HomeMy WebLinkAboutSWG2023-00489 - SWG As-Built - 12/19/2025 s
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2023-00489 Parcel # 220185000252
Applicant Name TRAN ET AL NGUYET Subdivision (Name/Div/Block/Lot)
Applicant Address 561 E Lake Shore Dr W
City, State, Zip Shelton, WA 98584 Installer Name Brandon Thompson
Site Address 561 E Lake Shore Dr W Designer Name Adam Hunter
INSTALLATION CHECKLIST
❑ Full System Installation ®Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type PP- 5Lif'-{ reatment Type N)A
>5 ft.from foiIi7atr? .
ndat - -- ® N/A ❑YES ❑ NO
>50 ft.from ells? _ _ 11- - - ® ❑ ❑
Z >50 ft.from ®� ��- ® El El
H Cleanout between building and tank? _ j .0 \ 1I ® ❑ ❑
U Tank baffles present? - \-1k ® ❑ ❑
a El Ell
access risers over each compartment?---- - -- - It
W Effluent filter installed?- -BY- - I ❑ ❑
N
Septic tank capacity(working) gal Manufacturer
0 D-box water level and speed levelers used? - - Q N/A ❑YES ❑ NO
BOLLJ Manifold/D-box accessible from surface?- - II El El
DOE Check valves installed? - -- Ill 0 ❑
6Q
2 Transport Line Size Schedule/Class
Bedrooms installed (check one) ❑ 2 0 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft.from foundation?- -- ® N/A 0 YES ❑ NO
0 >100 ft. from wells?- - ® El El
W >100 ft. from surface water? - - I ❑ ❑
LL >10 ft.from potable water lines?- - ® ❑ ❑
Z >5 ft.from property lines and easements?- 0 El CI
> 30 ft. from downgradient curtain/foundation drains? - - 0 ❑ ❑
Drainfield level and observation ports present - - 0 ❑ 0
❑ Graveless chambers or 0 Clean gravel used? (check one)
Proper cover installed over drainfield?- - UI ❑ ❑
Pump tank setbacks consistent with septic tank?- - 0 N/A Ill YES ❑ NO
Pump tank capacity(flood) 1250 gal Manufacturer ROTH
< 24"access riser(s)and accessible from surface?- - 0 It ❑
H
a Alarm or Control Panel Installed? - - It El
2 Control Panel equipped with Timer/ETM/Counter- - ❑ ❑ ❑
D
0. Pump installed in ❑ Bucket or 0 On Block or ❑ Other
d Pump Make/Model LIBERTY PRG101A ® Floats or ❑ Transducer
0.
a Tank draw down 1" in/min Pump capacity 128 qpm Squirt Height 36" ft
Pump on time 1 MIN 5 SEC Pump off time 4 Hours Daily flow set at 270 gpd
Upda:cd 8/21/2018
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Mason County OSS Installation Report pg. 2 Parcel# 220185000252
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - 0 YES ❑ NO
If yes, please describe:PUMP CHAMBER ABANDONED PER CODE
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - 0 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. Dramfiefd&manifold orientation&layout,Septicpump tank location.North arrow,reserve drainfield,existing and proposed buildings,location of wells.waterknes,
wets,observation ports.deanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays In final installation approval and related 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 inf rmation contained on this 1 further certify that all information contained on this
form and at ec wing is accurate. form and attached Record Drawing is accurate.
12/4/2025 - •
Signature of Installer Date of i `11j 5-i
��
it(
BRANDON THOMPSON 944:c 4.
Printed Name of Signee 00ti47 •'o,N;,�
•
MASON COUNTY PUBLIC HEALTH /a `rsl�
/� • f
The undersigned approves this Installation Report and �, 5100412
Record Drawing on behalf of Mason County Public ��',•' ADAM J.HUNTER %." ��
Health: % , t.
I).i 07•
\lbA31,\IACW L
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 8/21/2018
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