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HomeMy WebLinkAboutSWG2025-00376 - SWG As-Built - 12/19/2025 IIMMIlll Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2025-00376 Parcel # 42019-41-00000 Applicant Name Suzanne Rudoll Subdivision (Name/Div/Block/Lot) Applicant Address 323 E Lantern Loop Rd City, State, Zip Shelton, WA 98584 Installer Name TJ's Excavating Site Address 1521 W Little Egypt Rd, Shelton Designer Name Arrow Septic Designs, Inc INSTALLATION CHECKLIST J Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair ❑ Othe• System Type Sand-Lined Pressure Bed Pretreatment Type >5 ft. from foundation? - - - ❑ N/A ® YES ❑ NO >50 ft. from wells? - - - V ❑ IN ❑ Z >50 ft. from surface water? - u t ❑ I ❑ H Cleanout between building and tank? - - - 1 �(}2�j- -t� . ❑ 0 ❑ U Tank baffles present? - • DE� ❑ I ❑ P.- 24" access risers over each compartment. - - - -- ❑ 0 ❑ coW Effluent filter installed? �� - - - - - - ❑ El ❑ Septic tank capacity (working) 1,000 gal Manufacturer Hagerman CI D-box water level and speed levelers used? - - ❑ N/A El YES p NO DO Manifold/D-box accessible from surface?- - ❑ ❑ la u. mZ Check valves installed? - - ❑ II ❑ Q Q 2 Transport Line Size 2" Schedule/Class 40 Bedrooms installed (check one) ❑■ 2 ❑ 3 0 4 ❑ 5 ❑6 ❑Commercial/Other >10 ft. from foundation? - - ❑ N/A mg YES ❑ NO CI >100 ft. from wells? - - ❑ IN ❑ 1.11 >100 ft. from surface water? - -- ❑ 0 CI ti >10 ft. from potable water lines?- -- ❑ 0 ❑ Z > 5 ft. from property lines and easements?- - ❑ PO ❑ ie > 30 ft. from downgradient curtain/foundation drains? - - ❑ IN ❑ Drainfield level and observation ports present - - ❑ PO ❑ ❑ Graveless chambers or 111 Clean gravel used? (check one) Proper cover installed over drainfield?- - ❑ IN ❑ Pump tank setbacks consistent with septic tank? - - ❑ N/A Q YES ❑ NO ZPump tank capacity(flood) 1.000 gal Manufacturer Hagerman < 24" access riser(s)and accessible from surface?- - ❑ U 0 1-- Alarm or Control Panel Installed? - - ❑ UI ❑ a E Control Panel equipped with Timer/ ETM/Counter- - ❑ UI ❑ D n- Pump installed in ❑ Bucket or II On Block or 0 Other a Pump Make/Model Liberty 280 ❑ Floats or 0 Transducer a Tank draw down 2.5 in/min Pump capacity 49 gpm Squirt Height 7 ft Pump on time 1.2 min Pump off time 6 hr Daily flow set at 240 gpd Updated 8,21/2018 Mason County OSS Installation Report pg. 2 Parcel 20 Lci ' 4(' 00o00 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - El YES ® NO If yes, please describe: Were all components pumped out and properly abandoned per WAC246-272A-0300? - - p YES ID 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 Mum development. Typical Record Drawings contain: Drairtfieid 8 manifold orientation&layout.SepticJpump tank location,North arcw,reserve drairtfield,ersting and proposed butldmys,location of wells,waterlines, wails,observation ports,ckanouts,and other maintenance access pointS. Incomplete Record Drawings may create additional delays in final insialiacon approval and related permits. Sre-SZ- ,c4'i a,C)VjZ‘k ® 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 I further certify that all information contained on this form and attached Re 'rd Drawing is accurate. form and attached Record Drawing is accurate. r ; -4C._ ll -2.S-ZS Signature f Installer Date A Printed Name of Signee `s(y) MASON COUNTY PUBLIC HEALTH prt„,,„),The undersigned approves this Installation Report and I . ,�C�. Record Drawing on behalf of Mason County Public 510034g �•? Health: "Q- PAULA • JOY JOHNSON 'y-��.1i (Z ji-Ace\')9\1 17R.6( (--(S-- EXPIRFS $31$!GIV�1� 1 !! Signature of Environmenta Health Specialist Date 1 2.-�l - (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE up'''te0 8/21/2°1e o 25 50 ,zs Is (DO ' • to Aa-bu.lZ- J v ti1Q;5 ; :;DoLL \ .. 91Ace\ &A2 ±I CQGDD L521 vti 1.11 -e " S 414 --- )-------. 7 ‘ / Ztia 1 < < r-1 4 _____________v,„IE LL Slob x LE LEI t---'5.0'--> ° IC 3C` 7 -k D.F. r3 ED w c- -k `� �'' oto` x3o ' sg•-sV- o.F_ 3tD ` ism - 1-e�rt. © p�Q�J,2-� s t © 1 Audio-Visual Alarm- ort, Pos 4-t ac ( Cieai1CUt ro " 0 d WI X3 1,000 Gallon Septic Tank r 2-Compar=ent with k c Effluent Filter o. P ? 1000 Gallon Pump Chamber �O V E . \ MgsoNcoy�EC 9 2024- �Eh0Uh'MENTq�H i RFr LTN J �� IOG ' i -(11 ' ' -,j4k. I ix ', II J r��. ( 4� ace\ 0 42�1 q- 41-- DOOt o �� 5,P 1-4-, l 9•Ncor2� W 1 '`'p� PAULA JGY JCHNS 1• !-1 SlrirOj SIG CF(, tit ( Z-l\-25