HomeMy WebLinkAboutSWG2025-00021 - SWG As-Built - 2/26/2026 li .. T
Mason County OSS Installation Report p€g. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORM ,TION
Permit Number SWG 2025-00021 Parcel# 32016-53-05023
Applicant Name Empire Home Construction, LLC Subdivision (Name/Div/Block/Lot)
Applicant Address P.O. Box 241 SHRCRST TERRACE 4TH ADD BLK: 5 LOTS:23-24
City, State, Zip Kelso, WA 98626 Installer Name Mason County Excavatng
Site Address 31 E Sherwood PI, Shelton Designer Name Arrow Septic Designs, Inc
INSTALLATION CHECKLIST
Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair ❑Other
System Type Shallow Pressure Pretreatment Type NuWater BNR-500
>5 ft.from foundation? ❑ N/A 0 YES ❑ NO
>50 ft.from wells? - 0
ar -vwE
Q E-_,• >50 ft.from surface water? - r, El ❑
At Cleanout between building and tank? - -- - - . ElU, ; Tank baffles present? - FEB t 7 le n_ - It ❑
i24"access risers over each compartment?- - I ❑
LU Effluent filter installed?co) 8 B� _ - ❑
Septic tank capacity(working) NuWater 500 gal Manufacturer Hagerman
❑ D-box water level and speed levelers used? - - ❑ N/A ❑ YES ❑■ NO
®O Manifold/D-box accessible from surface?- - El ❑
DP.2 Check valves installed? -- - - --' - '"Af --V°`"" - ❑ 0 ❑
2 i; Transport Line Size 2 inch Schedule/Class 40
Bedrooms installed (check one) ❑ 2 0 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A ■❑ YES ❑ NO
>100 ft.from wells?
>100 ft. from surface water?- - ❑ 0 ❑
u_ >10 ft.from potable water lines?- - ❑ 0 ❑
> 5 ft. from property lines and easements?- ❑ 0 ❑
> 30 ft,from downgradient curtain/foundation drains?- - ❑ 0 ❑
el
Drainfield level and observation ports present - - ❑ ® ❑
® Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ a ❑
Pump tank setbacks consistent with septic tank?- - ❑ N/A 0 YES ❑ No
Pump tank capacity(flood) 1,000 gal Manufacturer Hagerman
Z El ® El
;;24"access riser(s) and accessible from surface?- -
et. Alarm or Control Panel Installed? - - ❑ ® ❑
* Control Panel equipped with Timer/ETM/Counter- - ❑ ® ❑
a- '!'Pump installed in O Bucket or ID On Block or ❑ Other
C' Pump Make/Model Zoeller N152
E. ❑■ Floats or E1Transducer
• Tank draw down 2.25 in/min Pump capacity 43 gpm Squirt Height 9 ft
Pump on time 2 min Pump off time 6 hours Daily flow set at 360 gpd
Updated 8/21/2018
4
Mason County OSS Installation Report pg. 2 Parcel# 32 0<<0— S3—OS 02-5
23
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES Dli NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - 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: 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.
. (5\02'
[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 /further certify that all information contained on this
form and atta ed Record Drawing is accurate. form and attached Record Drawing is accurate.
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Signature of Installer Date .
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Printed Name of Signee r �;
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MASON COUNTY PUBLIC HEALTH s�,
The undersigned approves this Installation Report and � .�" "`
Record Drawing on behalf of Mason County Public f r: 5100349 . .ii
Health: ,S-PAULA JOY JOHNSON y\
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Signature of Environments.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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• • '}. MASON COUNTY ENVIRONMENTAL HEALTH .
y��' 5100349 .:StV{)\
i°�' PAULA JOY JOHNSON '5"\A RET
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