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HomeMy WebLinkAboutSWG2025-00302 - SWG As-Built - 6/3/2026 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2025 00302 Parcel# 32124 52 00025 Applicant Name Sam Hayes Subdivision (Name/Div/Block/Lot) Applicant Address 3689 Sage Brush LN NW City, State, Zip Bremerton, Wa. 98312 Installer Name Trinity Excavation Site Address 311 Emerald Lake Dr. W. Designer Name Bob Paysse INSTALLATION CHECKLIST Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other System Type OS s __ Prttreatment Type Oscar XO2 >5 ft. from foundation? - - - - - - - - ❑ N/A ®YES ❑ NO >50ft.fromwells? - - - - - - - - - L� _ . ❑ II ❑ Z >50 ft. from surface water? - - - - --°u-u-Z&�� _ _. ❑ ® ❑ Cleanout between building and tan ? -___ __ _________ _ - ❑ ❑ O Tank baffles present? -- - - - - _ By_ _ -- - --- _- ❑ ® ❑ 24"access risers over each compartmen . --__ _ __ _ _ __ ❑ ® ❑ `W Effluent filter installed?-_ ___ ____ _ __ _ __ _ _ _ _ _ _ _ ____ - ❑ ❑ 10 Septic tank capacity(working) Oscar XO2 gal Manufacturer Haggerman D-box water level and speed levelers used? -- - - - - - - - - - - - - _ N/A ❑YES ❑ NO �O Manifold/D-box accessible from surface? - - - - - - -- - - - - - - - - ❑ © ❑ mZ Check valves installed? - - - - - - - - - - - - - - - - - - - - - - - -- -- ❑ U ❑ 0Q 2 Transport Line Size 1" Schedule/Class 40 Bedrooms installed (check one) ❑E 2 ❑3 ❑4 O 5 ❑6 ❑Commercial/Other >10 ft.from foundation?- - - - - - - - - - - - - - - - - - -- - - - -- -- ® N/A ❑ YES NO >100ft. fromwells?-- - - - - - - - - - - - - - - - - - - - - - - - - - -. ❑ ® ❑ W >100ft.fromsurfacewater? -- - --- - -- - - - - - - - - - - - - - - ❑ ❑ tO M >10ft. frompotablewaterlines?- - -- - - - -- - ---- -- - - - - -_ ❑ II ❑ Q > 5 ft.from property lines and easements?--J -u i- f--J2--- _- - ❑ I ❑ > 30 ft.from downgradient curtainJfoundatip, drains?-- -- ❑ ® ❑ Drainfield level and observation ports present ytN�R1EN,TG - ❑ ® ❑ ❑ Graveless chambers or ❑ Clean gravel used? (check one) Proper cover installed over drainfield?- ----------------- - ❑ ® ❑ Pump tank setbacks consistent with septic tank?- - - -- - - - - - -- - ❑ N/A YES ❑ NO `-r Pump tank capacity(flood)JScar XO'-gal Manufacturer Haggerman Z Q 24"access riser(s)and accessible from surface?- - - - -- - - - - -- - ❑ ® ❑ H d Alarm or Control Panel Installed? - - - - - - - - - - - - - - - - - - -- - ❑ ❑ 01 Control Panel equipped with Timer/ETM/Counter- - - - - - - - - - - ❑ 0 ❑ n- Pump installed in ❑ Bucket or ❑ On Block or ❑ Other Free standing a Pump Make/Model per mfg. ® Floats or ❑ Transducer Tank draw down per mfg. in/min Pump capacity per mfg. gpm Squirt Height N/A ft Pump on time per mfg. Pump off time per mfg. Daily flow set at 240 gpd Updated 8/21/2018 Mason County OSS Installation Report pg. 2 Parcel# 32124 52 00025 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? -- --- -- ------- - O YES NO If yes, please describe: Were all components pumped out and properly abandoned per WAC246-272A-0300? --- ---- - O YES 0 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 maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits. JUN 03 2026 MASON COUNTY ENVIRONMENTAL HEALTH JBW • 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 l further certify that all information contained on this form and attached Record Drawing is accurate. form and attached Record Drawing is accurate. Signature of Installer Date•• Keith Chamberlain "u Printed Name of Signee ,- �• 5100317 MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report and EXPIRES Record Drawing on behalf of Mason County Public He the Sign ure 43ironmontal Health 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 FUTURE WATERLINE (MAINTAIN 10'+TO SEPTIC COMPONENTS&LINES) a NSTALL PROPOSED 2 BEDROOM I HOME LOCATION OSCAR X02 PER MANUFACTURER INSTRUCTIONS BUILDING SETBACK S7- RESERVE AREA A (420 SOFT OSCAR XO2) PRIMARY AREA (420 SOFT OSCAR X02) S / O ,, / 1 / / �/ I o 2 ` // OSCAR XO2 TANKS / / (5O'+ TO LAKE) / FILL TO BE / / REMOVED IF / ) / RESERVE IS � // / EVER UTILIZED /' / / / 75'SETBACK ` // / / TO LAKE / / EMERALD (REQUIRES WAIVER / / LAKE APPROVAL) çi 1'�• �UN ® MENTA�HEAL��• s,a�^�•.�• MA �T � ,+ Rcin.1,AA ESE h AN ASBUILT/INSTALL SIGNOFF FEE WILL BE CHARGED AT TIME OF INSTALLATION PIONEER DIOGIN�INC. CUSTOMER: SAM 14AYES TEST HOLE I: TEST HOLE 2 TEST HOLE 3: PARCEL#:3212452-O0025 32+1111. 32+'111.1. 24+111.1. SEPTIC DESIGNS ADDRESS: 311 EMERALD LK DR W KOOTS @ 32 ROOT�@ 32 ROO I S c 24 3083E MASON BEN'ON RD. GRAPEVIEW,WA 985=x, DESIGNER: ROBERT FL PAYSSE DISCLAIMER:TICS IS NOT A SURVEY.REFERENCES INCLUDE APPLICANTTCOUNTY 78EP7nC PUTS OR SURVEYS,FIELD MEASUREMENTS AND COUNTY GIS.DESIGN INTENDED F OFFICE 36(}4261803 FAQ'36114272353 b PURPOSES ONLY PROPOSED DEVELOPMENT MAY BE SUBJECT TR SHEET: SITE PLAN SCALE 1 -30' OEPARTNEN'ONENCY REV EW DESIGNER NOT RESPONSIBLE FOR SETBACKS UNRO SEPTIC COMPONENTS. PROPOSED 2 BEDROOM 'INSTALL HOME LOCATION OSCAR X02 PER MANUFACTURER INSTRUCTIONS \ BUILDING SETBACK 100% RESERVE (420 SOFT) C/O \ PRIMARY AREA: /� 2 BEDROOM / OSCAR X02 SYS. O 0 O /Q OSCAR X02 TANKS PUMP ELE. 0.0' DF ELE. +12' \ 75'SETBACK TO LAKE \ (REQUIRES WAIVER APPROVAL) 1 FILL TO BE REMOVED IF RESERVE IS EVER UTILIZED Sr x.117 / 1,`)ivG�rZZl �Z� T / BE CHARGED AT TIME OF INSTALLATION CUSTOMER: SAM HAYES TEST I OLE I: TEST HOLE 2: TEST HOLE 3: PIONEER DIGGING, INC. 0-32( . 11-32 0.24G:SL. PARCEL#:3212+52-O0025 32+nu. 32+TILL 24+-nu. SEPTIC DESIGNS ADDRESS: 3u EMERALD LK DR W R00TS c 32 K00IS @ 32 RXT IS @ 24 3083 E 1MASON BENSON RD. GRAPEVIEW,%bA 98546 DESIGNER: ROBERT H.PAYSSE PUN A R NI TEV S NOT A SURVEY.REFERENCES INCLUDE DES ON INTENDED FORERSUR VIDED ��fTICE 3SED OEVELOPNENT MAY BE SUBJECT TO OTTER 6l}426 ItiO3 FAX 360 427 2353 SHEET: DF DETAIL SCALE IM=10 DEPARTMENT/AGENCY RENEWPURPOSES ONLY �DESIGNER NOT RESPONSIBLE FOR SETBACKS UNRELATED TO SEPTIC COMPONENTS • MASON COUNTY Public Health & Human Services FINAL INSPECTION: SWG2025-00302 ADDRESS: 311 Emerald Lake Dr W PARCEL: 321245200025 DATE: 5/21/2026 S�3,yz � � Y HOUSE TO DRAINFIELD ty•" DRAINFIELD TO HOUSE