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Home My WebLink AboutSWG2026-00031-ASBUILT - SWG As-Built - 6/16/2026 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT! PERMIT INFORMATION Permit Number SWG 2026-00031 Parcel # 22135-77-00180 Applicant Name Sara Stover Subdivision (Name/Div/Block/Lot) Applicant Address 14501 Wilmot Way City, State, Zip Lake Oswego, OR 97035 Installer Name T.J. Goos Site Address 430 E. Thornton Rd. Designer Name Dale L.Tahja INSTALLATION CHECKLIST Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair ❑Other System Type Pressure Trenches Pretreatment Type >5 ft. from foundation? - - - - - - - - El N/A YES NO >50ft. fromwells? - - - - - - - - - - - -� `" r Z >50ft. fromsurfacewater? - - - - - - - - El U ❑ Cleanout between building and tank? - - + #} -JUN-1 -205- - ❑ ® ❑ Tank baffles present? - - - - - - - - - - Olt ❑ ® ❑ 24" access risers over each compartment -- . j ❑ I El W Effluent filter installed?- - - - - - - - - - - - - -- - - - - - - - - - - - •- ❑ ® ❑ U) Septic tank capacity (working) 1,200 gal Manufacturer Hagerman D D-box water level and speed levelers used? - - - - - - - - - - - - - - - ® N/A ❑ YES ❑ NO OO Manifold/D-box accessible from surface?- - - - - - - - - - - - - - - - - ❑ ❑ mz Check valves installed? - - - - - - - - - - - ❑ ® ❑ OQ 2 Transport Line Size 2 inch Schedule/Class Sch. 40 Bedrooms installed (check one) ❑ 2 FM 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft. from foundation?- - - - - - - - - - - - - - - - - - - - - - - - -- ❑ N/A YES ❑ NO >100ft. fromwells?- - - - - - - - - - - - - - - - - - - - - - - - - - - - - ❑ ® ❑ W >100ft. fromsurfacewater? - - - - - - - - - - - - - - - - - - - - - - - - ❑ I ❑ >10ft. frompotablewaterlines?- - - - - - - - - - - - - - - - - - - - - - ❑ ® ❑ ; > 5ft.from property lines and easements?- - - - - - - - - - - - - - - - ❑ ® ❑ Q IX > 30 ft. from downgradient curtain/foundation drains? - - - - - - - - - - N' - ❑ ❑ Drainfield level and observation ports present - - - - - - - - - - - - - - ❑ ��' X 11 ❑ ❑ Graveless chambers or • Clean gravel used? (check one) Proper cover installed overdrainfield?- - - - - - - - - - - - - - - - - -- ❑ ® ❑ Pump tank setbacks consistent with septic tank? - - - - - - - - - - - - - ❑ N/A ® YES ❑ NO ZPump tank capacity (flood) 1,000 gal Manufacturer Hagerman Q 24" access riser(s) and accessible from surface?- - - - - - - - - - - - - ❑ ® ❑ H Alarm or Control Panel Installed. ❑ ❑ Control Panel equipped with Timer/ETM/Counter - - - - - - - - - - ❑ 0 ❑ Pump installed in ❑ Bucket or 0 On Block or ❑ Other _ Pump Make/Model Liberty 280 ® Floats or ❑ Transducer Tank draw down 2 in/min Pump capacity 44 gpm Squirt Height 8 ft Pump on time 2.7 min Pump off time 5 hrs 57.3 min Daily flow set at 270 gpd Lpdated 8/21/2018 Mason County OSS Installation Report pg. 2 Parcel 9 ABANDONMENflCOR Were e>dsting etepbc components abandoned as part of this project? ----- Q YES No If yes, please describe: Were all components pumped out and property abandoned perV0C240-272A,03001-------- YES Q NO RECORD DRAWING This M a pan..iva nand and nwst be ac smto and duce4diw anouoh to rotocao in the need at acdvee ant tu*n dsesiapmant 1W*M kao°rd orwmp�oott' *, Dye k*m a n+&O ld odaatatlon&! tank k a6o t,Northam%lust 6 dratnldd a�dednR and p,apoeed builn .IotMion of we s,v'0kv nee, W*K abeer Ian parts,deanouta,and other maintenance annum paints an mplats Record Dtvsk g&may Made add ofd dalays In/ant I adon ap(roa and talaMd pannats. Record Drawing Attached CERI1FICATION OF INSTALl.AIION INSTALLER DESIGNER/ENGINEER I certify that I installed the system k n accordance with I certify that the system has been installed In accor- the septic design stamped APPROVED"by Meson dance with Me septic design stamped"APPROVEV by County Public Health and that any deviations shown Meson County Public Health and that any deviations hem have been cIeersd�appmved by both the designer atiowm here have been cleareed?approved by both and Mason County Public Health and meet all States myself end Mason County Public Health and meet all and Mason County Codes. State and Mason County Codes I further certify that all Information co4a1n8d on this I further certtty that all Information contained on this form and attathed fiecord Drewiritm isccumM forts and attached Record nriaw is acc uriatee. (Y )I Signaturec ' tie Printed Name of Slgneer MASON COUNTY PUBLIC HEALTH shy The undersigned approves this installation Report and 5100214 Record Drawing on behalf of Mason County Public b Dale L.Tahiti Health: - LICENSED DESIGNER Signature of Em+>cnrnentat 11eeh Specialist Date (stamp, signature and date) THIS FORM MAYBE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE& &0N COU+rTY WEB SITE u aelsota 4 MASON COUNTY Public Health & Human Services FINAL INSPECTION: SWG2026-00031 ADDRESS: 430 E Thornton Rd PARCEL: 221357700180 DATE: 6/16/2026 f.. � HOUSE TO DRAINFIELD —• Lam : • • j DRAINFIELD TO HOUSE Kayla Milam From: DO NOT REPLY <noreply@masoncountywa.gov> Sent: Monday, June 15, 2026 5:59 AM To: Environmentalhealth Subject: OSS Inspection request for stover - 22026-00031 Submittal request for: stover Site Address: 430 e Thorton rd Shelton Permit Number: 22026-00031 Parcel Number: 22135 77 00180 %f JUN 15 2026 Installer Name: tyrone goos By Installer Phone Number: 3604900217 Installer Email Address: tgoos@mason-pudl.org Designer Name: dale tahja Designer Email Address: daletahja@gmail.com Inspection Request Date: 2026-06-15 Inspection Type: Full System Comment\ Notes: please call after inspection Thank you for submitting your final install request.The install should be complete and ready to inspect on the 'Inspe Request Date and remain uncovered for three business days to allow staff time to inspect. Poor weather situations r be accommodated by contacting onsite staff. Installer is responsible for obtaining Septic Designer/Engineer installati, 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 moalyover. Mason County Asbuilt Form, Record Drawing, and Installation fee mi be submitted for final installation app 1 Q - A f I r ) 9 m Iii 8 s�nrE 2 Z F : q ; 9 ?� Y� p St