HomeMy WebLinkAboutSWG2025-00057 - SWG As-Built - 5/18/2026 Mason County OSS Installation Report pg.
MASON COUNTY PUBLIC HEALTH
�ppLICAdTs`'PERMI_T 41F®RIATI�
Permit Number SwG 2025-00057
Parcel# 32021-55-01012
Applicant Name Empire Home Construction
Subdivision (Name/Div/Block/Lot)
Applicant Address P.O. Box 241 SHORECREST TERRACE 2ND ADD BLK: 1 LOT: 12
City, State, Zip Kelso,WA 98626 Installer Name Mason County Excavating
Site Address 121 E Ashwood Ln, Shelton,WA Designer Name Arrow Septic Designs
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Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair ❑ Other
NuWater BNR-500
System Type Shallow Pressure Pretreatment Type
��, r - ❑ N!A 0 YES ❑ NO
- ❑
>5ft.fromfoundation? --- - ---- = -
t
; f
' f ! i'- I_ ❑
>50 ft. from wells? - - - - - - - - - -- �j-JE� ll� ❑
>50 ft. from surface water? --- - - - - - -
0 6 2026- -+►� r - ❑
Z,. b- ----- - -1 L . ❑ ❑
Cleanout between building and tank? - ❑ ❑
--- - - - -- - - -
: Tank baffles present? --- - - - - -- - - ❑ 0 ❑
24"access risers over each compartm - - - ❑ ❑ ❑
- - - -- - - - - - - - - -
ddy Effluent filter installed?-- --- - --- - ---
t9d 'S®o Hagerman
Septic tank capacity(working) NuWater BNR gal Manufacturer
? - - ------ - - ❑ YES Q NO
D-box water level and speed levelers used'?
- NIA
❑ ® ❑
� '. Manifold/D-box accessible from surface?- -- - - - ------ - --- ❑ ❑ ❑
Ot ---- -
`0I3,�, Check valves installed? - - - - - --- - - - - - - - - - - - -
o-�
Transport Line Size
2 inch Schedule/Class 40
Bedrooms installed (check one) ❑ 2 13 ❑4 ❑ 5 ❑6 ❑Commercial/Other
--- - - - --- - - NIA YES ❑ NO
>10ft.fromfoundation?- -- - - --- - --- - - - ❑
>100ft. fromwells?- ---- - - -- - -- -- -- - ---- ---- --- ❑
�> >100 ft.from surface water? -- - - -- -- - ------ ------ - - - ❑ O ❑
>10ft. frompotablewaterlines?- - - ------ - -- - - - --- - - - - ❑ O ❑
:,.
> 5 ft. from property lines and easements?- - -- - - - - --- - - - - - ❑ ❑ ❑
30 ft,from downgradient curtain/foundation drains?- - - - --- - - - ❑ ❑
Drainfield level and observation ports present - - - - - - - -- - - - - -- ❑
® Graveless chambers or ❑ Clean gravel used? (check one)
..y -- ----- ------ a
Proper cover installed over dramfield, ---- -- ❑
:. ..
Pump tank setbacks consistent with septic tank?-- ---- -- --- -- O NSA I1 YES ❑
NO
Pump tank capacity (flood) 1.000 gal Manufacturer
Hagerman
24° access riser(s) and accessible from surface?------ --- - --- ❑ ❑
s ❑
Alarmor Control Panel Installed? ----- - -- -- - - - -- - - -- - ® ❑
Control Panel equipped with Timer/ETM/Counter-- - - --- -- - - O
Pump installed in ❑ Bucket or ® On Block or ❑ Other
�- Pump Make/Model Zoeller N152D 0 Floats or` ❑ Transducer
Tank draw down 2.5 in/min Pump capacity 48 gpm Squirt Height 12 ft
Pump on time 1.8 minutes Pump off time 6 hours Daily flow set at 3
Updated 821!2018
S
Mason County OSS Installation Report pg. 2
Parcel# �ZO Z t —� d t
ABANDONMENT RECORD
--------------- YESj NO
Were existing septic components abandoned as part of this project.
if yes, please describe: ❑
Were all components pumped out and properly abandoned per WAC246-272A-0300? -------' YES NO
❑
RECOR® ®RAVIIING
This is a permanent record and must be accurate and descriptive enough to re-locate in the need of maintenance activities and fuwte development Typical Record
Drawings contain: Drainlield&manifold orientation&layout,Septic/pump tank location,North arrow,reserve drainfield,ebsting and proposed buildings,Ioc anon 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.
Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that 1 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
/further certify that all information contained on this I further certify that all information contained on this
form and atta ed Record Drawing is accurate. form and attached Record Drawing is accurate.
OS DL /Z(,
signatih of Installer date
Pl1 C y\ V r\
Printed Name of Signee :_J;a`�p►�1
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County PublicpgULA '1 y 03J0HNS0N '
Health: ((/��
Signature of 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 8212018
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P Ra 705�S7 p
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\ \ O Audio-Visual Alarm
tiJj O2 Cleanout
I> r O NuWater.BNR-500 ATU Tank
O 1,000 Gallon Pump Chamber
O5 Valve Control Box
APPROVED
Mg 16 2026
MASON COUNTY ENVRONMENIAU HEALT
5900349 „r
PAULA JOY JOHNSON
EXPi f1