HomeMy WebLinkAboutSWG2024-00423 - SWG As-Built - 5/18/2026 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPI.lCANT1 PERMIT INFORI ATl (
Permit Number SWG 2024-00423 Parcel# 32021-55-01013
Applicant Name Empire Home Construction Subdivision (Name/Div/Block/Lot)
Applicant Address P.O. Box 241 SHORECREST TERRACE 2ND ADD BLK: I LOT: 13
City, State, Zip Kelso,WA 98626 Installer Name Mason County Excavating
Site Address 111 E Ashwood Ln, Shelton Designer Name Arrow Septic Designs
q �+ pP CHECKLIST
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Ii 1STALl TlON-ChIECKLIST
® Full System Installation ❑Tank(s)Only El Drainfield Only El Repair ❑Other
System Type Shallow Pressure Pretreatment Type NuWater BNR-500
>5ft. fromfoundation? -- ----- - - --- ---- - - -- - - - -- ❑ N/A OYES NO
>50ft.fromwells? - - - - - - - - - ---- - -- - � - - - ❑ 0 ❑
>50ft.fromsurfacewater? - - - - - - -- El 0 El
-- - - -Cleanout between building and tan -' - ❑ 0 ❑
0,16 -
.Tankbafflespresen₹? - - - - - - - - - ❑ ■❑ ❑
24°access risers over each compartrr�t �it?- ------- ❑ 0 El
tti w Effluent filter installed?- - ------ t`-- - - - - - - �- El El 0
Septic tank capacity(working) NUW t r 5QO- a Manufacturer Hagerman
D-box water level and speed levelers used? - - - - -- - - ---- -- - El N/A ❑ YES 0 NO
`�O-`• Manifold/D-box accessible from surface?-- - - - - -- - -- - - ---- El 0 ❑
p�
Checkvalvesinstalled? -- - - - - - - -- - - - - - - -- - - - - - - - - ❑ 0 El
Transport Line Size 2 inch Schedule/Class 40
Bedrooms installed (check one) ❑ 2 0 3 ❑4 5 ❑6 ❑Commercial/O₹her
>10ft.fromfoundation?- - - - --- ----� - -- --- - --- -- ❑ N/A ❑ YES NO
>100ft from wells?------- -- ------- - --- --- -- ---- ❑ ❑■ ❑
-°t ' >100ft.fromsurfacewater?- - - - - - -- -- ----- -- -- - - - -- ❑ ❑■ ❑
111
>10 ft.from potable water lines?- - - - -- - - ----- -- --- -- - - ❑ 0 El
> 5ft frompropertylinesandeasements?--- - - -- - ----- - - - El !❑ ❑
30 ft.from downgradient curtain/foundation drains? - - - - - - - - ❑ UI ❑
Drainfield level and observation ports present - - - -- - - - - ---- - ❑ 0 El
0 Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed overdrainfield?--- - - -- --- - - --- - - - - ❑ 0 ❑
Pump tank setbacks consistent with septic tank?-- ---- - --- - -- El N/A 0 YES ❑ NO
Pump tank capacity (flood) 1,000 gal Manufacturer Hagerman
24" access riser(s)and accessible from surface?-- -- ----- -- -- ❑ 0
Alarm or Control Panel Installed? ----- - - - - - -- - - - - - --- - ❑ 0 ❑
Control Panel equipped with Timer!ETM/Counter- - - - - - - - - - - ❑ 0 ❑
Pump installed in ❑ Bucket or 0 On Block or ❑ Other
Pump Make/Model Zoeller N152D Q Floats or ❑ Transducer
Tank draw down 2.5 in/min Pump capacity 48 gpm Squirt Height 10 ft
Pump on time 1.8 min Pump off time 6 hours Daily flow set at 360 gpd
Updated 8/2112018
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Mason County OSS Installation Report pg. 2 Parcel# 3202 l SS _C\ 0 t
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? -------- ❑ YES ❑ NO
RECORD DRAWING
This is a permanent record and must be accurate and descriptive enough to relocate 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,erdsting and proposed buildings,location of wets,waterlines,
wells,observation ports.eleanouts,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
1 certify that!installed the system in accordance with /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
1 further certify that all information contained on this /further certify that all information contained on this
form and atta ed Record Drawing is accurate. form and attached Record Drawing is accurate.
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Signaf of Installer Da
Pills& tr
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public 510034g \
Health: PAULA JOY JOHNgpN 'y°
�jQ� �� ��St�rllr•�{" -
Signature of Environment I 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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�a MAY 1 2026
MASON COON7 I In d. ` S10b349. •' • �:
��1ROPd ��• PAULA'JOY JOHNSt3(V"� C.
RED MENTAL HEAT tic KU jigw5IR. .