HomeMy WebLinkAboutSWG2026-00123N - SWG As-Built - 5/18/2026 s
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2ø2. 'A CO IZ3 Parcel # t123b7.. o OmLIZ
Applicant Name `lI'i�y_ 4 e Subdivision (Name/Div/Block/Lot)
Applicant Address )3&)3& 1311
City, State, Zip i.t A 983-70 Installer Name flir2Ør7�JK
Site Address 71 a' TtA7≥t DL Designer Name
INSTALLATION CHECKLIST
❑ Full System Installation Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type &� / Pretreatment Type
>5 ft. from foundation? .- - -- - - . - - - - - - ❑ N/A YES ❑ No
Z >50 ft. from wells? - - - - - - - - - - - - - - -R - - - - ❑ ❑❑
>50 ft. from surface water? - - - -- - - -
CC Cleanout between building and tank? -- - - -- ❑
Tank baffles present? - -- - - - - - - -
- - -Mgt] -- - - --
P 24"access risers over each compartment? - - ---- - - -- -- ❑
`W Effluent filter installed?- - - - - - - - - - -
-
- - - - .--�� ❑
Septic tank capacity(working) I 1 gal Manufacturer If11 i(1ZM & 1M^ IDtad
O D-box water level and speed levelers used? - - - - - - - - - - -- - - - ❑ N/A ❑YES ❑ NO
OJ
O Manifold/D-box accessible from surface?- - - - - - - - - - - - -- - - - O ❑ ❑
LL
DQ Check valves installed? - - - - - - - - - - - - - - - - - - - - -- - - ❑ El El
4 Transport Line Size Schedule/Class V �o'"�
Bedrooms installed (check one@ ❑ 2 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - - - - - - - - - - - - - - - - - - - - - - - - •- ❑ N/A ❑ YES NO
>100ft. fromwells?-- -- - - - - - --- - - -- - -- - -- -- -- --- ❑ El ❑
—i >100 ft. from surface water? - - - - - - - - - - - - - - - - - - -- - -- El ❑
Z >10 ft. from potable water lines?- -- - - - - - - - - - - - - - - -- - -- ❑ ❑ ❑
>5 ft. from property lines and easements?- - - - - - - - - - - - - - - - ❑ ❑ ❑
>30 ft.from downgradient curtain/foundation drains? - - - - - - - - - - ❑ ❑ ❑
Drainfield level and observation port present - - - - - - - - - - - - - - El ❑ ❑
❑ Graveless chambers or ❑ Cl1ean gravel used? (check one)
Proper cover installed over drainfielc{?- - - - - - - -- - - - - - ----- ❑ ❑ ❑
Pump tank setbacks consistent with 3eptic tank?- --- - - - - - - -- N/A ❑ YES ❑ NO
zPump tank capacity(flood) gal Manufacturer
< 24"access riser(s)and accessible from surface?-- -- - -- - -- - -- ❑ ❑ ❑
H Alarm or Control Panel Installed? - - - - - - - - - - - - -- - - - - - - - - ❑ ❑ ❑
Control Panel equipped with Timer/ ETM/Counter - - - - - - - - - - El ❑ ❑
Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
it Pump Make/Model ❑ Floats or ❑ Transducer
� I
0.
Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated a!2112018'
Mason County OSS lnstallatiorn Report pg. 2 Parcel# 4231 5o oVz.
ABANDONMENT'RECORD
Were existing septic c orients abandon ld as part of this project? - —— — — — — — — —— — — —- YES NO
If yes, please describe !VA
Were all components pumped out and grope ly 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,Septic/pump tank location,North arrow,reserve drainfeid,existing and proposed buildings,location of wells,waterlines,
wells.ooservation ports,cleanouts.and other maintenance access po'nts. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
i •
Record Drawing Attached
CERTSCAT kOO ISTALL T ION
INSTALLER DESIGNER/'ENGINEER'
l certify that l installed the system in accordance with i certify thafthe 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 shorn Mason County Public Health and that any deviations
here have been cleared/approved by both the designer P shown here have been cleared/approved by both
and Mason County Public Health and meet alit State 4 myself and Mason County Public Health and meet all .,i
and Mason County Codes. State and Mason County Codes
I further certify that ail infformatri contained on this 1 further certify that all information contained on this
form and attached r' - rd Drawing is acc:.rate. r'_-;err:':and attached Record Drawing is accurate.
51
Signature of! staller Date
..,
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
{
The undersigned approves this installation Report arid
Record Drawing on behalf of Mason County Public
Health:
Signature of Environmental 1ealth Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC V!FW ON THE VLASON COUNTY WEB SITE updatec 8/2112018
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APPROVE
MAY 18 202f
MASON COUNTY ENVIRONMENTAL HEALTH
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