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HomeMy WebLinkAboutSWG2023-00503 - SWG As-Built - 9/25/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2023-00503 Parcel # 32021-53-01044 Applicant Name Li Xia Ye Subdivision (Name/Div/Block/Lot) Applicant Address 3990 129TH PL SE, APT C202 SHORECREST ADD REPLAT BLK: 1 LOT: 44 City. State, Zip Bellevue, WA 98006 Installer Name Arrow Excavating Site Address 121 E Shoreline Ln Designer Name Arrow Septic Designs INSTALLATION CHECKLIST 0 Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair ❑ Other System Type Shallow Pressure Trench • -treatment Type NuWater BNR-500 >5 ft. from foundation? - - �( - - ❑ N/A ❑■ YES El NO >50 ft. from wells? ,t�, -�� - ❑ 0 ❑ u Z >50 ft. from surface water? - - �, -�Oj - ❑ 0 ❑ < Cleanout between building and tank?I— ��-, ❑ ❑� ❑ o Tank baffles present? - , ❑ ❑I ❑ E— 24" access risers over each compartme t?- - ❑ I ❑ W Effluent filter installed?- �'t - ❑ El 0 N - Septic tank capacity (working) NuWater 500 gal Manufacturer Infiltrator O D-box water level and speed levelers used? - - ❑ N/A ❑ YES 0 NO DO Manifold/D-box accessible from surface?- - ❑ II El m- Z Check valves installed? - ak frww-le - - - - - ❑ 0 ❑ O Q 40 2 Transport Line Size 2 inch Schedule/Class Bedrooms installed (check one) 0 2 ❑ 3 ❑4 El 5 ❑6 ❑Commercial/Other >10 ft. from foundation?- - ❑ N/A ❑■ YES ❑ NO 0 >100 ft. from wells?- - ❑ ❑■ ❑ W >100 ft. from surface water? - - ❑ 0 ❑ LL >10 ft. from potable water lines?- - ❑ 0 ❑ z > 5 ft. from property lines and easements?- - CI 0 Ela cc > 30 ft. from downgradient curtain/foundation drains? - - ❑ It El o Drainfield level and observation ports present - - ❑ I El ® Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?- - ❑ El ❑ Pump tank setbacks consistent with septic tank? - - ❑ N/A 0 YES ❑ NO • Pump tank capacity (flood) 1,060 gal Manufacturer Infiltrator < 24" access riser(s) and accessible from surface?- - ❑ 0 El ~ Alarm or Control Panel Installed? - - ❑ © ❑ a 2 Control Panel equipped with Timer/ETM/Counter- - El II ❑ D d Pump installed in ® Bucket or ❑ On Block or ❑ Other a'• Pump Make/Model Liberty 253 El Floats or © Transducer a Tank draw down 2.2 in/min Pump capacity 55 gpm Squirt Height 40 ft Pump on time 1 minute Pump off time 6 hours Daily flow set at 240 gpd ,:!,t,,c s,21.2o Mason County OSS Installation Report pg. 2 Parcel# 32021-53-01044 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - El YEs 171 NO If yes, please describe: Were all components pumped out and properly abandoned per WAC246-272A-0300? - - El 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. ()rant eld&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 Record Drawing Attached CERTIFICATION OF INSTALLATION INSTALLER DESIGNER/ ENGINEER I certify that l 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 l further certify that all information contained on this form and att ed Record wi is ate. form and attached Record Drawing is accurate. /8'/ ature of Installer Date • os L5,04, Printed Name of Signee of er•s.**1). Of- . A • v` MASON COUNTY PUBLIC HEALTH � � `-) ! � ��h • The undersigned approves this Installation Report and `saa t Record Drawing on behalf of Mason County Public c L'fC PAULA' i �1 JOY?JOHNSON ` GN>rft"�-,•� Health: (�,,� Exp 15� om, „►' I 111 �`( o -ZS 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 i4ccateda2'231s &a' SC/AL, : - a.o i o 2.0 3o o AO APPROVED j L�a, 1, SEP 25 2025 3(0, PA Ez_# 43z0u-53-OtO 38 • MASON COUNTY ENVIRONMENTAL HEALTF _1 ..1 E &-toRELINE Lt.i RET i.4.igh we've Lino i a ^ a � i.9 n '' ctNS SAt t7 , p 7 42 Ttt1T 5112u( C R .�� co � c ` 3v, SL t Q-oo"cS (2;C3 iN ICI' Se), DE-512t5' r . ZSg 7.7M.'`.71..1 , r(o) 2,t25 )cc.,3 7 -s•et-,,r,.;,4.. .r.?H-1-124‘ / . woS - Q ® © >` ?9 / a i Km ou► — — Q Audio-visual Alarm i ' o )C o n Cleanout I .4.i ` tb—f� O3 NuWater B1V12-500 ATL'Tank Q� R II O 1.000 Gallon Puma Chamber O Valve Control Box c.f.i., f •J G T V - L S xot2L_tNE . •L_N. :►t • ir); I ..., , . . G,i ,0,,,,--c-\-- . Sr() 15,v,9-e-szr-Aa, .." s 14-) ° .4.,v .!5), 1 . . o��/� S • 519.340 1 QA c C �f!^ ;67 PAULA JOY JOHNSON.. sum 11 %° -CO -2.4"--