HomeMy WebLinkAboutSWG2025-00118 - SWG As-Built - 11/5/2025 limmook
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2025-00118 Parcel # 12330-52-00043
Applicant Name CUCULIS C/O B-LINE Subdivision (Name/Div/Block/Lot)
Applicant Address 2971 E PHILLIPS LK LP RD
City, State, Zip SHELTON WA 98584 Installer Name B-LINE CONST.
Site Address 351 NE SCHOONER LOOP Designer Name CINDY WAITE
INSTALLATION CHECKLIST
❑ Full System Installation ❑Tank(s)Only ® Drainfield Only ❑ Repair ❑Other
System Type GRAVITY Pretreatment Type N/A
>5 ft. from foundation? - - ❑ N/A El YES ❑ NO
>50 ft. from wells? - _ ❑ El
>50 ft. from surface water? -
z RUINER 0 0 0
Cleanout between building and tank? - ❑ 0
❑
H Tank baffles present? - ill_ AV 11_l_Z02S _ l- _ ❑ ❑ 0
a. 24" access risers over each compartme El 0
W Effluent filter installed? 0
to - $�- - v_- ❑ ❑
Septic tank capacity (working) 11 gal Manufacturer EXISTING
D-box water level and speed levelers used?
0 N/A ® YES ❑ NO
0O Manifold/D-box accessible from surface?- - ❑ It ❑
COz Check valves installed? - ® ❑ ❑
pQ -
E Transport Line Size 4 Schedule/Class 3034
Bedrooms installed (check one) ■❑ 2 ❑ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A ® YES ❑ NO
CI >100 ft. from wells?- - ❑ ® ❑
—> >100 ft. from surface water? - ❑ ® ❑
W -ti >10 ft. from potable water lines?-
- ❑ ® ❑
z > 5 ft. from property lines and easements?
❑ 0 ❑
12
G > 30 ft. from downgradient curtain/foundation drains? - - 0 In El
Drainfield level and observation ports present - - ❑ I ❑
❑ Graveless chambers or No Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ IN ❑
Pump tank setbacks consistent with septic tank? - - ❑ N/A ❑ YES : NO
Pump tank capacity (flood) gal Manufacturer
Z
< 24" access riser(s) and accessible from surface?- 0 ❑ ❑
H Alarm or Control Panel Installed? -a 0 ❑ ❑
Control Panel equipped with Timer/ETM/Counter- - ❑ ❑ ❑
a Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
a.
2 Pump Make/Model
❑ Floats or ❑ Transducer
d Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time
Daily flow set at gpd
,
Updated 8/21/2018
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Mason County OSS Installation Report pg. 2 Parcel # 12330-52-00043
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - II YES 0 NO
If yes, please describe: O.l O.v its (fin e..vl Q L r--
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - II 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 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.
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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 and att hed Record rawing is accurate. form and attached Record Drawing is accurate.
(— I2-2S
Sig ature of Installer/ Date
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a'/I Q,r tovimey /-, Qc`SAS "�•9
Printed Name of Signee / I ^�„.i
MASON COUNTY PUBLIC HEALTH ��� N
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The undersigned approves this Installation Report and O CND i- .•vAITE'-
Record Drawing on behalf of Mason County Public •
LICENSED DESIGNER �y�
.owe •'-r—
Health:
\Lzt),Nstiptvory) II '[J J{.,��
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 8/21/2018
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MASON COUNTY ENVIRONMENTAL HEALTH1
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10d From Mason County DMS
Printed from Mason County DMS