HomeMy WebLinkAboutSWG2024-00166 - SWG As-Built - 10/1/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG ? 1..M C)hW)L.0 Parcel # Y2 L2-t-t- 1u- o oo-Sv
Applicant Name ca0 '�QO' `bVV.\ Subdivision (Name/Div/Block/Lot)
Applicant Address P `bt _ m
City, State, Zip c,V(11 . f\l( t 9 co 0 Installer Name \kdW, Ifi•I rS
Site Address k\,� E lar ,'R1a, Designer Name (60.'(Y\ C--\lr
INSTALLATION CHECKLIST
3 Full System Installation 0 Tank(s)Only 0 Drainfield Only 0 Repair 0 Other 1 Or
System Type - -
Pretreatment Type (U(1u41"r,�r &U1C.50647t (Jr
>5 ft.from foundation? - - - - - ❑NIA 10 YES ❑ NO
>50 ft. from wells? -k{ll� ❑ ❑
Y >50 ft.from surface water? - 0 0
Zand tank? - - -SEE Z 4 ZO.25- ❑ j ❑
• Cleanout between building ❑
U Tank baffles present? ❑
I— 24"access risers over each compartment'By 0 0
W Effluent filter installed? 0 W 0
Septic tank capacity(working) Vino gal Man
ufacturer Pais\-
cn,
-....3• D-box water level and speed levelers used? - - ❑ N/A El YES
El
NO
DO Manifold/D-box accessible from surface?- - 0 ❑ V
'4.
0? Check valves installed?
0Q - �1(`h Schedule/Class S(h LID 0A:tar dl )094'
2 Transport Line Size i J
Bedrooms installed (check one) 0 2 113 3 0 4 0 5 ❑6 0 Commercial/Other
>10 ft. from foundation?- - ❑ NIA 0 YES 0 NO
• >100 ft. from wells? ❑ 6 ❑
W >100 ft. from surface water? - 0 0
El
LT >10 ft.from potable water lines?- 0 CI—• > 5 ft. from property lines and easements?- -
IX > 30 ft.from downgradient curtain/foundation drains? - - El El
• Drainfield level and observation ports present - - 0 Ukba 0
0 Graveless chambers or [ Clean gravel used? (check one) 0 0
Proper cover installed over drainfield?
Pump tank setbacks consistent with septic tank? - - ❑ N/A 1` YES
NO
• Pump tank capacity(flood) `1 gal Manufacturer 1C\\kl
--
< 24" access riser(s)and accessible from surface?- - 0 4/ El~ Alarm or Control Panel Installed?
2 Control Panel equipped with Timer/ETM/Counter
m
0- Pump installed in ❑ Bucket or [g On Block or ❑ Other
a \-.., C\- 1 ❑ Floats or LI Transducer
• Pump Make/Model V�,v�- 't t� S ft
a_ Tank draw down Z in/min Pump capacity L-f6j gpm Squirt Height
a
-2 -r n„, Pump off time V A.,1 Daily flow set at gpd
Pump on time Updated821/2018
Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - 0 YES 0 NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - El YES 0 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.
[ Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER!ENGINEER
I certify that I 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 nd attached Record Drawing is accurate. form and attached Rec.r• era•ing is accurate.
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S ature o4-1
er •'.. -, 1
Date ••
) oe1 - �/ ,tea : ''
Printed Name of Signee �6 /$ ..,...� •/.,rc')
1.
MASON COUNTY PUBLIC HEALTH d't.^'. ' of. • 1 •1.
C� ,-,•
The undersigned approves this Installation Report and, 0� $. ADAPA JuNtlNTFR / �#�
Record Drawing on behalf of Mason unty PG Iff, g •`i. Z ��='4 '
Healt NTyFN�/ �/n,. '''1,0,-‘ k" ••:F4...; 0 i.1,10/(/ ZO If-
ray
Signature of Environmental Health Specialist Date ¢' (stamp, signature and date)
Updated&2tr20t8
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE
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