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Home My WebLink AboutSWG2026-00054 - SWG As-Built - 4/22/2026 C Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/PERMIT INFORMATION Permit Number SWG ' D1 p- (X `{ Parcel# 2 () 9 — Applicant Name C?Vt'4 - 2QV\V\&cr Subdivision (Name/Div/Block/Lot) Applicant Address 9 a)%Rp A Ly \f e3 City, State, Zip UQ ro\o.\e 'W&_ cW 2 Installer Name j\AU,\ Site Address \�° E Lv\ Designer Narfle t-i INSTALLATION CHECKLIST 7[O1Full System Installation o.Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other System Type \ W\ COV Pretreatment Type D-O V\e- >5 ft.from foundation? ---------------------- ❑ NIA YES 0 N >50 ft from wells? --- ----------------- ❑ ❑ >50 ft.from surface water? ------ -- 1 QCleanout between building and tan - __ _ - ❑ ❑ v Tank baffles present? -------_ ___ `� ` ❑ ❑ H 24"access risers over each compartm _ __ 1__ ❑ ❑ a W Effluent filter installed?----______-__ ------- ❑ ❑ rn Septic tank size \v ��y gal � �'� r�nufacturer D-box water level and speed levelers used? --------------- ❑ NIA ❑YES o DO Manifold/D-box accessible from surface? ---------------- ❑ ❑ ❑ OQCheck valves installed? -___________________ _____- ❑ ❑ Z Transport Line Size Schedule/Class Bedrooms installed(check one) ❑2 ❑3 ❑4 ❑ 5 ❑ Commercial/Other >10 ft.from foundation?----------- ❑ N/A ❑YES ❑ NO >100ft.fromwells?------------- - ❑ ❑ ❑ W >100ft.fromsurfacewater?------------ ----------- ❑ ❑ ❑ u. >10ft from potable water lines?------ --------------- ❑ ❑ ❑ Qz >5 ft.from property lines and ease is?---------------- ❑ ❑ ❑ OC >30 ft.from downgradient c m/foundation drai ?---------- Drainfield level and o ation ports present --------- --- ---- ❑ ❑ ❑ ❑ Graveless catbers or ❑ Clean gravel used? (check one) Proper co installed over drainfield?------------------- ❑ ❑ ❑ Purftank setbacks consistant with septic tank?------------- ❑ N/A "f'YES ❑ No Pump tank size d(J20 gal Manufacturer *G� Z 1(' '\ < 24"access riser(s)and accessible from surface?------------- ❑ ❑ iF- o. Alarm or Control Panel Installed? --------------------- ❑ ❑ Control Panel equipped with Timer/ETM/Counter----- ------ El ❑ Pump installed in `6 Bucket or ❑ On Block or 0 Other O'r °-1 IL Pump Make/Model • C0NX C C._£)S ?O 1loats or ❑Transducer Tank draw down VJ A in/min Pump capacity 'N 4' pm Squirt Height 1J/6 ft Pump on time N l4 Pump off time -.3fA Daily flow set at / apd Updated 81212079 Mason County OSS Installation Report pg. 2 Parcel# ABANDONMENT RECORD Were existing septic components abandoned as part of this project? --------------- YES NO If yes, please describe: G1y'S\\'C G,v d, .( t;\Qd 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,Septidpump 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. 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 fu that all information contained on this I further certify that all information contained on this to and Record Drawing is accurate. form and attached Record Drawing is accurate. Sin of Installer Date 0 OLY w\ no, 76 Printed Name of Signee MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation�j b 1ft Record Drawing on behalf of Mason County Public He , Lfi/1Ulc 26 alt Sig fure of Environmental Health Specialist Dated '/i)ON�F (stamp, Signature and date) THIS FORM MAY BE SCANNED ANDAVAILABLE FOR PtIq1EW ON THE MASON COUNTY WEB SITE Updated nmrz018 RECORD DRAWING(continued) rft ___ �I E� \( - Z 1 S t 5 z Xo1 • cA1 2 42 I - , c ( F f 1 ot ic:i ) as (i. TQ 4s aP r •