HomeMy WebLinkAboutSWG2023-00452 - SWG As-Built - 10/9/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2023-00452 Parcel # 221055100020
Applicant Name Nathanael Lea Subdivision (Name/Div/Block/Lot) �A7.
Applicant Address 12055 Baneer Rd Se OCT City, State, Zip Port Orchard, WA 98359 Installer Name Kat Trax 0 9��S
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Site Address 3870 E Mason Lake Drive W Designer Name Apex RF'fFO
INSTALLATION CHECKLIST
❑ Full System Installation ®Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type Nuwater to Gravity Pretreatment Type i S—ov
>5 ft. from foundation? - - ❑ N/A ®YES ❑ NO
>50 ft. from wells? - - ❑ ® ❑
Z >50 ft. from surface water? - - ❑ III CI
HCleanout between building and tank? - - CI II
U Tank baffles present? - - ❑ IN ❑
d24" access risers over each compartment?- - ❑ II El
W Effluent filter installed?- - If ❑ 0
co
Septic tank capacity (working) 1250 gal Manufacturer Hagerman/Nuwater
CI D-box water level and speed levelers used? - - 111 N/A ❑ YES El NO
DOJ Manifold/D-box accessible from surface?- - . ❑ ❑
o0Z Check valves installed? - - ® ❑ ❑
GQ
2 Transport Line Size may;Skiy� Schedule/Class
Bedrooms installed (check one) l ❑ 2 ❑3 ❑4 0 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ® N/A ElYES ❑ NO
>100 ft. from wells?- 1./.54.µ.Y - ❑ ❑
W >100 ft. from surface water? - - 11 CI CI
LL >10 ft.from potable water lines?- - II ❑ ❑
Z > 5 ft. from property lines and easements?- - 0 ❑ ❑
d > 30 ft. from downgradient curtain/foundation drains? - - 0 ❑ ❑
Drainfield level and observation ports present - - in ❑ El
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - it ❑ ❑
Pump tank setbacks consistent with septic tank? - - ® N/A ❑ YES ❑ NO
Pump tank capacity(flood) gal Manufacturer
Q24"access riser(s)and accessible from surface?- - ® ❑ ❑
H
a Alarm or Control Panel Installed? - - NE ❑ ❑
2 Control Panel equipped with Timer/ ETM/Counter- - El ❑ ❑
n
EL Pump installed in ❑ Bucket or El On Block or ❑ Other
M Pump Make/Model ❑ Floats or ❑ Transducer
0.
a Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time_ Pump off time Daily flow set at gpd
Updated 8/21/2018
Mason County OSS Installation Report pg. 2 Parcel# 221055100020
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - El YES El NO
If yes, please describe: Decommisioned existiing tank
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - 0 YES 0 NO
RECORD DRAWING
This is a permanent record and must bo 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 dranfield.existing and proposed buildrgs.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 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 and a ed Record Drawing is accurate. form and attached Record Drawing is accurate.
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gnature of Installer Date 1Q irk:•�:,
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Printed Name of Signee A P:7ive � S,,I
MASON COUNTY PUBLIC HEALTH :r.l i,l�-
I � .
The undersigned approves this Installation Repo/lLTd >�o•Lawrence M$3Purdum••. ��',,,
Record Drawing on behalf of Mason/ y Pub i 1 ff 1 - LICENSED DESIGNER ',,y
Hea cooNTyFN U2S EXPIRES 2/25/`l, v�,
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0 75 op,x. ,
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of Envi onmental Health Specialist Date �rH
g p (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8:21+2e•8
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TANK PUMPING REPORT
Sea Name:
Locatlon:3870 E MASON LAKE DR WEST Service Company:
Grapeview p y�
Tax ID:221055100020 KITSAP SEPTIC PUMPING
us.: 5201 E.Hillcrest Dr.
Port Orchard,WA 98366
360.871.5258
Serviced:04/10/2025 by: Ross Miller Submitted 04/14/2025 by:Angle Miller
Dump Location:Blo-Recycling Jurisdiction ID:221055100020
COMMENTS
Tank pumped for demo.
TANK:Septic Tank-2 Compartment
Tank Pumped: YES
Tank Size(Gallons)(Number only,no text): 750
Effluent level within operational limits(if NO explain in comments): YES
Total Gallons pumped from tank(Number only,no text): 750
Effluent returning back into tank after pumping: NO
Tank depth below grade(inches): 10
Access Risers installed to grade(N/A If not present): YES
Tank Construction Material: Concrete
Tank Condition Good: YES
Baffles in good condition(N/A If not present): YES
Effluent screen leaned(N/A if not present): N/A
Effluent surfacing around site components(N/A if not checked): NO
Tank abandoned after pumping: YES
Were repairs made to the Tank or Tank Components?(if YES explain in comments): NO
Compartment 1 Scum accumulation(Inches,if other specify):
Compartment 1 Sludge accumulation(Inches,if other specify):
Compartment 2 Scum accumulation(Inches,if other specify):
Compartment 2 Sludge accumulation(Inches,If other specify):
This report hdicales certain characteristics of the on site sewage system al the timed visit in no way is this report a guarantee aoperation or future performance.
ReportiD:795983 View pump reports online at www.onlinenne.com Page 1 of 1