HomeMy WebLinkAboutSWG2002-00362 ABANDONMENT RECORD - SWG Photos - 8/6/2026 ABANDONMENT RECORD
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2002-00362 Parcel # 12130-75-00020
Applicant Name Brian P. Evans Subdivision (Name/Div/Block/Lot)
Applicant Address 170 E. Ash Ln Harstine Island
City, State, Zip Shelton Installer Name Homeowner
Site Address 200 E. Asti Ln Designer Name
INSTALLATION CHECKLIST
❑ Full System Installation ❑Tank(s) Only ❑ Drainfield Only ❑Repair ❑Other
System Type Pretreatment Type
>5 ft. from foundation? ----- ------- -- - ---- --- -- - - - ❑ N/A YES ❑ No
>50ft. fromwells? - -- -- - - -- - - -- - ---- - - - - - - - - - - - ❑ O ❑
>50ft. fromsurfacewater? - -- - - -- -- - -- - - - -- - - - - - -- ❑ ❑ ❑
Z
Cleanout between building and tank? -- --- - --- ---- --- - -- ❑ ❑
V Tankbaftlespresent? - - - ---- - - - - - - - - - -- -- -- -- - -- ❑ ❑ ❑
24" access risers over each compartment?---- - ---- - ------ ❑ ❑ ❑
W Eftluentfilterinstalled?- ---- - ----- ----- --- -------- ❑ ❑ ❑
Septic tank capacity (working) gal Manufacturer
D-box water level and speed levelers used? ---- - ------- --- - ------- - - ❑ NIA ❑YES ❑ NO
0O Manifold/D-box accessible from surface?- - --- -- -- - - ❑ ❑ ❑
0°Z Check valves installed? -- - - - - - -- - - - - - - ❑ ❑ ❑
Da
Transport Line Size /C
Bedrooms installed (check one) ❑ 2 ❑3 ❑4 ❑5 ❑6 ❑Commercial/Other
>10ft. fromfoundation?-- - - - -- -- - - - - -- -- -- --- - - - ❑ NIA DYES ❑ No
>100ft. fromwells?- -- -- ----- _ - -- --------- - - - - ❑ ❑ O
W
>100ft. fromsurfacewater? - - - - - --- ---- - - -- - - ------ ❑ ❑ ❑
LL, >10ft. frompotablewaterlines? ---- - ------- - - - - --- -- ❑ ❑ ❑
Z > 5 ft. from property lines aneasements?- - -- -- --- - -- -- -- ❑ ❑ ❑
9 > 30 ft. from downgradie curtain/foundation drains?-- - - - - - - -- ❑ ❑ ❑
Drainfield level and nervation ports present -- - --- - - - -- - - - ❑ ❑ ❑
❑ Graveless c bers or ❑ Clean gravel used? (check one)
Proper cover" stalledoverdrainfield?---- -- --- ---- - -- - -- ❑ ❑ ❑
Pum ,j setbacks consistent with septic tank?-------- - ---- ❑ NIA ❑ YES ❑ No
Y P p tank capacity(flood) _ gal Manufacturer
Z
24" access riser(s) and accessible from surface?-- --- --- -- - - - El ❑ ❑
a Alarm or Control Panel Installed? - - -- - - -- -- - - - - - - -- - - - - ❑ ❑ ❑
Control Panel equipped with Timer/ ETM I Counter - - - - - - - - - - ❑ ❑ ❑
a Pump installed in ❑ Bucket or ❑ On Block or O Other
tZ Pump Make/Model ❑ Floats or ❑ Transducer
a Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated&x2112018
Mason County OSS Installation Report pg. 2 Parcel ft 12130-75-00020
ABANDONMENT RECORD
Were existing spptic c(.w)l'4-,1—t, :th nrloned as part of this projeCY - - - - - - - - - - - - - - - Q YES Q NO
If yes, please describe Ptr 1iltlk ;Ind Pump Tank al+;u toned Drain Field Retained.
Were all components puni fed out and piopony abandoned prat WA(,i4(, 2 iiA 0"UU- - - ----- - j] YES NO
RECORD DRAWING
This Is a permanent record and must be accurate and descdpttw enough to to-locate In the need o InHemnce activkres and future day elopav nt. 7ypral Record
Drawings c witain D ainffetd A manifold o ntation A layoj,Sep 1cflsnrtgr tank rooatron, 1nrth arrow,reserve dra*ifreid,esisIJng and prima M hoar rqs irrration of wells waterlines
wells.observation ports,cleanouts,and other maintenance arxess poInt3 tnoomgkle Reowd DrnMrigs may rreatp additional delays in*Peal mzrai+atinn apparel and related permmrts
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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 I further certify that all information contained on this
form and attached cord yawing is accurate. form and attached Record Drawing is accurate.
1---
Sign re of lists er Date
(Homeowner)
Brian P1. Evans
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
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
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