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HomeMy WebLinkAboutSWG2022-00165 - SWG As-Built - 10/13/2025 Docusign Envelope ID:82ACBCFB-C193-436D-8EB4-F009387CC9F1 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG ?CZZ.— pot(05 Parcel # .3 a© 3 Z --3Z (=IOA(O1 Applicant Name K�A � U``-e_c-' Subdivision (Name/Div/Block/Lot) Applicant Address ?o )( 1\1 (�, City, State, Zip gneA -,5k` \V(� `�►gs�� Installer Name i ' \ csito► Site Address Z k S 1k CV W Designer Name [v`YC'_c�k `I\\/€z- INSTALLATION CHECKLIST (Full System Installation ❑ Tank s)Only Drainfield Only ❑ Repair ❑Other / � System Type /UuZ-Itc �l � e'ert.try Pretr ent Type 1 u�Nck.t/er >5 ft. from foundation? - 7��_ N/A Es NO >50 ft. from wells? '� -- -' 0 ❑ Z• >50 ft. from surface water? - a-ma.3 /425- 1 ❑ NI' ❑ H Cleanout between building and tank? - Dr El U Tank baffles present? - - ❑ a24" access risers over each compartment?- ' .- - 0 ❑ W fflueni, lter installed?- - - - - ❑ ❑ A Septic tan capacity (working anu acturer CI D-box water level and speed levelers used? - - Et N/A ElYES ❑ NO 0O Manifold/D-box accessible from surface?- - ❑ ❑ co- Check valves installed? - ❑ C Q "[ 2 Transport Line Size Schedule/Class Bedrooms installed (check one) ❑ 2 Xr3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft. from foundation? - - ❑ N/A Vff YES ❑ NO O >100 ft. from wells?- ❑ K ❑ W >100 ft. from surface water? - ❑ 15Zr ❑ L.T. >10 ft. from potable water lines?- - ❑ a ❑ Z > 5 ft. from property lines and easements?- - ❑ l' ❑ a cc > 30 ft. from downgradient curtain/foundation drains? ❑ El 0 Drainfield level and observation ports present - - ❑ ❑ ❑ Graveless chambers or `eI Clean gravel used? (check one) Proper cover installed over drainfield?- - ❑ ❑ Pump tank setbacks consistent with septic tank? - ❑ N/A YES ❑ NO • Pump tank capacity(flood) /Z? 3 gal Manufacturer ,> I c < 24"access riser(s)and accessible from surface?- - ❑ ❑ I— a Alarm or Control Panel Installed? - - ❑ riST ❑ 2 Control Panel equipped with Timer/ ETM /Counter- ❑ , 'l ( ❑` a Pump installed in ❑ Bucket or ❑ On Block or [ Other c)1 �-'l t ek ve ig r/c./� kter n' Pump Make/Model L,/ -/ 2gC EltPloats or ❑ Transducer 2 R Tank draw down "2- in/min Pump capacity Lit, gpm Squirt Height ft //�� Pump on time / /yt.//I Pump off time � E-ra.,,,- Daily flow set at 776 gpd Updated 8/21/2018 uocusign tnvetope IL):o.AGt3Gt-I3- 1as-4sbu-at1244-UU9iafU t3b1 Mason County OSS Installation Report pg. 2 Parcel# 32032-32-90064 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - ❑ YES tiSkI NO If yes, please describe: 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 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 draintield.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. L —DS Owners: Initial: ` Ca [R 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 a•- , ac led Rec,.• I - : ' - •• - e• form and attached Record Drawing is accurate. 7A7 zE ,,, ign. ure .• Date do 0 II 00 V\1\143 ACCAc ,.1 s AV Printed Name of Signee 0 11 MASON COUNTY PUBLIC HEALTH /1 f It � ,+11 The undersigned approves this Installation Report and ` ,II. Record Drawing on behalf of Mason County Public 010001011 Health: f UGE D DESIGNER 0 ISCANMANVILIMINSON; + 1ie I'. 17( I a' z-•aonek2Z Signature of Environ ental Health Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8/21/2018 • Tabloid 11"X 17". o Abbreviated Description:TR 6-D OF NW SW TR C-4 OF SP #750 TR D OF SP #2334 .IIo m / '< / co / $ O / m o C" / zen w r- IV co CD 5 /ni > n m it 161, /- 4° 2 —' W 0 e\ e\ </\ e\ O N I (J) I c) 0 z N <in \ 11 rn I O m E ' ¢ \\\\\\\ 1i� (1 (ZO I o0 vp\P�� �1\\\A\ �\ \ N 1 C13 �� 0) \ \ \ \ \ \ \ \ \ \ `So, \� O 1 ado \J\� \ \ \ I :re: 1 I • • W �, I I in .� . I 1 1 - • I I • C' mi au111-10C15U al luanl}}3 ,�, I I R. NJ -76, • � • ..• tpIIIIIIIIIII\ % ) II ' \ to I — — — \ 0 I • — N ti I I 100-W-11 R dic,S \o II I + 10p, � � ` \ r \ \ 1 1 �d ius \ I lS\ I imp N \ \ I z 1 \ \ I C I N. \ 1 a 1 OP O \ \ \ O II \ \ \ U 1= rt I . - 1 1l-0 -� \\ \ m I I 0ll � \\ \ I I rn x= = I IA. 0 \ 1 I 11 2N N I1 \\\ II O 1 II 1 I 1 \ —C \ (W 1 \ I 11 II I ` \ I 1I II L Waterline I \ i I I IJ -O IT 1 C I I 1 I y�CO o) � � wN co -oZW o `° o . 30 NE (0N Nco &N— (DD I �I co 3 m m v (sl N c � � ` A 3N. Ov < �-1 � a _1 I 10 p o � � 9' 6 3 E..D � ncD CD �Ir aD / , U t.Dcilco a O 0 13- n 'O D = Z 9, O / I ° NfiCO3o CD vm0DXB fi 0 , zOO , • O � D Q rt N� O O '' O Di T rts la) CO 'o CD CD D co / I N � cfl n � (DDn n Q1 _ OD NU1 ELD' Co CD ? tC 6 Q fn u_ szi: tl, ,, o/ / `". �/ / / \`` ' L co I o rt co no (1 / / �� 0/03„``. 20 ox (1) 73 3 FE' / / / rir m N O D cc,0 (DN 3 5t. co_ Ul 4.- co M.Halverson Design LLC ° Chris Auseth Site Info- Parcel# 32032-32-90064 SHEET NUMBER PO Box 1519 Shelton Wa 98584 m Mailing: PO Box 2192 Halversondesignllc outlook.com Shelton Wa 98584 21 SE NEILAND CT WEST II REVISION..