6ib i 1 51'Z-- to c Designer Name Bob Paysse INSTALLATION CHECKLIST ® Full System Installation 0 Tank(s)Only ❑Drainfield Only 0 Repair 0 Other S stem Type Oscar x02 Prefrqatment Type Osacar Y >5 ft.from foundation? - - 63 f�{� Y--`4' 0 NIA ®YES ❑ NO >50 ft.from wells? - -,+�11n-+1— --\II , ❑ © 0 z >50 ft.from surface water? -- - -- 1 2 �Z�-y r4 ❑ ® ❑ FQ- Cleanout between building and tank? - - It ❑ ® El V Tank baffles present? - ` ❑ M ❑ G~. 24"access risers over each comport y---- - -- ❑ ® ❑ UJ N Effluent filter installed?- - ® 0 0 Septic tank capacity(working) 1250 gal Manufacturer Hagermens D-box water level and speed levelers used? - - ® N/A 0 YES 0 NO OO Manifold/D-box accessible from surface?- - El 0 DOZ Check valves installed? - - ® 0 0 C< 2 Transport Line Size 1" Schedule/Class 40 Bedrooms installed (check one) 2 23 ❑4 ❑5 ❑6 ❑Commercial/Other >10 ft.from foundation?- - ❑ N/A Ni YES ❑ NO C1 >100 ft.from wells?- - 0 ® 0 W >100 ft.from surface water? - - 0 ❑ on >10 ft.from potable water lines?- - ❑ ® ❑ Z >5 ft,from property lines and easements?- - 0 I ❑ IR >30 ft.from downgradient curtain/foundation drains?- - 0 ® ❑ 0 Drainfield level and observation ports present - - ❑ ® 0 0 Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?- - ❑ I 0 Pump tank setbacks consistent with septic tank?- - 0 NIA ® YES ❑ NO • Pump tank capacity(flood) 1250 gal Manufacturer Hagermens < 24"access riser(s)and accessible from surface?- - ❑ I 0 H a Alarm or Control Panel Installed? - - 0 0 El • Control Panel equipped with Timer/ETM I Counter- - 0 0 0 li Pump installed in ❑ Bucket or 0 On Block or 0 Other rPump Make/Model pf 2005 ❑ Floats or ❑ Transducer 1 d Tank draw down 1.5 in/min Pump capacity_ 30 gpm Squirt Height N/A ft Pump on time P Pump off time Daily flow set at qpd Updated 821,2018 Mason County OSS Installation Report pg. 2 Parcel# 222125800034 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - 0 YES 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: Oraini*Id&manifold orientaton&layout,Sept chump tank location North arrow,roservo droinfiield,ex6sting and proposed buildirgs.location of wells.waterlines. wells,observation ports,cteanouts,and other maintenance access poirts. Incomplete Record Drawings may create additional delays in final installation approval and related permits. li 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 I further certify that all information contained on this I further certify that all information contained on this form and attached Record is accurate./ form and attached Record Drawing is accurate. ��d/zv�s Signature f Installed Date p� 1 Ns Printed Name of Signee 1/ '•.,Ilk c o:w„� A MASON COUNTY PUBLIC HEALTH 1,1., 11, �r The undersigned approves this Installation Report and 111;. r�aE�1D0317Y•SE Record Drawing on behalf of Mason County Public 1 •• •• •• •• Health: EXPIRES L \i/1 °I(if 6(--- -- Signature of Environme tat Health Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8r2112018 N N N N. N` BIG CEDAR / „ . / HOOD CANAL \\ a- 3 BEDROOM OSX-360-5 `\ �Qfs, PRIMARY 13X35=455 SOFT /:„... N/ (W/ SETBACK WAIVER) N r� // SD RESERVE 100% ` / - . p . i , ,..,11itC-/ ,,,., * ' .447, Ak 'X -,... :\-,4" --i . .4 ,./ X02 TANKS `./'/ \// V� zz212-ss-0003� (W/ WAIVER) �/�Oi` )'. \ .� / •/ / \•\ OJT AREA / . , / ,� •• / / ` '�� (POOR SOILS) / / / - / `",, T � / // 10' FOUNDATION \ � )9 SETBACK EXISTING / .,. ..\,.. / DRAINFIELD / .` \ \ PER RECORDS \ / EXISTING HOME , \\\ / TO BE REPLACED / �� V\` / N A.PPIbv D / // �� N �� '/ r 1 �`.�p • // �T 3 O MASON CONTYSEP ENVIRON ENTAL HEALTH `, RET / `(-' EXISTING YN O ;`'� SEPTIC TANK N '� / PER RECORDS \ 77712-58-00034 1 J/ / N / �, 0 / PUMP OUT& ABANDON 0`` N / � EXISTING TANK AND DRAINFIELD � Q. • „ ATTIME OF INSTALLATION . Ni (-1 :p:T :�, �. ci' SS0317 9\.,gAnse . AV 1 I O-7/5 L y r : !'44-�IVr ''"y,-Y AN ASBUILT/INSTALL SIGNOFF FEE WILL E>"1n=� BE CHARGED AT TIME OF INSTALLATION PIONEER DIGGINC, INC PAR EL#17??l $-000 TEST . TEST I: iSH 2 0-37 CH 0-27 $ 37+'IIlA. 27+TILL SEPTIC DESIGNS ADDRESS: 17681 STATE ROUTE 106 3083E MASON BENSON RD. -GRAPEVIEW,WA 98546 DESIGNER: ROBER-T H.PAYSSE Ot3GLM1Elt TNY p NOT A SURVEY.REFEREC INCLUDE APPLICANT/COUNTY PROVIDED PUTS OR SURVEYS FIELD MEASURESENTS AND COUNTY S/S DESONINTENDED FOR SEPTIC �(�f PURPOSES ONLY PROPOSED DEVELOPMENT MAY BE SUBJECT TO OTHER OFFICE 36(}4261803 FAX 36l}427 2353 SHEET: SITE PLAN SCALE P�=20 OEPARTMENTIAGENCV REVIEW DESIGNER NOT RESPONSIBLE FOR SETBACKS UNRELATED TO SEPTIC COMPONENTS.