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HomeMy WebLinkAboutSWG2025-00094 - SWG As-Built - 10/1/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2,..D23J. ono, `r Parcel # 326 l7 �& 12- Applicant Name j c-o, Mv S Subdivision (Name/Div/Block/Lot) Applicant Address 02? ('erg City, State, Zip � �� c� f W A. Installer Name C�c i e 13`"4'� '^ Site Address c .v a ,C. ,(ecL-^o►& .ti _ Designer Name vt• J (&)o..i 4--G INSTALLATION CHECKLIST ❑ Full System Installations (j�Tank(s)Only ❑ Drainfield Only El Repair ❑Other Ai i System Type LA 54.E o., fs er4,,1147 Pretreatment Type 7A- >5 ft. from foundation? - ❑ N/A ®YES El NO ❑>50 ft. from wells? - } B-111.41-g- • >50 ft. from surface water? - - ❑ Gil CI z ' ❑ FQ- Cleanout between building and tank? - i - -JUL-2-1- 2QT- - ❑ g U Tank baffles present? - ❑ I- 24" access risers over each compartme tg itlye_ ❑ hi ❑ a y ❑ W Effluent filter installed?- ❑ El Septic tank capacity(working) 62615 V.v.'- gal Manufacturer Sw 0 D-box water level and speed levelers used? - - ® N/A ❑ YES Ei NO o0 Manifold/D-box accessible from surface?- aC CImZ Check valves installed? - - o 2 Transport Line Size Z"( '41. ' 1�`a•Z"`-+AUSchedule/Class '- Bedrooms installed (check one) ❑ 2 El 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft. from foundation?- - ❑ N/A ® YES ❑ NOin ❑ >100 ft. from wells? CI 121 Li, >100 ft. from surface water? CI CI LT. ® CI>10 ft.from potable water lines?- CI ❑ z > 5 ft. from property lines and easements?- - ❑ © ❑ Q Et > 30 ft. from downgradient curtain/foundation drains? ❑ 0 CI level and observation ports present - - El❑ Graveless chambers or El Clean gravel used? (check one) ❑ Proper cover installed over drainfield?- - ❑ 0 Pump tank setbacks consistent with septic tank? - - ❑ N/A 0 YES ❑ NO 11 Pump tank capacity (flood) ll?57) gal Manufacturer CI Q 24" access riser(s) and accessible from surface? ❑ ® ❑ ~ Alarm or Control Panel Installed? a E Control Panel equipped with Timer/ ETM /Counter- ❑'""-A."^O^L D a Pump installed in ❑ Bucket ornn0 On Block or El Other L< n. Pump Make/Model <•I�^ �L' ( 0 Floats or ❑ Transducer - ��A a_ Tank draw down in/min Pump capacity / gpm Squirt Height tiA ft Pump on time Pump off time -- -- Daily flow set at -.-gpd Updated 8l2112018 Mason County OSS Installation Report pg. 2 Parcel# ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - ❑ YES NO If yes, please describe: �p El NO Were all components pumped out and properly abandoned per WAC246 272A 0300? ❑ YES y,,f 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.cleanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits. A +� pig ❑ 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 Drawing is accurate. form and attached Record Drawing is accurate. ::1,,, --6, "7 - 2,('2 S--'- iii Signature of Installer Date • 0 . i,, oldi \a1AAie— tx'lielrG"4.v, Printed Name of Signee l '�'' MASON COUNTY PUBLIC HEALTH 7 fC041 : 1 The undersigned approves this Installation Report ndI e: LICENSED SEDD DESIGNER i`�b1 • � � Record Drawing on behalf of Mason County Publ C F*a `i % �����_"`'a,�„�� Health: U T ` tt7.. Ear tkts�,�10 . _c, �01 1 �zc JO4 , Signature of Environmental alth Specialist Date 0,,i9 NTq4 H (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 821/2018 * w + 0 N4r . •x CJI a .3 *-4 4 7 i ,, LL i I t . ij -,\ \c- t ....,, 2 4- ,..$„, c:c.) . . ; a � e, - c kkt.-3A„„Ak, ,c4, t i * ,...,‘ a.. ti ' 1. (,? k Y l N Y. Q w x @I ' ''t n q.'' 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