HomeMy WebLinkAboutSWG2021-00107 - SWG As-Built - 3/6/2026 c
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT!PERMIT INFORMATION ,' :
Permit Number SWG 2021-00107 Parcel # 32104-58-00040
Applicant Name Daniil Dozhuk Subdivision (Name/Div/Block/Lot)
Applicant Address 20213 71st St E Alderbrook G&Y/Div9/Lot 40
City, State, Zip Bonney Lake,WA 98391 Installer Name TJ's Excavating
Site Address 20 E Susan Ct, Union Designer Name Arrow Septic Designs, Inc
INSTALLATION:CHECKLIST
0 Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair IJ Other x,000 Gal Pre-Trash Tank
System Type Shallow Pressure Trench et atment Type NuWater BNR500
>5 ft. from foundation? - ;--; 1.�� ❑ N/A Ei YES El NO
. >50 ft. from wells? 3r-t \ .I - 7 ❑ El
>50 ft. from surface water? 6 5 10- -; Li o
1,16
...-,<. : Cleanout between building and tank? - - 1 -v R - ❑ ❑■ l=1
cy Tank baffles present? - - - - - ❑ 0 ❑
6- 24°access risers over each compartment? By ❑ 0 O
_;LU. Effluent filter installed?- - ❑ ❑ ❑■
Septic tank capacity(working) NuWater 500 gal Manufacturer Hagerman
'3 D-box water level and speed levelers used? - - ❑ N/A ❑ YES ❑� NO
C3.,. Manifold/D-box accessible from surface? - ❑ 0 O
00E. Check valves installed? - - - - .0t* _PuS3 - v\- - ❑ 0 O
044';
j' 2; Transport Line Size 2" Schedule/Class 40
Bedrooms installed (check one) ❑ 2 0 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft.from foundation?- - - - - Se_ - O` ❑ NIA ❑ YES ❑■ NO
>100 ft.from wells?
•
u >100 ft. from surface water? - - ❑ 0 ❑
L,:::. >10 ft.from potable water lines? Ali E. ti 0 ❑
> 5 ft. from property lines and easements?- z 6. t Di n'-'
`� iv "
g � r ❑
> 30 ft,from down gradient curtain/foundatlo;tG,iins? aria
,
Drainfield level and observation ports prese,h$j 4- -MAR .-6-arf a - ii9 0 ❑
❑ Graveless chambers or 0 Clean grvi.VIGuseO�N(9I1PPJ 10)1ENTAL HE�,LT'HI
Proper cover installed over drainfield?- S ;_ - - - ❑ 0 ❑
Pump tank setbacks consistent with septic tank?- - ❑ N/A 0 YES O NO
k,., Pump tank capacity (flood) 1,000 gal Manufacturer Hagerman
:..4-.:: 24"access riser(s) and accessible from surface?- - D 0
Alarm or Control Panel Installed?
.Ta:':-::Control Panel equipped with Timer/ETM/Counter- - ❑ 0 ❑
;..Pump installed in ❑ Bucket or 0 On Block or ❑ Other
-EL,
Pump Make/Model Liberty 250 ❑! Floats or O Transducer
;``Tank draw down 2 in/min Pump capacity 38 qpm Squirt Height 4 ft
,;:: :, Pump on time 2.3 min Pump off time 6 hr Daily flow set at 360 gpd
Updated 8/21/2018
,
2 �`� -� �
Mason County OSS Installation Report pg. 2 Parcel#_ 3
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ❑ YES 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 S manifold orientation&layout.Septic/pump tank location,North arrow.reserve drainfield,existing and proposed buildings,location of wells,waterlines,
wells,observation pons,cleanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
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MASON COUNTY ENVIRONMENTAL HEALTH
J n I P:! ® Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
/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 Re rd Drawing is accurate. form and attached Record Drawing is accurate.
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Signatu---9
e of Installer Date
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Printed Name of Signee . '~s VA y ^%.a
MASON COUNTY PUBLIC HEALTH �;w.. % y�` �.,J•,�',,
i The undersigned approves mis Installation Report and .1-10'
i-•;!...:;-. .''1.9 PP P 1' 5100349
Record Drawing on behalf of Mason County Public Q: PAULA JO`(JOHNSON '•.'f•'H-al : i.tall.t15Vc:S';C;t:NRt..
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EXPIF2S-t 91151
U Ai.% 540--- c 3 —s—Zcp
Si. at• nvirh ental Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE updated a212°ta
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