HomeMy WebLinkAboutSWG2024-00078 - SWG As-Built - 1/2/2026 •
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 20 Z'-( O O o- Parcel # C L0 ` - — -7 S- ci Ou `t (l
Applicant Name i 7,,;,� �,,.r1f, Subdivision (Name/Div/Block/Lot)
Applicant Address �(^; (- r u , t Lc L.,- l L V / /..,/c� ,'s.-t___-_%S /a,J
City, State, Zip S4--r`I to,.,.,,, L.,‘....., 1 S Installer Name /-1 ,..,>,,.._ tG cV J
Site Address i C'- E L(c •`'t- L"\, Designer Name Adt,<44_, I-i w Q,/'
INSTALLATION CHECKLIST
128 Full System Installation ❑Tank(s)Only 0 Drainfield Only ❑ Repair ❑Other
System Type 91\6' _.'r Pretreatment Type
>5 ft. from foundation? --- ❑ N/A ®YES ❑ NO
>50 ft. from wells? - I Cf-_,,f1- E ❑ (g ❑
>50 ft.from surface water? - Lr' ❑ a ❑
Z
FQ- Cleanout between building and tank? - 1 -BEG-3-G 2E5-- ❑ EA ❑
V Tank baffles present? - - - - - - - - - - -I- - El ❑
a24"access risers over each compartm-rg? - - I - -- ❑ ❑
N Effluent filter installed?- w% ❑ El
Septic tank capacity(working) ( v S c.J gal Manufacturer /-L,r a-r ru-4✓t. pre_c �
9 D-box water level and speed levelers used? - - N/A ❑ YES ❑ NO
00 Manifold/D-box accessible from surface?- - ;_.�
r ❑
u.
1vw
QQ Check valves installed? - - ❑ OE "' 0
2 Transport Line Size L Schedule/Class L1,4 BIZ
Bedrooms installed (check one) 0 2 0 3 r4 4 0 5 ❑6 ❑Commercial/Other
>10 ft from foundation?- - ❑ N/A ® YES ❑ NO
0 >100 ft. from wells?- - ❑ RI ❑
W >100 ft. from surface water? - - Ela ❑
ti >10 ft. from potable water lines?- - ❑ m ❑
z > 5 ft. from property lines and easements?- - ❑ ® Eld > 30 ft. from downgradient curtain/foundation drains?- - 0 8 ❑
ra
Drainfield level and observation ports present - - ❑ m ❑
gli Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ RI ❑
Pump tank setbacks consistent with septic tank? - - ❑ NIA IN YES ❑ No
ZPump tank capacity(flood) 12 S C) qal Manufacturer ).1 e/`rwwv'L f('Q.c.4, r
Q 24"access riser(s)and accessible from surface?- - ❑ lifi ❑
aAlarm or Control Panel Installed? - - 0 ® ❑
E Control Panel equipped with Timer/ETM/Counter- - ❑ ❑
D
a Pump installed in ❑ Bucket or cil On Block or ❑ Other _
a' Pump Make/Model N I .5`'2-- Z d W- a Floats or El Transducer
a Tank draw down 2-� in/min Pump capacity U gpm Squirt Height 2 / ft
Pump on time / L ,..Q Pump off time V/ - Daily flow set at 4"6 i gpd
Updated 8212018
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 WAC248-272A-0300? - - 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. Drairieid&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 reate additional delays in final installation approval and related permss.
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 l further certify that all information contained on this
form and a the Record Drawing is accurate. form and attached Record Drawing is accurate.
1�t.c,- -t'�t3 Z-S'
Signature of Installer Date ,
A// 1._ K; l(K"
Printed Name of Signee �.,.
MASON COUNTY PUBLIC HEALTH ter..
;'•,�,
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public SIOUlt2
Health: ,• ADAM J.HUNTER
-►� �;{'1'M,tl•ry err;i.���:`. .
IKINLAItVe 0
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Signature of Environmenta/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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