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Home My WebLink AboutSWG2025-00401 - SWG As-Built - 11/18/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2025-00401 Parcel# 221055200022 Applicant Name Margaret Goebel Subdivision (Name/Div/Block/Lot) Applicant Address Mason Lake City, State, Zip Installer Name Wes Graves Site Address 2560 E. Mason Lk. Dr.W. Designer Name N/A INSTALLATION CHECKLIST El Full System Installation 0 Tank(s)Only ❑ Drainfield Only ❑Repair El Other System Type Gravity eatment Type >5 ft. from foundation? - >50 ft. from wells? - t ❑ N/A ID YES El NO Z >50 ft. from surface water? - ri �t�� _ - ❑ 0 H Cleanout between building and tank? - _ ��-- �U - ElU Tank baffles present? - -- -_ El 0 El El ❑ n~. 24"access risers over each compartment - - _ WW Effluent filter installed?- BY - - ❑ 0 ❑ ❑ 0 ❑ Septic tank capacity (working) 1250 gal Manufacturer Roth Cl D-box water level and speed levelers used? 0 N/A ❑ YES El NO oO Manifold/D-box accessible from surface?- c9E Check valves installed? - ❑ ❑ El GQ - 0 ❑ El a Transport Line Size Schedule/Class Bedrooms installed (check one) ❑ 2 El 3 El 4 ❑ 5 ❑6 El Commercial/Other >10 ft. from foundation?- ❑ N/A ❑ YES ❑ NO o >100 ft. from wells?- - El ❑ 0 -J >loo ft. from Gurface water? ❑ W O ❑ Z >10 ft. from potable water lines?- 0 ❑ El 47 > 5 ft. from property lines and easements?- El ❑ 0 > 30 ft. from downgradient curtain/foundation drains? - - ❑ ❑ El Drainfield level and observation ports present - _ 0 ❑ El ❑ Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?- - ❑ ❑ 0 Pump tank setbacks consistent with septic tank? - - 0 N/A El YES ❑ NO ZPump tank capacity (flood) gal Manufacturer <- 24"access riser(s)and accessible from surface?- - ❑ 0 0 Q. Alarm or Control Panel Installed? - - ❑ ❑ ❑ Control Panel equipped with Timer/ETM/Counter- - El ❑ El a Pump installed in El Bucket or ❑ On Block or El Other CL 2 Pump Make/Model ❑ Floats or El Transducer down in/min Pumpcapacity Tank draw aci p ty 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# 221055200022 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - If yes, please describe: Pumped and removed septic tank 0 YES NO Were all components pumped out and properly abandoned per WAC246-272A-0300? - Q YES 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: Drainfiield&manifold orientation&layout,Septic/pump tank location,North arrow,reserve drainfield,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. I 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 form and attached Record Drawing is accurate. form and attached Record Drawing is accurate. !.L/� 10-11-25 Signatur f In� Date Wes Graves Printed Name of Signee MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report and Record Drawing on behalf of Mason County Public Health: (( ((alzc 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 Updated 821/2018 RECORD DRAWING (continued) r• H QS o VA Le Dr W Co- u 1 Gkare • v C:2N < � 0 ! 1 { , i Q P <--5.-4 "34:. HOUSe_. i i 25. $2, zr- • Vi"---' --.. vIC Jon Lck\Ke -04- 0 A-0 gait, APPROVED tIn‘ .- NOV 182025 �� ,,��4-"' M•ASON COUNTY ENVIRONMENTAL HEALTH RET