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HomeMy WebLinkAboutSWG2022-00294/ASBUILT - SWG As-Built - 9/26/2025 • _ -- CLEAR FORM Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2022-00294 Parcel # 223037500110 Applicant Name WaslhIHallman Subdivision (Name/Div/Block/Lot) Applicant Address 312 PERRY AVE N UNIT 3 TR 11 OF SURVEY 6/151 City, State, Zip PORT ORCHARD WA 98366 Installer Name Pam Busek Site Address 101 NE Blacksmith Dr, Belfair 98528 Designer Name Jim Zimny INSTALLATION CHECKLIST IM Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other System Type pump to gravity Pretreatment Type >5 ft. from foundation? - 4.".-:'{rl � lr, N/A ®YES El NO >50 ft. from wells? - ii- II . -i `L i) IP ❑ >50 ft. from surface water? - jj�� �r 5 H Cleanout between building and tank? ---="•f IT I 1 202- Jiii ❑ D ❑ U Tank baffles present? - By - - - - - - )❑ © ❑ a24"access risers over each compartment. -- -- -- - I El m El W Effluent filter installed?- - 11 0 ® ❑ Septic tank capacity (working) 1250 gal Manufacturer Hagerman 0 D-box water level and speed levelers used? - - ❑ N/A INYES ElNO oO Manifold/D-box accessible from surface?- • ElI El mz Check valves installed? - - ❑ ® ❑ oQ 2 Transport Line Size 1 1/2 Schedule/Class sch 40 Bedrooms installed (check one) ❑ 2 0 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft. from foundation?- - ❑ N/A ® YES ❑ NO 0 >100 ft. from wells?- - ❑ IN ❑ W >100 ft. from surface water? - - ❑ II El it >10 ft. from potable water lines?- - ❑ ® ❑ Z > 5 ft. from property lines and easements?- - ❑ ® ElE > 30 ft. from downgradient curtain/foundation drains? - - 0 ® 0 Drainfield level and observation ports present - - ❑ II ❑ 0 Graveless chambers or RI Clean gravel used? (check one) Proper cover installed over drainfield?- - ❑ IF ❑ Pump tank setbacks consistent with septic tank? - - ❑ N/A o YES ❑ NO • Pump tank capacity (flood) 1000 gal Manufacturer Hagerman < 24" access riser(s) and accessible from surface?- - ❑ ® 0 dAlarm or Control Panel Installed? - - 0 • ❑ • Control Panel equipped with Timer/ ETM/Counter- - ❑ I 0 D a Pump installed in e Bucket or ❑ On Block or ❑ Other n' PumpMake/Model libertyI-280 � Q Floats or 0 Transducer 0_ Tank draw down 2" in/min Pumpcapacity 40 Height p gpm Squirt Hei ht n/a ft Pump on time 1.1 min Pump off time 4 hrs Daily flow set at 264 gpd pcated Bi21!J18 Mason County OSS Installation Report pg. 2 Parcel P ZZ 037 Soo ,lI 0 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - Q YES ❑ No If yes. please describe:PUMPED&ABANDONED EXISTING SEPTIC TANK Were all components pumped out and properly abandoned per WAC246-272A-030G? - -. - - ® YES ❑ NO RECORD DRAWING This is a permanent record and must be accurate and descriptive enough to relocate in the nerd of maintenance activities and future development. Typical Rec,r I Drawings cnntarr. Dramfield&manifold orienta+.co&layout Sep:.cipsre tank Lois' lion Nolo arrow. reserve Oreunrite0,ev sting and proposed tr:nd.nys.IOc5Wn of wells.waterlines wells.c5servatan torts deano,ts.and otw^tamtenanre access points IrrwnNetn Rernrd Dra..ag5 may ueate add2:onal^clays m fatal.nstatWtan approval and related perm t, ❑ 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 0 County Public Health and that any deviations shown Mason Courtly 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 at/information contained on this f and attached Record Drawing is accurate. form and attached Record Drawing is accurate. Si\ ). '\;V\\— C\ nature of Installer Date A • (I PAM M BUSEK #• Printed Name of Signee .r. o �f� try f ,, MASON COUNTY PUBLIC HEALTH y� ,,f4# I he undersigned approves this Installation Report and l or J a%Dm,/ i LICE ED r SIGNER . Record Drawing on hehalf of Mason County Public .... ILA% ����d, Health: 1(<1\1-010\,()� lo(z�t(r� �?At-2� Signature of Environmental Health Specialist D to (stamp, signature and date) THIS FORM MAY BE SCANNED AND A44ILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE "r"'1Co e'-'2='' r \ \• \ / I \\;\ �,. \X I \ \• \ / sn►pra PM ,OOI ,, \�dt / \\ O o / A `\'\ o / -r \ / \\ \\\ 0 \;\ / \`\\\ /' W /// \\\ +�. / O // O 3 O �� 3 I Po CD to fD N -0 O VED '� OCT 2 4 2025 MASON co„„YEN ; ; �ROKMENTALHEALT O. c o RET o Po w t j:::41ir -CS o ' uii iaadoad o1 ,08 i� (D E N A) � U 0 D i��% pi cn co A� N (`D N -p �° y 5 fD — i qy�� 1 N O ~ (D N W to A� - U Q' x p to ' /r �\ % O W = � Q ( r.4 / V . ,4r U.) N..) v < � � Ds #4.— ; ` '‘% -raa _ _ Nr 1 D S- M u,o 8, A V1 O — to w -' O c m "0 , a p r- - 3