HomeMy WebLinkAboutSWG2023-00447 - SWG As-Built - 10/21/2025 •
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG Zo2 -00_1( -? Parcel # g Lou- yo - 09()i t
� Applicant Name Zohr Opel I at, Subdivision (Name/Div/Block/Lot)
Applicant Address 2zf,1 k ) -t r G!t 28
City, State, Zip c1\Q1,\c1, 9 g Li Installer Name 1, 1 t17j'k _0a\d).
Site Address L .S5C SirrA 1l I Designer Name A i # WI I-T 01 ri—C4/
INSTALLATION CHECKLIST
4
Full System Installation ❑Tank(s)Onlyzz ID Drainfield Only ❑Repair ❑Other
System Type (�( �>re, U(,[) Pretreatment Type
>5 ft. from foundation? % - ❑ N/A [ YES ❑ NO
>50 ft. from wells? - - � � i' �\I ❑ CI
Z >50 ft.from surface water? - ��'� fir . ❑ CI
1.41 Cleanout between building and tank? - - --' ❑ CI
4 U Tank baffles present? - - ❑
I 24"access risers over each compartment. -�..- - - - - - - ❑
W Effluent filter installed?- - - - ❑ ❑
cn
Septic tank capacity(working) )-1,00 gal Manufacturer
0 D-box water level and speed levelers used? - - N/A ❑ YES ❑ NO
p0 Manifold/D-box accessible from surface?- - CIJI CI
‘N-- Off z Check valves installed? - - 0 ❑ CIE Transport Line Size it it `Schedule/Class I uD
Bedrooms installed (check one) ❑ 2 V3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft.from foundation?- - ❑ NIA YES ❑ NO
>100 ft. from wells?- - 0 ❑
W >100 ft. from surface water? - - CI
7 >10 ft.from potable water lines?- - ❑ ❑
Z > 5 ft. from property lines and easements? ❑ ❑
> 30 ft.from downgradient curtain/foundation drains? - - ❑ ❑
o
Drainfield level and observation ports present - - ❑ ❑
❑ Graveless chambers or Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ 0' ❑
Pump tank setbacks consistent)with septic tank?- - `❑ N/A [p YES ❑ NO
Z Pump tank capacity (flood) /1 gal Manufacturer L4 Q P� j-
Q 24" access riser(s) and accessible from surface?- - Cl 619 ❑
F-
a Alarm or Control Panel Installed? - - CI5 CI
2 Control Panel equipped with Timer/ETM /Counter- - ❑ 1 ❑
m
II- Pump installed in ❑ /Bu'Bucket or rd) On Block or ❑ Other
. Pump Make/Model 1 fA4'� PP tOo 7 i 7 )oats or ❑ Tran ducer
� V
a Tank draw down �� in/min Pump capacity G, gpm Squirt Height ft
Pump on time Pump off time )It . Daily flow set at .CQ0 gpd
Updated 8/21/2018
Mason County OSS Installation Report pg. 2 Parcel#
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ YES
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 1 further certify that all information contained on this
fo and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
7
\ i/t,--<- tOltrIlr
S na ure of Installer Date
. \ -(M-( i 10/17/25
Printed Name of Signee of.
MASON COUNTY PUBLIC HEALTH y,,�f
The undersigned approves this Installation Report and ;•.
Record Drawing on behalf of Mason County Public �• ., ' .,,.,ff
Health: ,( --*• HDADJ J.HUNTER f
Signature of Environmental Health Specialist Date (stamp, signature and date)
Updated&2v2ots
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE
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