HomeMy WebLinkAboutSWG2023-00439 - SWG As-Built - 12/29/2024 I
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CLEAR FORM
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2023-00439 Parcel# 223177590061
Applicant Name KEVIN WATERBURY Subdivision (Name/Div/Block/Lot)
Applicant Address 2502 PERRY AVE 0 TR 6A OF SURVEY 3/82 TR A OF SP#345
City, State, Zip BREMERTON WA 98310 Installer Name Jack Johnson
Site Address'111111E Blacksmith Tahuya Rd Designer Name Jim Zimny
ii
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only ❑ Drainfiel ❑Repair ❑Other
System Type > [�& \\,11 treatment Type
- / YES NO
>5 ft. from foundation? � ❑ N A ® ❑
>50 ft. from wells? -5EE44-ZOZS - - - - - ❑ ® ❑
Z >50 ft. from surface water? - - - -- - - ❑ El
FQ- Cleanout between building and tank? - - - - - - -- ❑ ® ❑
U Tank baffles present? - By_ - - 0 ® ❑
a24"access risers over each compartment?- - ID In
W Effluent filter installed?- - ❑ ® ❑
cn
Septic tank capacity (working) 1200 gal Manufacturer Hagerman
a D-box water level and speed levelers used? - ❑ N/A ® YES ❑ NO
00 Manifold/D-box accessible from surface? - 0 Pi 0
co Check valves installed? - - ■ ❑ ❑
OQ
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
O >100 ft. from wells?- - ❑ ® ❑
W >100 ft. from surface water? - - ❑ Pi
u. >10 ft. from potable water lines?- - ❑ ® ❑
Z > 5 ft. from property lines and easements?- - 0 ill
d > 30 ft.from downgradient curtain/foundation drains? - - 0 ® 0
• Drainfield level and observation ports present - - ❑ ® ❑
II Graveless chambers or El Clean gravel used? (check one)
Proper cover installed over drainfield? - ❑ II ❑
Pump tank setbacks consistent with septic tank?- - iii N/A ❑ YES ❑ NO
• Pump tank capacity (flood) gal Manufacturer
< 24" access riser(s) and accessible from surface?- - ❑ ❑ ❑
d Alarm or Control Panel Installed? - - ❑ ❑ 0
E Control Panel equipped with Timer/ETM/Counter- - ❑ ❑ ❑
D
a Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
a• Pump Make/Model ❑ Floats or 0 Transducer
a_
a Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 8/2112G18
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Mason County OSS Installation Report pg. 2 Parcel# ?Z 3 I ") 7 S/-66(O f
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES ❑ NO
If yes, please describe: —
Were all components pumped out and property abandoned per WAC246-272A-0300? - - ❑ YES 0 NO
RECORD DRAWING
This is a permanent record and must be accurate and daseriplrve enough to reaocate in the need of maintenance activities and future development. Typical Record
Q'awind.nontan, O.o,nFoid&mandold onentatwn&iiyorA.Sepkbrinp tank kx•ahnn.North arrow reserve drevli rkl.exis nq end proposed burkirnos.location of weds.n'alenmes,
wells.observation ports.CIoanrl.l'_awl other marreena.re aeAASS[rants Incomplete Record['rewires may create edrdror'ai delays in final installation approval and rotated permits
❑ 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
foøj,
nd att hod Record Drawing is accurate form and attached Record Drawing is accurate.
S - / ."'2 S 1
Si.cure of Installer Date
--,JG c.Is! v k c riv ��I
Printed Name of Signee S •t,
MASON COUNTY PUBLIC HEALTH .A . •' '�+�I
The undersigned approves this installation Report and ;y , o:Y3033 my t
Record Drawing on behalf of Mason County Public .or°ticENs'E13 DESIGNER
Health: q ' r- L
9 Q_I-0\clitlyqL6vv\ '1- 12,1 tc l'
Signature of Environmental! hHealth Specialist Date (stamp.signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE UPrlereo&2+'2ola
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