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HomeMy WebLinkAboutSWG2024-00452 - SWG As-Built - 9/16/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2024-00452 Parcel # 519133100020 Applicant Name Donovan Nelson Subdivision (Name/Div/Block/Lot) Applicant Address 916 W Bulb Farm rd City, State, Zip Shelton, WA, 98584 Installer Name Mike R Fesenbek Site Address 916 W Bulb Farm RD Shelton WA Designer Name Justin Russell INSTALLATION CHECKLIST El Full System Installation ❑ Tank(s)Only ❑ Drainfield Only ❑ Repair ❑ Other System Type new ADU 2-bedroom pressure system Pretreatment Type >5 ft. from foundation? - ❑ N/A a YES ❑ NO >50 ft. from wells? - 0\-- 12- ❑ ❑ Y• >50 ft. from surface water? - - El [U III < Cleanout between building and tank? --:a - - �P � - El0 ❑ U Tank baffles present? - S - - ❑ ❑■ ❑ h 24" access risers over each compartment.- - �- X ❑ a W Effluent filter installed?- 'al- - - ❑ 0 ❑ cn Septic tank capacity (working) 1200 gal Manufacturer Sound Precast o D-box water level and speed levelers used? - - 1 N/A ❑ YES ❑ NO DOJ Manifold/D-box accessible from surface?- - ElI ill co Check valves installed? - - 0 ❑ ❑ th Q 1.5 Schedule/Class 2 Transport Line Size Bedrooms installed (check one) 0 2 1113 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft. from foundation?- - ❑ N/A ID YES ❑ NO o >100 ft. from wells?- - ❑ CI ❑ W >100 ft. from surface water? - - ❑ ❑� [1] u.. >10 ft. from potable water lines?- - ❑ ill ❑ Z > 5 ft. from property lines and easements?- - ❑ El ❑ £ > 30 ft. from downgradient curtain/foundation drains? - - ❑ I ❑ 0 Drainfield level and observation ports present ❑ ■❑ Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?- - ❑ 0 ❑ Pump tank setbacks consistent with septic tank? - - ❑ N/A ❑■ YES ❑ NO `-L Pump tank capacity (flood) 1200 gal Manufacturer Sound Precast < 24" access riser(s) and accessible from surface?- - ❑ 0 ❑ ~ Alarm or Control Panel Installed? - - ❑ © ❑ a E Control Panel equipped with Timer/ETM/Counter- - ❑ El ❑ 0 CI- Pump installed in ❑ Bucket or 0 On Block or ❑ Other a Pump Make/Model Liberty L30 III Floats or ❑ Transducer Tank draw down 2 in/min Pump capacity 27.72 gpm Squirt Height 5 ft Pump on time 1 Pump off time 4.5 Daily flow set at ,P5 gpd Updated 8f21/2018 Mason County OSS Installation Report pg. 2 Parcel# 519133100020 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 ❑ 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: Drainrield&manifold orientation&layout,Septic/pump tank location,North arrow,reserve draintiield,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. ❑ Record Drawing Attached CERTIFICATION OF INSTALLATION INSTALLER DESIGNER/ ENGINEER I 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 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. 9/7/2025 Signature of Installer Date •. Mike R Fesenbek ' rl f/ 1 Printed Name of Signee y//v/2i- MASON COUNTY PUBLIC HEALTH �'4:-• 4-' JJ11 The undersigned approves this Installation Report and 1:e 22030834 7!1 /: JUSTIN 5 RUSSEU Record Drawing on behalf of Mason County Public Ni&• CE Ns,DI SI R Health: I/ /z Can Signature of Environmental ealth Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8l21/2018 1 ^ V z C • a. a 0y(pV a N O S(V o N = W W O i > F Y < K Z•- 0r U. z " WO i Z I-N " R >a $ O a < 1 1321.6I' o< b N 3 1. 3 WATER _-7 �_ - a i; 2G 1-r •\ W- j m " Q. w w W r ?Cl . 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