HomeMy WebLinkAboutSWG2025-00307 - SWG As-Built - 11/7/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION I
Permit Number SWG2O2 -) " 60 36 7 Parcel #1-12c'6`( So --cc 5'-ICG
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Applicant Name I' 5a '\ Subdivision (Name/Div/Block/Lot)
Applicant Address 116 I .Jas a cT ..j 14
City, State. Zip 0LO-a 4 14 3 1�- ll- Installer Name -F t3(' L 'cl^Ca-
Site Address 71 1` Ica-c Designer Name II, kitir
INSTALLATION CHECKLIST
fii Full System installation ❑Tank(s)Only ❑ Drainfield Only i ❑Repair ❑Other
System Type—LIMO? 3 1111r '0.tretreatment Type
>5 ft. from foundation? -- ElN/A [ YES El NO
>50 ft. from wells? - • 2' - ElElZ
• >50 ft.from surface water? - Et-ti‘
- ❑ 1J' El
H Cleanout between building and tank? - - - -v �1 `- 1- - - 0 81 El
U Tank baffles present? - AO ❑ Z El
a24"access risers over each compartme - - - - - - - - ❑ r� El
N Effluent filter installed?- 81- - _ - -- - - - - ❑ lgr El
Septic tank capacity(working) Vim' gal Mafufacturer 50u.Y1GI a- '�1` -
0 D-box water level and speed levelers used? - - XN/A ❑ YES ❑ NO
OLL
O Manifold/D-box accessible from surface'?- - ❑ Vf El
C9Q ElCheck valves installed? - - ❑
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2 Transport Line Size� Schedule/Class 411
Bedrooms installed (check one) ❑ 2 V3 ❑4 ❑ 5 ❑6 ❑CommerciallOther
>10 ft. from foundation? ❑ N/A A YES ❑ NO 1
G >100 ft. from wells?• n'`'"S'"1 U - ❑ jEl:
.g
—1 >100 ft. from surface water? - - . ❑LL >10 ft. from potable water lines?- - ❑Z > 5 ft.from property lines and easements?- - ❑ `1aR > 30 ft. from downgradient curtefn/foundation drains? - - [E`• Drainfield level and observation ports present - - ❑ 2❑ Graveless chambers or Clean gravel used? (check one)Proper cover installed over drainfield?- • ❑Pump tank setbacks consistent with septic tank?- - -- 0 N/A YES• Pump tank capacity /flood) 1 15 gal Manufacturer ��Y14 I ►'Q 24" access riser(s) and accessible from surface?- - ❑ Zf ,
HAlarm or Control Panel Installed? - - ❑a2 Control Panel equipped with Timer' ETM/Counter- - - - ❑d Pump installed in ❑ Bucket or `e On Block or [] Other •
1 . Pump Make/Model�_�-'61L- 2_. — i2"� Floats or ❑ Tran�/ ia Tank draw down 2`' S in/min Pump capacity 4' / gpm Squ rt HeightPump on time ' .� !+'l i0J Pump off time G A� kV Daily flow set a
. Upd+:ed d21/2018
-/2. .Sec- 1 Z 4 4 Pl.
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Mason County OSS Installation Report pg. 2 Parcel# 4/ZC'b/ ~ O zs`/C)
ABANDONMENT RECORD
Were existing septic components abandoned as part of tnis project? - - 4-YES [] NO
If yes, please desecribe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - - - - +-- Ati YES El NO
RECORD DRAWING
Thib hi a permanent record and must be accurate end descriptive enough to re-Ic.:ate in the need of maintenance activities end future development. Typical Record
Jrariings contdin. ❑rainfield d rtandou cr,ectation&layout.SepticrpJmp tank location,.f o.lh arrow,reserve oraint.e d.etistUtg and proposed buildings.location of wells.waterlines.
wells.observation ports,clearouts.and other"-.a ntencnce access points. Incomplete Recap i;rawings may create additional delays in final installation approval and related permits.
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Record Drawing Attached
CERTIFICATION OF INSTALLATION
• INSTALLER DESIGNER/ENGINEER
ii 1 certify that 1 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. Siete and Meson County Codes
{ I further certify that all information contained on this i further certify that all infor-�ation contained on this
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form and attach cord Drawing is accurate. form an()attached RecC a+.,,;ing is accurate.
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Signature of installer Date u.�. `��'.
Printed Name of Signee '° • '6it1t S ?' . ' -' C
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CiIVDY E��I E'' 1 � V�
MASON COUNTY PUBLIC HEALTH �. LICENSED DESIG ER
The undersigned approves this Installation Report and 01/41,0-tts us tot
Record Drawing on behalf of Mason County Public
Health:
KtVA/Vt. sogi
1 l /717 C
Signature of Environmental Health Specialist Date (stamp] signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE updateo e12120'ri
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MASON COUNTY ENVIRONMENTAL HEALTH
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