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HomeMy WebLinkAboutSWG2025-00279 - SWG As-Built - 12/5/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2025-00279 Parcel # 32214-51-05024 Applicant Name B-LINE CONST. C/O HATHAWAY 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 261 NE MADRONA AVE Designer Name INSTALLATION CHECKLIST ❑ Full System Installation ❑Tank(s) Only El Drainfield Only Q Repair ❑Other REBUILT SAND FILTER System Type Pretreatment Type >5 ft. from foundation? - ❑ N/A ❑YES ❑ NO >50 ft. from wells? - - T-% III - ❑ ❑ ❑ >50 ft. from surface water? - ''' ❑ CI znts H Cleanout between building and tank? - - ` -D %a Vi - - ❑ CI ❑ U Tank baffles present? - � + - ❑ ❑ ❑ EL 24" access risers over each compartment?:- -- - - - -. ?--= ❑ ❑ ❑ W \ Effluent filter installed?- ` - ❑ ❑ Septic tank capacity (working) gal Manufacture 0 D-box water level and speed levelers used? - - ❑ N/A ❑ YES ❑ NO �O Manifold/D-box accessible from surface?- {�' - ❑` ❑ ❑ mZ Check valves installed? - a ❑ ❑ ❑ 6Q 2 Transport Line Size Sched /Class Bedrooms installed (check one) ❑ 2 ❑ 3 4 5 ❑6 ❑Commercial/Other >10 ft. from foundation? - - ❑ N/A ❑ YES ❑ NO O >100 ft. from wells? - - ❑ ❑ ❑ W >100 ft. from surface water? - 1,--)- El ❑ ❑ Li >10 ft. from potable water lines?- G_ - ❑ ❑ ❑ Z > 5 ft. from property lines and easements?- - El El ❑ ce > 30 ft. from downgradient curtain/foundation dr .ns? - - ❑ ❑ ❑ a Drainfield level and observation port present - - ❑ El CI ❑ Graveless chambers or ❑ can gravel use ? (check one) Proper cover installed over drainfi d?- - ❑ ❑ ❑ Pump tank setbacks consistent h se tic tan ? ❑ N/A ❑ YES ❑ NO `-L Pump tank capacity (flood) al Manufacturer < 24" access riser(s) and accessible from su ace? - - ❑ ❑ ❑ a Alarm or Control Panel Installed? - - ❑ ❑ El • Control Panel equipped with Timer/ ETM /Counter- - ❑ ❑ ❑ a- Pump installed in ❑ Bucket or ❑ On Block or ❑ Other a• Pump Make/Model ❑ Floats or ❑ Transducer cL a 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 Mason County OSS Installation Report pg. 2 Parcel # 32214-51-05024 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - YES El NO If yes, please describe: EXISTING SAND AND PEAGRAVEL FROM SAND FILTER Were all components pumped out and properly abandoned per WAC246-272A-0300? - - EI YES ri 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. S(X," 3-14'd o -\- c\r•,10,‘ 1,-0 c 01\ al 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 further certify that all information contained on this I further certify that all information contained on this form and attached Record Drawing is accurate. form and attached Record Drawing is accurate. \ Sig ture of Installer Date I '� 1ef en7 Printhd Name of Signee MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report and Record Drawing on behalf of Mason County Public Health: R.di-N.Q.k(A1)(6Y1* I Lck,� 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 812112C1F ! } (4,) tJ i 1/ LJ ,, 1 il.... A 8 I 1.. ) V (1 . 4. R. 1.1 2 0 D 01,,E -------___ . - rsil � r de• l` fi rti' t�� 0 •r,• h s 50 a -1,ct `11.% Ial , c,w.: CD © �o sir ) $o . \ ilic....3 _,,________1_ j .it, c 3. ....______,...). 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W ritny ar I E, . ... s JAN 1 9 moo JSei c.At T �9srerc I tea. / mats& .? / — - - y ----lr • '11? t:. . •.;-"7"::---Y) i A �� ►IO IOft:MBA' 4411W►40 66.4 Print • from Mason County )MS MRt K xRtg44t'owat_4 M 1•paa■�rb ,r -, v 4 •f uc 1:4.Coma= • ek Drai iskt&moil* orientation &hyoid �r ' Trench/bed dimming diademcritical titreit esi, within layoui .:. itta,....4.‘s1 • I li 1k°t . t�p�placement . : , O A L O� Loatbn of building. ,.9.4 Ta 4 t f,.'' y 1 V�� - • Observation pod&clean- _ A_Lowe -` — 1` ' '�e+ 0� �r out location. �, -- �` 1Loation of wells& W f oj G;:. ` K f t 1• 0- ' f .5r '' y itroads. r \Usti:Ind:red native soli • J�!'r .' ' die.— D•:�+�e(,l • i► tlie!orth 416 t 1 .r 31 a3 4° fti� S 4$ - A!! cayr.At 4 does awaiLt4. 8 ‘9 ; 58 9 , 63w�•1_� 4} eindgitaSPI I aerse .hy d e e el i sjitirdigriltit 0 ar:a t I V Balighiggese Installer Cheek a box from Raw"A"and"B",sip and dabs the catificadon A. Cl I that I wedbd the system widaout aqy iil i tlntall ken the deeiga damped d�from the design stamped"AP ROV' D"by y Awn w t it.soo1n N�,M r MCDHS moot ices B. i I certify that I contacted the designer and loft the O I did not contact the olsolassrpriorb that cover because the system open for iospeadoa up to 48 bra prior to desipar waived the addikores requit me t. Cover. I Bather ant*that all infaeeantion contained ce this tam Is aconite. I undenlaad drat!the isBOprantioa oaedisd herein is sot acara s,there will bojom caw ibr biwedbte napaoaioo of my lomat ceedlfoedoa. • art l east rya*fir+✓ ,fir c a.i.wt ? 1f'2 /— _vo .:. iP.41 wwr sust.l�L1 4,- = or The uodcrsigned approves this fmtalletioe on behalf of Mason County Deperdnaot of Beath Services. Hitter O I 1 i , -.• ... • I s : I _ •a a .a II t, , l ' • • • •.; 1:.• • 1 aeon •un . . \ Pn Imo• •m on County •MS