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HomeMy WebLinkAboutSWG2024-00008 - SWG As-Built - 7/2/2026 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2024-00008 Parcel # 22107-50-00036 Applicant Name Lewis Griqqs Subdivision (Name/Div/Block/Lot) Applicant Address 25216-238th Ave SE City, State, Zip Maple Valley, Wa 98038 Installer Name Active Underqround LLC Site Address 1420 E Mason Lake Dr S Designer Name Bob Paysse INSTALLATION CHECKLIST ® Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair El Other System Type Pressure Pretreatment Type >5 ft. from foundation? - - - - NIA © YES NO >50 ft. from wells? - - - _ - - _ _ _ _ El >50 ft.from surface water? - - - _ t=g� _ - El Z v -- ❑ ❑ ❑ Cleanout between building and tan _-_______ ❑ U Tank baffles present? - --- - - - - - _ •_ ® ❑ a24"access risers over each compa ment? _ _ ❑ El W Effluent filter installed?- - - - - - - ❑ ® ❑ Septic tank capacity(working) 500 gal Manufacturer D-box water level and speed levelers used? - - - - - - - - - - - - - - - ® N/A ❑ YES ❑ NO 00 Manifold/D-box accessible from surface?- - - - - - - - - - - - - - - - _ ❑ Q OQ Check valves installed? - _ _ _ ❑ Ill El Transport Line Size 2 Schedule/Class 40 Bedrooms installed (check one) ❑ 2 ❑3 U 4 ❑ 5 El 6 El Commercial/Other >10 ft. from foundation?- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -' ❑ N/A Q YES El NO O >100ft. fromwells?- - - - - - - - - - - - - - - - - - - - - - - - - - - - El L j >100ft. fromsurfacewater? - - - - - - - _ _ _ _ _ _ ❑ u. >10ft. frompotablewaterlines?- _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ❑ ❑ Z > 5 ft. from property lines and easements?- - - - - - - - - - - - - - -- X > 30 ft. from downgradient curtain/foundation drains?- - - - - - - - - - ❑ O Drainfield level and observation ports present - - - - - - - _ - - _ - El Ill ❑ ❑ Graveless chambers or UI Clean gravel used? (check one) Proper cover installed over drainfield? - - - - - - - - - - - - - - - - -- El O ❑ Pump tank setbacks consistent with septic tank? - - - - -- - - - - - - - ❑ N/A OYES ❑ NO z Pump tank capacity(flood) 1500 gal Manufacturer SPS Z 24"access riser(s)and accessible from surface?- - - - -- ❑ O ❑ a. Alarm or Control Panel Installed? - - - - - - - - - - - - - - - - - - - - ❑ It ❑ Control Panel equipped with Timer/ETM I Counter- - - - - - - - - _ _ Pump installed in ❑ Bucket or El On Block or 11 Other Pump Silo Pump Make/Model Liberty FL51 M ® Floats or ❑ Transducer a Tank draw down 1.75 in/min Pump capacity 48 gpm Squirt Height 6 ft Pump on time lmin 15sec Pump off time 4hour Daily flow set at 360 d 9P Updated 8/21/2.018 Mason County OSS Installation Report pg. 2 Parcel ii 22107-50-00036 ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - -- - - - - -- If yes, please describe: Q YES NO Were all components pumped out and properly abandoned per WAC246-272A-0300? - - - - - - -- 0 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. ❑ 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 certi ' formation contained on this I further certify that all information contained on this form attached af-$rav_vnll accurate form and attached Record Drawing is accurate. 6/19/26 signature of Installer Date James Medcalf �. Printed Name of Signee Of wa MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report and O� ROBERT�M3 P4YSse . ........... .. Record Drawing on behalf of Mason County Public Health: - p EXPIRES���1 r 1 1 •7 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 8/21018 • r MASO -ç \ N�1�E APPROX, MAINTAIN 100'+ FROM ALL WELLS OHWM TO DRAINFIELDS, 50'+ TO TANKS AND SEPTIC LINES. PROPOSED BUILDING � PROPOSED TANKS \ LOCATION MAINTAIN 50'+ /' BIN REPLACEMENT) t FOUNDATION WATERLINE \. MAINTAIN 10' 1 MAINTAIN 30'+ TO TO OSS LINES OR DBL SLEEVE �/ DOWNGRADIENT WELL FOUNDATION DRAINS , 8100 PROPOSED `, DRAINAGE DITCH O SEASONAL Jrr,\ DRAIN FIELD RUNOFF \ �� r' (4 BEDROOM)\ NOT SURFACE WATER , riJJIJrJ" rrJJt rJr r>> �v \� �rriJJr°JIiJ l�rttrrrt1J r�\ I�dry% :� � ` rrttJrrJJ�JitrrJJtJrr�J�JJJt�" INSTALL 4"3034 r'rrJl \ .j SEWER LINE FOR fZ10o' FUTURE SHOP \ BATHROOM ,aq p � WELL p n'n WELL O,�yFN�R O 0(76 WELL RFr f/F� •'- WELL i SO u rJ<.. �ceENT:, vat•se ' Q� .cam O� t:: lh 5 NAPS AN ASBUILT/INSTALL SIGNOFF FEE WILL BE CHARGED AT TIME OF INSTALLATION Vi '{ ' I - PIONEER DIGGING, INC. CU'STOMER: L,EWIS GRIGGS TEST HOLE I: TEST HOLE 2: PARCEL#:22107-50-00036 SEPTIC DESIGNS ADDRFJS: 1420 MASON LK DR.S I OIS.37 ROOIS-42 308 D E MASON BENSON RD. GRAf EVIEW,WA 98546 DESIGNER.. ROBERT H PAYSSE DISCLAIMER:THIS N NOT SURVEY.REFERENCES INCLUDE APPLICAMICOUNTY PROVICED OFFICE 360 4261803 FAX 360-427-2353 - PLATS OR SURVEYS FIELD MEASUREMENTS AND COUNTY OIS.DESIGN INTENDED FOR SEPTIC PURPOSES ONLY. PROPOSED DEVNOTRE T MAy RE SETBACKS RE OTHEO SHEET: SITE PLAN SCALE 1 -40' CEPAR'MENTIAGENLY REVIEW DESIGNER NOT RESPONSIBLE FOR SE BACKS UNRE ATED TO SEPTIG COMPONENTS. Ka la Niilam DO NOT REPLY <noreply@masoncountywa,gov> Sennt:t From Monday, June 15, 2026 10:07 AM To: Environmentalhealth Subject: OSS Inspection request for Griggs - Swg2024-00008 Submittal request for: Griggs Site Address: 1420 E Ma$on Lake Dr S Permit Number:Swg2024-00008 Parcel Number:221075000036 installer Name: Active Underground LLC installer Phone Number: 3602397779 installer Email Address:fames@activeundergroundllc.com 1p ' \ Designer Name: Bob Paysse �� Designer Email Address: pioneerdigging@yahoo.com Inspection Request Date:2026-06-15 Inspection Type: Full System Comment\ Notes: 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/Engin n eer installation 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. 1 iRr MASON COUNTY Public Health & Human Services FINAL INSPECTION: SWG2024-00008 ADDRESS: 1420 E Mason Lake Dr S PARCEL: 221075000036 DATE: 6/16/2026 ,yJ . HOUSE TO DRAINFIELD DRAINFIELD TO HOUSE