HomeMy WebLinkAboutSWG2025-00180 - SWG As-Built - 4/30/2026 1
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG - 0O't-90 Parcel # t-fo -5 a. - 6)000(-1
Applicant Name Je z11 E:'t +„� ��� ����� Subdivision (Name/Div/Block/Lot)
Applicant Address 1f() 1 /V '3 $4 J a4cl r~u�.f'5
City, State, Zip '' cLGF L./A Installer Name tJ ,k'v .
Site Address 2 6 1 r7 bt✓y ft1 Designer Name '44-►r
MTALLATI.ON CHECKLIST .
❑ Full System Installation rTan (s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type t - W - 4' i' Pretreatment Type____________________ ®�
>5 ft.from foundation? -- -- ---- - - - E N/A ❑YESj No
>50ft.fromwells? ---- --- --- -- ----- - -- -- - - ❑ ❑
Z >50 ft. from surface water? --- - - - - - -AP- - .=z��� - ❑ J' ❑
Cleanout between building and tank? - - -- -- - �'-Q--(�- - --- ❑ �' ❑
v Tank baffles present? - - - --- - - - - Sy- -C `-'�_- - - ❑ ❑
a24"access risers over each compartment --- --- -- -- - El I' El
CLU/)
Effluent filter installed?-- - --- - - --- - ----- -- ---- --- -- 9 ❑ ❑
Septic tank size d>__ gal Manufacturer
.0 D-box water level and speed levelers used? ---------- ---- - , N/A ❑ YES [] NO
O ' Manifold/D-box accessible from surface?-- -- --- -- ------- - El El
M2 Check valves installed? -- -- - -- - - - - - - - Eloa - - -
❑
E Transport Line Size Schedule/Class
Bedrooms installed(check one[) El 2 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other 1/D
>10ft.fromfoundation?-- -- - - - - -- - - - --- -- -- - - - - -- ®"N/A ❑ YES ❑ No
>100ft.fromwells?- - - ----- -- - ----- -- - -- -- - --- -- ®' ❑ ❑
>100ft.fromsurfacewater? --- - - - -- --- --- -- -- --- - - - Js� El El
w
>10ft. frompotablewaterlines?--- - -- - -- - -- -- -- - - - - - - ® El ❑
> 5ft. frompropertylinesandeasements?- - - --- -- -- - - - - -- �f El El
> 30 ft.from downgradient curtain/foundation drains? -- - - - - - - - - El ❑
Drainfield level and observation ports present - - -- -- -- - - - - -GraveJess chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- --- - - -- - -- --- - - - -- a El El
Pump tank setbacks consistent with septic tank? ----- ------- - ❑ YES ❑ NO
Y Pump tank size gal Manufacturer
24"access riser(s) and accessible from surface?----- -- - - - - -- ❑ ❑
Alarm or Control Panel Installed? -- - -- - -- ----- -- - -- - - - [CF� El El
Control Panel equipped with Timer/ETM /Counter - --- - -- - - - ❑ ❑
Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
(L Pump Make/Model ❑ Floats or El Transducer
Tank draw down ' in/min Pump capacity gpm Squirt Height ft
Pump on time _ Pump off time Daily flow set at gpd
Updated 8121/2018
a,
Mason County OSS Installation Report pg. 2 Parcel# L/Z2-0 1 . L VOCl()L(
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? -------- Nr YES NO
RECORD DRAWING
This is a permanent record and must he accurate and descriptive enough to re-locate in the need of maintenance activities and future development. Typical Record
Drawings contain: Dralnfleld&manifold orientation&layout,Septicipump tank location,North arrow,reserve dralnfleid,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 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.
SiaturIntalIer Date
Printed Name of Signee i5as"r,j;t; (),
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and "' ril.u.tt2r t.
ADAM J,I•luNJ'flp2
Record Drawing on behalf of Mason County Public çCiiri ,i t l'i' f,1t,''
Health: t;.t.::r:; ,. .
Signature of Environmental ealth Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8/21/2018
RBM IS GROUND EL.@ PROPERTY CORNER(RBM=100.0)
ABANDONED SEPTIC TANK(PER CODE)
EXISTING NUWATER BNR500 ATU TANK(IN.EL.-98.5/OUT.EL.-98.2)-TANK,RINGS,RISERS H20 RATED
/.� •� ea WBATERLINE (10 TO SEPTIC COMPONENTS)
KING SP CE - - - as-�-� - - - -
a '
QOO I �I
LL
Z� > I I I I o
N
S B UT/CL AOUT(I .-99.0)
w k ❑ of ' RAFFIC B FRIER
HOOD CANAL
x FOUNDATI Ill
FOR 1 B M CAB ( w
Z Q J
I I
LI L_ _
5.0 35'SETBACK LINE TAO; A'WALL
70' STEPS
SCALE-1"=20'-0"
SITE IS FLAT
APPROVED
APR302026
MASON COUNTY ENVIRONMENTAL HEALTH
RET
JIM HUNTER & ASSOC. CONTRACTOR
P.O. BOX 162, OLY,WA 98507 JOHN KING
;� :� 04/.226-��:. 753-1226
fi
Fdr JHANDASSOCIATES@HOTMAIL.COM INSTALL DATE- 12/2025
lam` SITE ADDRESS/LEGAL
r,.
RECORD DRAWING
25540 N HWY 101
•` ! 'v' OWNER- BOB WOODCOCK
=t r FINAL DATE- 12/2025
AOAL J-NUNiER
�i'r��ii? .5It•
TP# 422015200004 SITE# 2025-00180