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Home My WebLink AboutSWG2025-00079 - SWG As-Built - 4/1/2026 I % Mason County OSS Installation Report � P pg. MASON COUNTY PUBLIC HEALTH APPLICANT/PERMIT INFORMATION Permit Number SWG 2025-00079 Parcel# 31904-14 90020 Applicant Name Tad Smith Subdivision(Name/DIvBlock/L )ot Applicant Address 1540 E.Shelton Springs Rd. City,State,Zip Shelton,Wa 98584 Installer Name Proficient Excavation LLC Site Address 201 SE Ellis Rd Designer Name Bob Paysse INSTALLATION CHECKLIST F24 ystem Installlation O Tank(s)Only ❑Drainfield ONYQ� ❑Repair ❑Otherstem Type ire (5YQ lli' 1 Pretreatment Type N/A mfoundation? ---_______--------- WAmwells? -- --_ ® s ❑ NO msurfacewater? ❑between building and tank? • --_les present? --- � _`_----- ❑s risers over each compartme ____ _____ ® ❑ LUEffluent finer Installed?- -----__ _- _ __ ❑ e ❑ Septic tank capacity(working) 15 gal Manufacturer Sound Placement .0 D-box water level and speed levelers used? ------------- 3 Manifold/D-b - ❑WA IVES ❑ NO fl ox accessible from surface?----__-- ❑ flz Checkvalvesinstalled?--------------------- - - ❑ Transport Line Size 4" ❑ Schedule/Class 3034 Bedrooms installed(check one) ❑2 ❑3 I14 ❑5 ❑s >10 ft.from foundation? ❑Commercial/Other 1DDf#.fromwells?----------------- ---------- - ❑WA ®res ❑ NO>100 ft.from surface water?----_- _----------- _----- ❑❑------->10ft.frompotablewaterlInes?---------------------- ❑ ❑ >5 ft.from property lines and easements? -------------- - ❑ fl ❑>30 ft.from downgradient curtain/foundation drains?---------- ® ❑ O ® ❑ Drainfield level and observation ports present------------- O eraveless chambers or fJ Clean gravel used? (check one) Proper cover installed over drainfield?------------------ - ❑ Pump tank setbacks consistent with septic tank?------------ - 1!1 WA ❑ YES ® NO Pump tank capacity(flood) gal Manufacturer 24"access riser(s)and accessible from surface?------------- ❑ ❑ ❑ Alarm or Control Panel Installed?--------------------- ❑ ❑ ❑ Control Panel equipped with Timer/ETM I Counter ---------- O O ❑ Pump installed in O Bucket or ❑ On Block or ❑ Other Pump Make/Model ❑Floats or ❑Transducer Tank draw down in/min Pump capacity apm Squirt Height ft Pump on time Pump off time Daily flow set at apd Updated 812112018 •1 .4 Mason County OSS Installation Report pg,2 Parcel# 39904-14-90020 JillABANDONMENT RECORD Were existing septic components abandoned as part of this project? - if yes,please describe' -------- - ❑ YES Q No Were all components pumped out and properly abandoned per WAC246-272A-0300?------ ❑YES ❑ No RECORD.DRAWING_ This is a Pormaneft mcmd and must be aearede and deserlptiva enou mrawinge�nmane t to eld&tnantiotd orierrtaffon&Payout Se to 1v 4o in the need of realnionanee aetivitles and future develo Wets,absemWon• Ptidpump tank location,Nodh arrow,reserve draktfield, tmnedr. Typical Record Pods'cleanouts,and other tenence ads points.Incomplete Record DrerAh s eltLshrtg and Proposed buildings location a wells,ed errmes, 9 may crests additlonat do"Vs In final Installation approval and related permits, i II Record Drawing Attached CERTIFICATJ0N0FINSTALLATI0N. INSTALLER aESIGNERI ENGINEER I certify thatIinstalledthe 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 an 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 ��gring is accurate. form and attached Record Drawing is accurate. William Cooksey, „�„�,, ,,, March 23,2026 Signature oftnstaller Date William Ode Cooksey Pdrited Meme ofsignee MASON COUNTY PUBLIC-HEALTHY s8. The undersigned approves this Installation Report�l • sr Record Drawing on behalf of Map County P/ tic 51 -P I'7eafu�� /r�0 I� �,� R08ERTH MYSSE asul 4/7/ 'Y /d/CO I�77iP0 EXPIRES.. Si nature of Envirvnmenta/Health Specialist P (stamp,signature and date) THIS FORM MAYBE SCANNED AND AVAILABLE F t'JUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 851/7018 . I- 28b'-!- I- - - ___ - - IT I ! 1 I4U7 ii ! I PROPOSED 4 BEDROOM 720'-- GRAVITY DRAINFIELD I j I I (W/50'ATTN. ZONE) .1!, 1 : 1 4 4"3034 TRANSPORT LINE FI DRIVEWA 1 1- PROPOSED SEPTIC TANK (5O'+ FROM WELLS) I I _ I PROPOSED HOME 1L----------I 1 LOCATION O P Sr � \ �i ® PROPOSED ` � I a �� WELL \\\• / I NCO/NJ, ' ti SlS7S I •„-- N C9 yYdSy � "V AN ASBUILTI INSTALL SIGNOFF FEE WILL ��'�;p DIGGING, CHAR43ED AT TIME OF INSTALLATION PIONEER DIG . INC A T OE TFST HOLE l: TW HOLE ?br SIT. 26OXaA7TL SEPTIC DESIGNS ADDRESS: 201SEEUE RD ROYI'S@ 26 RuuTs c�26 (183 MAk7NBE�L N1t.D. �aR� EVIEW WA985 66 DESIGNER ROBERZTI-LPAYSSE uu wnu�cmrae r xEs su ,�ri,cwneowmvaiv�m almcE-360,42&1803 FAX-360.427-2353 vursa�suavtya n------ ae�wncawnaao anommroaOTh SHEEP: 91E PLAN SCALE• P.1(HY =1.1-. ,°° * ► m �„�„