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HomeMy WebLinkAboutSWG2026-00001 - SWG As-Built - 7/1/2026 Docusign Envelope ID: F96D2237-CC74-8797-8172-9FF2790FBA00 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG SWG2026-00001 Parcel # 42018-13-00050 Applicant Name AUSTIN navrn s Subdivision (Name/Div/Block/Lot) Applicant Address pn box 225 City, State, Zip Shelton Wa 98584 Installer Name Jamie Workman Site Address 7621 W Shelton Matlock Rd Designer Name Micah Halverson INSTALLATION CHECKLIST ® Full System Installation ❑Tank(s) Only ❑ Drainfield Only ❑ Repair ❑ Other System Type Nttwater to Pressi ire Red Pretreatment Type RNR-5nn >5ft. fromfoundation? - - - - - - - - - - - --- � �� N/A ® YES NO >50ft. fromwells? - - - - - - - - - - - - - 4h.--- - - - - - - - - - -II ® ❑ >50ft. fromsurfacewater? - - - - - - - - -I '` JU i-O_5 Z026 _ ® ❑ Cleanout between building and tank? - - - - - - -- - - --- ❑ U Tank baffles present? - - - - - - - - - - - - - -'- - - - - ® ❑ a24" access risers over each compartment?- - - - - - - - - - - - - - - ❑ X❑ ❑ W Effluent filter installed?- - - - - - - - - - - - - - - - - - - - - - - ❑ ❑ Septic tank capacity (working) gal Manufacturer Sound Placement D-box water level and speed levelers used? - - - - - - - - - - - - - - - ❑ N/A ❑ YES ] NO �O Manifold/D-box accessible from surface?- - - - - - - - - - - - - - - - - ❑ ❑ E ] C9 Check valves installed? - - - - - - - - - - - - - - - - - - - - - - - - - - ❑ ❑ 2 Transport Line Size 2° Schedule/Class Sch40 Bedrooms installed (check one) ❑ 2 ® 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10 ft. from foundation? - - - - - - - - - - - - - - - - - - - - - - - - - - Li N/A ® YES Li NO >100ft. fromwells? - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ❑ ® ❑ W >100ft. fromsurfacewater? - - - - - - - - - - - - - - - - - - - - - - - - ❑ ® ❑ ii >10ft. frompotablewaterlines?- - - - - - - - - - - - - - - - - - - - - - ❑ ® ❑ ? > 5ft. frompropertylinesandeasements?- - - - - - - - - - - - - - - - ❑ ® ❑ W > 30 ft. from downgradient curtain/foundation drains? - - - - - - - - - - ❑ ❑ ❑ Drainfield level and observation ports present - - - - - - - - - - - - - - ❑ X❑ ❑ ❑ Graveless chambers or © Clean gravel used? (check one) Proper cover installed overdrainfield?- - - - - - - - - - - - - - - - - - - ❑ ® ❑ Pump tank setbacks consistent with septic tank? - - - - - - - - - - - - - ❑ N/A ® YES ❑ NO Y Pump tank capacity (flood)1223 gal Manufacturer Sound Placement Q24" access riser(s) and accessible from surface? ❑ ® ❑ Alarm or Control Panel Installed? ❑ ® ❑ Control Panel equipped with Timer/ ETM / Counter- - - - - - - - - - - ❑ © ❑ Pump installed in X❑ Bucket or ❑ On Block or ❑ Other _ CL Pump Make/Model 7neller N152 ® Floats or ❑ Transducer 0- Tank draw down 7 in/min Pump capacity 45 gpm Squirt Height 5 ft a Pump on time 1 min Pump off time 4hrs Daily flow set at 270 gpd Updated 8/21/2018 Docusign Envelope ID: F96D2237-CC74-8797-8172-9FF2790FBA00 Mason County OSS Installation Report pg. 2 Parcel# 42018-13-00050 _ ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - - - - - - - - - - - - - - - LI 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 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. RI itial Owners Initials: ® Record Drawing Attached CERTIFICATION OF INSTALLATION INSTALLER DESIGNER/ ENGINEER I certify that I 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 /further certify that all information contained on this I further certify that all information contained on this f Ay ,At Ached Record Drawing is accurate. form and attached Record Drawing is accurate. - - Signature of Installer Dat% Jaixue- o km n Printed Name of Signee MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report Record Drawin behalf of Mason County Public 4 T41 yF > w 5tHmm"MVEneon Health: ql t�, 0EMONER �, Signature of Environmental 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 Docusign Envelope ID: F96D2237-CC74-8797-8172-9FF2790FBA00 NEW 3 BEDROOM ON-SITE WASTEWATER AS BUILT Existing Well / Z , ' SWG2026-00001 . W w 402±/- / / \ o \ / Easement 30 O \ M cc \ N � R=10n' li O Well / s✓ O \ / APPROXIMATE LAND SIZE 4AC O E-I N / U) _ LU rn I� — CI O 00 + (V I p I �� m Xo = CD �N 1 7 m DRAINFIELD D AREA IS FAIRLY LEVEL k1 o, tT L —co 0 7t a) Owner/ Applicant: JGALLOUTS z 1) 4" ASTM3034 With Cleanout 10 (� 2) Sound Placement Trash/Pump Tank o J 00 o JUL 3) NuWater BNR-500 Tank 5 o J C) MASON���NrYF , ?0?6 4) Nuwater Control 5) 2"S h40 Effluent Transport Lianel on ne 3 o IL C DJ,A NMFNr4L/I 6) Sweep Access This End ✓f �' o •� o 7) Observation Ports 2X ` 6 0 0 o U Mawlnw�reoN Y O L1 DER o L L C This is not a survaL N EXPIRES:W161s`� U) 0 "U) This Asbuilt Drawing is intended for the purpose of o a n i locating and maintaining the septic system on this parcel. ew26 N-4 E N '- c Measurements and distances are approximate. • °' E •> x con It is advised by septic designer Micah Halverson PROPERTY LINES ESTABLISHED OTHER Q w m to use a licensed surveyor to determine lot lines, a� N t � � elevations,topography and to provide a legal site plan. 0' 20' 40' o 0 _ Owner is responsible for establishing all property lines, initial Initial a W a easements and/or right-of-ways. [727 n Scale:t"=40 C 0 U U .O.O N X QF- (n W Inspection Date: 5/291202b