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HomeMy WebLinkAboutSWG2020-00079 - SWG As-Built - 1/15/2026 { CLEAR FORM Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2020-00079 Parcel # 12230-75-90142 Applicant Name Kerry Wooley Subdivision (Name/Div/Block/Lot) Applicant Address PO Box 541 TR 15-B OF SURVEY 2/108 LOT:2 OF SP#2744 AF#S30287 City, State, Zip Allen , WA 98524 Installer Name Kerry Wooley Site Address E 340 Sherwood Hills,Allen Designer Name Jim Zimny INSTALLATION CHECKLIST ® Full System Installation ❑Tank(s)Only El Drainfield Only ❑Repair ❑Other System Type Pretreatment Type >5 ft. from foundation? - - - - -- - ❑ NIA ® YES ❑ NO >50 ft. from wells? - � '`,---❑©❑z >50 ft. from surface water? - - - - Aq - - ❑ ® CI • Cleanout between building and tan - 31‘ ❑ ❑ ❑ ✓ Tank baffles present? - -4e. ❑ CI ❑ a 24" access risers over each compart --- - - -- ❑ 0 CI W Effluent filter installed?- ❑ ® ❑ Cl) Septic tank capacity (working) 12 gal Manufacturer Hagerman `CI D-box water level and speed levelers used? - - El N/A ® YES ❑ NO ><O Manifold/D-box accessible from surface?- - CIIt CI mz Check valves installed? - - ® ❑ ❑ O< 2 Transport Line Size 4" Schedule/Class 3034 Bedrooms installed (check one) ❑ 2 ❑ 3 ❑4 ❑■ 5 ❑6 ❑Commercial/Other >10 ft. from foundation?- - ❑ N/A 0 YES El NO G >100 ft. from wells?- - ❑ ❑■ ❑ W >100 ft. from surface water? - - Li IN ID u. >10 ft. from potable water lines?- ❑ ® ❑ Z > 5 ft. from property lines and easements?- - O ® O a cc > 30 ft.from downgradient curtain/foundation drains? - - ❑ © O ci Drainfield level and observation ports present - - El ® ❑ ® Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?- - ❑ IP ❑ Pump tank setbacks consistent with septic tank? - - ® N/A ❑ YES ❑ NO • Pump tank capacity (flood) gal Manufacturer < 24" access riser(s) and accessible from surface?- - ❑ ❑ ❑ a Alarm or Control Panel Installed? - - O ❑ ❑ 2 Control Panel equipped with Timer/ ETM/Counter- - O O ❑ m a Pump installed in ❑ Bucket or O On Block or ❑ Other _ a. Pump Make/Model El Floats or ❑ Transducer M D • 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# 12230-75-90142 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - [] YES ■Q NO If yes, please describe Were all components pumped out and properly abandoned per WAC246-272A-0300? - - O YES ■0 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 APPROVE JAN 15 2025 MASON COUNTY ENVIRONMENTAL HEALTH JBW El 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 Record Drawing is accurate. form and attached Record Drawing is accurate. rr c,c> I�.n 3-�2� Signature of atler Date Printed Name Signee - MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report and 0! 33 t. Record Drawing on behalf of Mason County Public uc� xr. tz stiff _. Health: 3 - a,2 (.1)I 01 -75d4 Signal re vironmental Health Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8/21/201S r 50' co .- u, . . i i / Dbox wi Locking lid riser %� I �TH #1 1 m ('I vi f2. NDtn w ` 1 " O O x 1 m f° =. TH43 o , water&Utiliies i c rho °; am ° g 376' - d N N` Th#2 N.. IP° co I L o__.� J 1 o `!� z ASbuilt Date: t- z 3/7/2022 Page Pa Designer nfo: r ,�, Applicant Info: � g Jim imny -� �l h �: APD D Kerry Wooley <, �;p 7178 Windflower PL NW Sr,:.' PO Box 541 F Scale � r �,�z o ,,�r,_ �� �y y�� Sea k,WA 98380 r, Allen, WA 98524 i r�rr,, z 122307590142 1" = 40' AP esigns@icloud.com - y-2-7✓