HomeMy WebLinkAboutSWG2025-00459 - SWG As-Built - 1/14/2026 1,
0
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG202S -00C45C1 Parcel #41 .32 - 1 -0000g
Applicant Name sTePfrcij an(*con Subdivision (Name/Div/Block/Lot)
Applicant Address 290 N. c32UGh 1a'- 1-Mc Cutwan tro -nR 8I6 `e1(2
City, State, Zip R)n- LuctLow:mqqN.05 Installer Name moors c vailrC�
Site Address 5 (�N-I/s1 ,CUolayAn Qt Designer Name IL S t (i Lid&
INSTALLATION CHECKLIST
❑ Full System Installation EfTank(s)Only 0 Drainfield Only 0 Repair 0 Other
System Type L►f\ c rion Pretreatment Type
>5 ft.from foundation? - - ❑ N/A ❑YES ❑ NO
>50 ft.from wells? - D Erifip9E_- - - • ❑ ❑ ❑
• >50 ft.from surface water? - ❑ 0 0
Z
Q Cleanout between building and tank? - /11/- 0 0 0
VTank baffles present? - jA" 1-2-1-026- - 0 0 0
0~. 24"access risers over each compart €14?- - - - - - - - -" t - ❑ 0 0
N1
Effluent filter installed?- ____ I-- 0 0 0
Septic tank capacity(working) gal Manufactiaier
0 D-box water level and speed levelers used? - - 0 N/A ❑ YES ❑ NO
00 Manifold/D-box accessible from surface?- - 0 0 0
t9-±- Check valves installed? - - 0 0 0
QQ
z Transport Line Size Schedule/Class
Bedrooms installed (check one) ❑ 2 0 3 0 4 0 5 ❑6 0 Commercial/Other
>10 ft.from foundation?- - 0 N/A 0 YES ❑ NO
el >100 ft.from wells?- - 0 0 0
W >100 ft.from surface water? - - El El
T. >10 ft.from potable water lines?- - 0 0 0
a > 5 ft.from property lines and easements?- - 0 0 0
ce > 30 ft.from downgradient curtain/foundation drains? - - 0 0 0
Drainfield level and observation ports present - - 0 0 0
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - 0 0 0
Pump tank setbacks consistent with septic tank?- - 0 N/A IVES 0 NO
• Pump tank capacity (flood) 5 S-L gal Manufacturer tine 11-iwfar S9O g4,1I t A
< 24" access riser(s)and accessible from surface?- - 0 0J 0
~ Alarm or Control Panel Installed? - - 0 0
a.
• Control Panel equipped with Timer/ETM /Counter- - `En 0 0
a Pump installed in ❑ Bucket or 6 On Block or 0 Other
a Pump Make/Model Z�c 11{� 24y ).,1�'S' Pv'"`P ❑ Floats or 0 Transducer
a
Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 8/21/2018
Mason County OSS Installation Report pg. 2 Parcel# 42332- ("0 oe�d
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - YES [l NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ YES 1211 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: Drainfield&manifold orientation&layout,Septic/pump tank location,North arrow,reserve drainfield,existing and proposed buildings,location of wells,waterlines,
wells,observation ports,cleanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
dRecord 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 Record Drawing is accurate. form and attached Record Drawing is accurate.
Signature of Installer Date
Shu,'t, Mat pi cc
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:‘e_Trtyy„p!,,a 1 I i`i I�
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
4
n
C''
4
i
N
W
N I �_
6
I /
cs' I I
3 0
a D -,� - s4-NDo 00 / , m
�0 I z 0
I
O
I z 4..._ O I , #`" l•rns � p h / S� D
I z r'.)4:1) 4 /y/"t jl O
��p� / S'
0
I T
z
CD
Q
i.
1
r
I
f
t