HomeMy WebLinkAboutSWG2025-00415 - SWG As-Built - 12/29/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2025-00415 Parcel # 22132-11-00030
Applicant Name Derral Meyer& Kimmi Walsh Subdivision (Name/Div/Block/Lot)
Applicant Address 61 E Gibler Ln
City, State, Zip Shelton, WA 98584 Installer Name Mason County Excavating
Site Address same Designer Name Arrow Septic Designs, Inc
INSTALLATION CHECKLIST
❑ Full System Installation III Tank(s)Only ❑ Drainfield Only Q Repair ❑Other
System Type Gravity Trench Pretreatment Type
>5 ft. from foundtion? 1 S ri !�J ❑ N/A a YES 0 NO
>50 ft. from wells? `" ''. - ❑
Z >50 ft. from surface water? - -l11:DEC ❑ 0 ❑
Li
FQ- Cleanout between building and tank? - --
U Tank baffles present? - - - -
❑ ❑■ ❑
a 24" access risers over each compartment?-BY- - - - i❑ 1=1 ❑
W Effluent filter installed?- - ❑ 0 ❑
u) Infiltrator
Septic tank capacity (working) 1,060 gal Manufacturer
0 D-box water level and speed levelers used? - - ❑ N/A 0 YES ❑ NO
00 Manifold/D-box accessible from surface?- - ❑ ❑ E]
ODZ Check valves installed? - - ❑ ❑ I
oa E Transport Line Size 4" Schedule/Class 3034
Bedrooms installed (check one) 0 2 ❑ 3 ❑4 ❑ 5 ❑6 ['Commercial/Other
>10 ft. from foundation?- - ❑ N/A pi - ❑ NO
0 >100 ft. from wells?- - ❑ ❑ ❑
W >100 ft. from surface water? - •
''S- -C j:.- ■ ❑ ❑
u. >10 ft.from potable water lines?- .:*\- - ❑ ❑ ❑
Z > 5 ft. from property lines and easements?- - - ❑ ❑ El
a ❑ ❑ ❑
� > 30 ft. from downgradient curtai :. •ation drains?- -
O
Drainfield level and o• - ,a ion ports present El ❑
❑ Grave -.- ambers or ❑ Clean gravel used? (check one)
••er cover installed over drainfield?- - ❑ ❑ ❑
Pump tank setbacks consistent with septic tank?- - ❑ N/A ❑ YES ai NO
Y Pump tank capacity (flood) gal Manufacturer
< 24" access riser(s) and accessible from surface?- I - Ill El El
— Alarm or Control Panel Installed? - �� - ❑ ❑ ❑
D.
E Control Panel equipped with Timer/ ETM/Counter- - -
❑ ❑ Elm
n- Pump installed in ❑ Bucket or ■ e :lock or ❑ Other
a'• Pump Make/Model ❑ Floats or ❑ Transducer
a
• Tank dra n in/min Pump capacity gpm Squirt Height ft
-ump on time Pump off time Daily flow set at gpd
.:dated 8/21.2018
Mason County OSS Installation Report pg. 2
Parcel# 2 ZA.31'- ` - 0 00 5a
ABANDONMENT RECORD
Were existing septic components e ,abandoned s part off this project? - - � YES
NO
If yes, please describe:_ �`-�elJ'r"� NO
Were all components pumped out and properly abandoned per WAC246-272A-0300? YES
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,e>csbng and proposed buildirgs,location of wells,waterlines,
wells,observation ports,cleanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installaton approval and related permits.
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® 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 atta ed Record Drawing is accurate. form and attached Record Drawing is accurate.
Signature of Installer Date A
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Printed Name of Signee fv
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MASON COUNTY PUBLIC HEALTH ifitt ! III •'-
The undersigned approves this Installation Report and ,t•• e,o 3aa
Record Drawing on behalf of Mason County Public • PAULA JOY JOHNSON
Health: I 'L • `yli
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! Specialist Date signature and date)
of Environmental Health p (stamp, s g
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8212018
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