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Home My WebLink AboutSWG2026-00069 - SWG As-Built - 4/22/2026 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit.Number SWGZC1 O29 9 Parcel #-3I. Z 3k2ZO Applicant Name lie-ii 1 arr7 Subdivision (Name/Div/Block/Lot) Applicant Address'1029 t"t vic`' 1jt46'i) .City, State, Zip S4Ik,k'o ' 10 2_ Installer Name u�Q e. Site Address 13� S¢' S-1-S. Designer Name INSTALLATION CHECKLIST ❑ Full System Installation Tank(s)Only ❑ Drainfield ❑Repair ❑Other System Type w+✓L f'� ►�li c-=' ` retreatment Type Rt�cf >5 ft. from foundation? - - - - - - - - -- - - - --- ❑ NIA VYES ❑ NO P >50 ft. from wells? - - - - - - - �s - - - ❑ ❑ >50.ft. from surface water? - - - - - �� - - - - - ❑ ❑ Cleanout between building and tank. -�Q -- - - - - - ❑ ❑ CJ Tankbaftlespresent? - - - - - - - - - - - - - - - = - - -- ❑ ❑ d24"access risers over each compartme t - - - - - - - - ----- ❑ ❑ W Effluent filter installed?- - - - - - - - - - - - - - -= - - - - - -- - - ❑ ❑ U) Septic tank capacity(working) gal Manufacturer ® D-box water level and speed levelers used? - - - - - - - - - - --- - - ❑ N/A YES ❑ NO oOManifold/D-box accessible from surface?- - - - - - - - - - - - - - - - - ❑ ❑ mZ Check valves installed? - - - - - - - -- - =- - - - - - - - - - - - - - •- El ❑ 2 Transport Line Size Schedule/Class Bedrooms installed (check one) ❑ 2 ❑3 4 ❑ 5 O 6 ❑Commercial/Other >10 ft. from foundation?- - - - - - - - - - - - - - - - - - - - - - - - - - ❑ N/A YES ❑ NO >100ft. fromwells?-- -- -- - - -- -- - - - - - - - - - --- -- - - -- ❑ ❑ W >100ft. fromsurfacewater? - - - - - - - - - - - - - - - - - - -- -- -- ❑ ] 0 U >10 ft. from potable water lines?- - - -- - - - - - - - - - -- - - - - -- ❑ ❑ QZe� > 5 It. from property lines and easements?- - - - - - - - - - - - - - - - ❑ ❑ DC > 30 ft. from downgradient curtain/foundation drains?- - - - - - - - - - El to' ❑ ® Drainfield level and observation ports present - - - - -- - - - -- - - - ❑ ❑ ❑ ❑ Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?-- - - - - -- -- - - - - --- -- El ❑ ❑ Pump tank setbacks consistent with septic tank? --- - -- - - - - --- Nf YES ❑ NO ZPump tank capacity(flood) gal Manufacturer 24"access riser(s)and accessible from surface?-- - - - -- - - - - -- ❑ ❑ ~ El ❑ 0. Alarm or Control Panel Installed? - - - - - -- - - - - - - - - - - - -- - Control Panel equipped with Timer/ETM/Counter- - - - - - - - - - - 'tJ ❑ ❑ 0. Pump installed in ❑ Bucket or On Block or ❑ Other a Pump Make/Model loats or�F ❑ Transducer Tank draw down in/min Pump capacity gpm Squirt Height ft Pump on time Pump off time Daily flow set at gpd Updated 8'21/2018 'Masan County 058 Instaflatl!on Report pg. 2 parcel# 3 l90Z L!''3"` 93O ABANDONMENT RECORD Wele existing septic car vents aaan 'ones as part o. this pr ;ec -- - - - - --- - - - - YESD NO ii yes, please describe:- 6 d� r<` G�� Were all components pumped but and property a andoned 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 mainteratce access po°nts. Incomplete Record Drawings may create additional delays in final installation approval and related permits. z , ( Record Drawing Attached CERTifCAT gON OF INSTAL ON INSTALLER DESiG11ERi Et GUNE•ER 1 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 :wison County Public Health and that any deviations here have been cleared/approved by both the designer shorn,here have been cleared/approved by both..- aand Mason County Public Health and,meet all State -nyser'f anti'Mason County Public Health and meet all and Mason County Codes. State and Mason County Codes I further certify that ar'i form-^ti n cantairc ci on this : sirr:;hcr edify t"iat all information contained on this �' ` ," f ' ,�: rr e. 2: ;brm and attached Record Drawing is accurate. fo r, and aitac. c Record� ..1ra, :r:,ry is�cc::, -,�, Signature ofIr ° � Date Printed Name of Signee �^ MASON COUNTY PUBLIC HEALTH; The undersigned approves this Ir•stallation Record Drawing on ber elf of Mason County Public' Health: d42 / 1 (z Signature of Environmental Health Specialist Date /�'rpN� (star,-p, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR VlrW.ON THE MASON COUNTY WEB SITE Updatac 5(21!2018 ZT�, lGm lfAV Feld& manifold orientation u &layout r `3'p f' ions and 3 X - a cticaal dial ® with layout ' 44s N 4P1p ��tank ( 5 6. cOO �? 6 p`racet=t 2r� _ I3FN�� C1� R d stn of ®`'4�iy�,�F�✓Tq /buildings / F JV Observation�t&• �„ �t nsl�•,r7 9Th /clean-out location �1 Location of wells& ; ads Undiaturbed native { soil between � I�IaarEh arma� 't �i al r s � FEE! �•^K _L_ i) CAUTION:Minor septic taut location and efrr.z141e1d ordentat on made to the field by thlier.ar table the desig�a to both amd the design could ale fmsttrita cxrsts povnose 3lte viab�dity the sysj�it,,1t is e' 's mobility the system. Ase�' fro �imtst�bes above + �' J hat affect Inetal1Il Check a box from Inv"A"and"B",sign and date the•certific ation A. I certify that I sastelPed the system without any C I certify that all deviations from the design,stamped deviation from the design stamped"APPROVED"by ° "APPROVED"by MCPH am shown above. MCPH 1I. ® I certify that I contacted the designer and left the I did not contact the designer prier to foal cover because the system opon for inspection t to 48 hrs prior to cover, designer waived the notification iegarirenasat, I further certify that all infimnotion contained on this form is acctnate. I undcx Land that if the' herein is not accurate,there will be just cause for ivanadiate suspension of my installer certificartaon. q tare of er stn uadsiged appaova:s this installation on behalf of Mason County Public Health.Sigaturcof anitarian Date