HomeMy WebLinkAboutSWG2026-00033 - SWG As-Built - 3/23/2026 Mason County OSS Installation Report pg. 'I MASON COUNTY PUBLIC HEALTH
APP.LICANTLPERMIT,,INIFORMAT N,_. .'
Permit Number SWG 2026-00033 Parcel# 22030-13-90031
Applicant Name Shelly Avery Subdivision (Name/Div/Block/Lot)
Applicant Address 5630 SE Arcadia Rd
City, State, Zip Shelton, WA 98584 Installer Name Maples Excavating
Site Address same Designer Name Arrow Septic Designs, Inc
INSTALLATION CHECKLIST
❑ Full System Installation ❑■ Tank(s)Only ❑ Drainfield Only ❑ Repair ®Other High-Level Alarm panel
System Type RV Holding Tank Pret atment Type
>5ft.fromfoundation? - ----- - - - -- -- - p}y�q�A ❑ N/A ❑■ YES O N
>50ft.fromwells? - - - - - - - - - - - ❑ ❑
>50ft.fromsurfacewater? - - - -- - - -- El El
Cleanout between building and tank? - - -\'- - "- - - --- ❑ ■❑ El
Tank baffles present? - - - -- - - - - - - - - -- - El III El
24"access risers over each compartment. - — - ❑ 0 El
y ❑
UJ Effluent filterinstafled?-- - - - - - - -- - - - - - - - - - - - ❑ ❑ ■
Septic tank capacity(working) 1,500 gal Manufacturer Hagerman-single comp, no outlet
D-box water level and speed levelers used? -- - ------- - -- -- ❑ N/A ❑ NO
Manifold/D-box accessible from surface?-- -- - - ---- - -- ❑ ❑
00�.'' Check valves installed? - - - - - - - - - - - - - - - - - - --- - ❑ ❑ ❑
Tra ize Schedule/Class
Bedrooms installed (check one) ❑ 2 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10ft.fromfoundation?- - - - - - - - -- - - - - - - - - - - - --- - - ❑ NIA ❑ NO
>100ft. fr::l: e ; :ii:iiiiiiiiiiiiiiiiiil ?---- - - ❑ ❑ El
—t ❑ ❑
: >10ft.frompotablewaterlines?- - - - -- - - --- - -- -- - - ❑ ❑ El
> 5ft. from propertylinesand easements?-- - - - - - - - -- - - - El ❑ El
fY. > 30 ft from downgradient curtai ation drains?- -- - - - ) -, � L ❑ El
Drainfield level and o ation ports present - - -` �^❑ ❑ ❑
❑ Grave ambers or ❑ Clean g a_eledw? (check one)
per cover installed over drainfield? -- � - -- -- - --y - --
Pump tank setbacks consistent with septic fat4 - - ` �1��`,�h-`\ ❑ N/A ❑ YES NO
Pump tank capacity(flood) gal �; }"F
24"access risers and from surface? ---nufact,are7
p ty
riser(s) accessible -- ------ ----- ❑ ❑
AlarmorControlPanelInstalled? - - --- - - - - - - - - - - - - - - - ❑ El ❑
Control Panel equipped with Timer!ETM/Counter - - - - - - - - - El ❑ ❑
...... .......
Pump installed in ❑ Bucket or ock or ❑ Other
Pump Make/Model El Floats or ❑ Transducer
"Tank draw in/min Pump capacity gpm Squirt Height ft
ump on time Pump off time Daily flow set at gpd
Updated 8/21/2018
2i'Ou 0 � O 0 1
Mason County OSS Installation Report pg. 2
Parcel# -
ABANDONMENT RECORD
---------- --- - YES ® NO
Were existing septic components abandoned as part of this project? ❑
If yes, please describe: ❑ NO
Were all components pumped out and properly abandoned per WAC246-272A-0300? -------- ❑ YES
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.deanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
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® Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER!ENGINEER
I certify that I installed the system in accordance with /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
/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.
ii- 22
Signature of Installer Date
Printed Name of Signee •d.", '•z�t�
GA �
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
R ord Drawing on behalf of Mason County Public PAULA JOY JOHNSON •;y�
e ith: LIC i~b� �� N�cllz
�✓ � exPll�s�3srs
tgna f 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 61018
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