HomeMy WebLinkAboutSWG2023-00341 - SWG As-Built - 6/15/2026 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATION
Permit Number SWG 2023 00341 Parcel# 419022100010
419022100010
Applicant Name Tab iha Romero Subdivision(NanlelDly/Btock/Lot)
Applicant Address 324 Watercress Street
City. State, Zip Shelton, WA 98584 Installer Name Mike Skinner
Site Address 3520 W Shelton Valley Rd Designer Name Richard Bazzell
INSTALLATION CHECKLIST
Full System Installation ❑ Tanklsi Only ❑prainrield only ❑Repair ❑Other
System Type Pump to Gravity Pretreatment Type_
>5 It from foundation? - - - - - F,,-J `17•1 ❑NIA 0 YES ❑ No
>50 ft from wells? D .► - .i ❑ U ❑
>50 It from surface water? • - - - - - -
_ 1292� ❑ ■ a
Cleanout between building and tan ------ - -L- - • - - ❑ ■ ❑
Tank baffles present? • - - - - - - - - - - - - - - - - - - - - 0 U ❑
a24"access risers over each comps f✓a�fnt? - ❑ ❑
W Effluent filter installed? ❑ ® ❑
Septic lank capacity(working) 1250 gal Manufacturer Hagerman Precast
0 0-box water level and speed levelers used? ❑ NIA ® YES ❑ NO
)O Manifold/0-box accessible from surface? - - - ❑ ® ❑
mZ Check valves installed? ❑ ❑
CQ
M Transport Line Size 2" Schedule/Class 4013034
Bedrooms installed(check one) ❑ 2 ®3 ❑4 ❑ 5 ❑6 ❑Commeiciallother
>10 f from inundation? - - - - - - - - - - - - - - - - - - - - - ❑ N/A YES ❑ NO
O
>100ttfromwells?- - - - - - - - - - - - - - - - - - - - - - - - - - - - ❑ U ❑
W >100 ft. from surface waler? - - - - - - - - - - - - ❑ ® ❑
li >10 It from potable water lines? - - - - • ❑ ■ ❑
>5 It from property lines and easements? - - - - - - - - - - - - - - ❑ U ❑
>30 ft from downgradient curtain/foundation drains? - - - - - - - - - ❑ U ❑
Drainfield level and observation ports present ❑ U ❑
❑ Graveless chambers or fJ Clean gravel used? (check one)
Proper cover installed over drainfield? - - - - - - - - - - - - - - - • - ❑ U ❑
Pump tank setbacks consistent with septic lank? - - - - - - - - - - - 0 N/A 0 YES ❑ NO
Pump tank capacity(flood) 1000 gal Manufacturer Hagerman Precast
Z
Q 24 access riser(s)and accessible from surface? ❑ ® ❑
Alarm or Control Panel Installed? - - - - - - - - - ❑ U ❑
Control Panel equipped with Timer I ETM/Counter- - - - - - - - - ❑
Pump installed in ® Bucket or ❑ On Block or ❑ Other
CLPump Make/Model Liberty 280 • Floats or ❑ Transducer
Tank draw down 2 inInun Pump capacity 22 gpm Squirt Height n/a ft
Pump on time 1.48 min Pump ott time 3.98 hours Daily flow set at 264 gpd
'Jrxanud lV:�;1J t ll
Mason County OSS Installation Report pg. 2 Parcel# 419022100010
ABANDONMENT RECORD
Were existing septic components abandoned as part of this prolect7 - - - - - - - - - - - - - • O YES ® NO
If yes please descnbcf
' re ail components purnpea txn and properly abandoned per WAC246 272A-0300? - - - - - - - - ® YES NO
RECORD DRAWING
Thls M a permtawnd rwpd and must be.trot.*and dt,,ct"ive snougit to radocaie al it,,nwd of,is mirrors ou"im and tutu,,d..Noprnum. tyrw t ftowrd
omny: .Gairl tbniiofd&mamik"41 m'ndWn..& I.r. snow,rx.ra Qrae.4eW.v.uLng and pPt+tsh)l.rldeVs l<Kaba•ntwcIi `raln.brea
t obs"VatyM polo oesnatlts.I'd ult*nUdiinilce*Met,s poet hxomi*ft Rocotd U4.ndgs ntay create a�M.c oMayt a+HW hitaNatkW approval Mid'dMn+f pmnwts
E
IJ 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 cleatedlapproved by both the designer shown here have been clearedlapproved 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 at/information contained on this I further certify that all information contained on this
form and atta had Record Drawing is accurate form and attached Record Drawing is accurate
)y 24'
Signature of Installer Dare
Mike Skinner
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and d
Record Drawing on behalf of Mason County Public 21037126
Health f � ( �j RICHARD L RAZZEL L
�`� cr yy/ c F `#u LICESIGNER
Signature of Environmental healTh Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR IIUBLIC VILW ON THE MASON COUNTY WEB SITE upd.rt$f7lrnIA
• MASON COUNTY
Public Health & Human Services
FINAL INSPECTION:
SWG2023-00341
ADDRESS: 3520 E Shelton Valley Rd
PARCEL: 41902-21-00010
DATE: 5/13/2026
HOUSE TO DRAINFIELD
3 DRAINFIELD TO HOUSE
�1r
r - rr ___
, ,� Rhonda--
Thompson
From: DO NOT REPLY <nore I Sent: Monday,May 11,2026 12 O0 Ptoncountywa.gov>
To:Subject: Environmentalhealth
� :#
OSS Inspection request for tabltha romero-SWG2023-00341
Submittal request for:tabltha romero
Site Address:3520 w shelton valley rd
Permit Number:SWG2023-00341
Parcel Number:419022100010 J
Installer Name:skinner
Installer Phone Number:3607103538
Installer Email Address:skinnersrinc@gmail.com v'
Designer Name:richard bazzelL
Designer Email Address:RICHARD@CALIBERSEPTICDESIGN.COM
Inspection Request Date:2026-05-11
Inspection Type:Full System
Comment\Notes: ,rim
Thank you for submitting your final install request.The install should be complete and ready to inspect on the'Inspection
Request Date'and remain uncovered for three business days to allow staff time to inspect.Poor weather situations may
be accommodated by contacting onsite staff.Installer is responsible for obtaining Septic Designer/Engineer installation
4 approval prior to backfill of system components.If no contact is made by the health department within the three
business days of notice,the installer may cover.Mason County Asbuilt Form,Record Drawing,and Installation fee must
be submitted for final installation approval.
S .
1
LEGEND CALIBER�-- --�-� RECORD OF CONSTRUCTION-AS-BUILT ---- PROPERTY LINE
/ SEPTIC DESIGN
/ Feasibility-New Construction-Repair
\ PROPERTY CORNER MARKER
1 _ ' 165 Tupleo Way
- - /--_--_ EL 1000 Poulsbo,WA 98370
t.360.509.7900
ON-SITE SEPTIC SYSTEM COMPONENTS / - •
� �- �
Tankage(Hagerman) /"
Septic Tank-1250 gallon,2 compartment,precast concrete .j �I
Discharge Tank-1000 gallon,1 compartment,precast concrete �� � : ���. \
Pump(Liberty 280) �
Gallons/Min-30 /r / NE PAR L PROFESSIONAL STAMP
Gallons/Dose-44 �J �� I EXPIRES:JUNE 18,2024
EL 100.
Setup Daily Flow-264gpd , R100\p^ I I �
Control Panel(OrencoAl)Settings I Ps I \
ON Time-1.46 minutes o ,
OFF Time-3.98 hours / /1 Gravel) \\ /
•
w I ;
Y
Dispersal Component(Site Constructed I l
Distribution-equal / `— / I \ 21037128
Number of Trenches-5 �� \ �� j LiCEN5EDt>F EL L
Trench Length-40 ft / I \ Rm,
Trench Width-36 in I
Installation Depth-15-19 in
Vertical Separation-36 in I % - / REVIEW STAMP
SINGLE FAMILY / ,!/ , z
\ RESIDENCE _ 0
ONTROL PANEL' -� p �'
`= DISTRIBUTION BOX
,- - O / / 7 / //// /
/
_. i CLEANOUT
/�� RESERVE ' UMP TANK,1000 GALLONS' - ' !
RE$E /l ! REVISIONS
\ i RVE / SEPTIC TANK,1250 GALLONS"/" ___________________________
N0. DESCRIPTION DATE
Rz::f E PRIMARY&RESERVE \� `� i �
i ( (JRV
DRAINFIELO(3,465 SF) �
/• _ Project:
`� ��% Romero Residence
�' f 0 W Shelton Valle Rd
________
!Z-ice y
, Shelton, WA 98584
1 j _ TAX ID# 419022100010
Date: June 3,2026
Sheet Name
Q SITE PLAN A P PR n V E n Site Plan - Inset
za 40' 80 (RECORD OF CONSTRUCTION)
JUN 15 2026 Sheet Number
MASON COUNTY ENVIRONMENTAL HEALTH
RET S D-1
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