HomeMy WebLinkAboutSWG2026-00213 - SWG As-Built Mason County OSS Installation Report pg. I MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 202(p - w213 Parcel # 7 o lit 5k -0(x)2(-4
Applicant Name 1.\Or1(1A1 S Subdivision (Name/Div/Block/Lot)
Applicant Address qcl Sr RYCUtU'l, W .
City, State, Zip l(i Y� j g75V9 Installer Name WQ\?S c c(Qt)at t'
Site Address 1150E Trrr.beylGILA E DL Designer Name nI C".-
INSTALLATION CHECKLIST
❑ Full System Installation Tanks)Only ❑ Drainfield Only ❑ Repair ❑Other
System Type V 1 Pretreatment Type
>5 ft. from foundation? -- - - - - - - - �{ it r ❑ N/A 'DYES ❑ NO
>50 ft.from wells? - -- -- - - -- ---- ' I Z( ❑ ❑
Z >50 ft.from surface water? - JUL j 2026 I'Ll9�J))i ❑ a ❑
Cleanout between building and tank? - JLL1 - - - - -- - - - - - -±1-F ❑ ❑
U Tank baffles present? - - - - - - - - - B- -- - - - - - - - - - - t' ❑ +� ❑
a
24"access risers over each compadm _ ,:= =--=-- -Y----- - ❑ � ❑
W Effluent filter installed?-- - - -- - - - - - -- - -- - - - - - -- - ---- ❑ ❑
(l,
Septic tank capacity(working) 12`�V oat Manufacturer I r
o D-box water level and speed levelers used? - - - - - --- - - - - -- - ❑ NIA 0 YES NO
QJ
O Manifold/D-box accessible from surface? - - - - - --- -- - - - -- - ❑ ❑ ❑
d?z Check valves installed? - - - - - - - - - - - - - - - - - - - - - - -- -- ❑ ❑ ❑
O<
t Transport Line Size Schedule/Class
Bedrooms installed (check one) ❑ 2 1]3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft.from foundation?- - - - - - - - - - - - - - - - - - -- - - - - -- ❑ NIA LIVES NO
>100ft.from wells?-- __ _ _ __ _ _ _ _ ___ _ __ _ _ _ ____ _ _ _ - ❑ ❑ ❑
J >100 ft. from surface water? - - --- - - - -- - --- - - - ---- -- - ❑ ❑ ❑
w
ti >10ft.from potable water lines?- - - - - - - - - - - - - - - - --- - - - ❑ ❑ ❑
aZ > 5ft.from property lines and easements?- - - - - - - - - - - - - - - ❑ ❑ ❑
> 30 ft.from downgradient curtain/foundation drains?- - - - - - - - -- ❑ ❑ ❑
Drainfield level and observation ports present - - - - - - - - - - - - - ❑ ❑
LI
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed overdrainfield?- ----- - - - - --- -- - -- - ❑ ❑ ❑
Pump tank setbacks consistent with septic tank? - - - - -- - - - - - -- ❑ NIA ❑ YES NO
Y Pump tank capacity(flood) gal Manufacturer
. 24"access riser(s)and accessible from surface?- - - - ---- - - -- - ❑ ❑ ❑
Alarm or Control Panel Installed? - - - --- - - - - - - --- - - --.- ❑ ❑ ❑
Control Panel equipped with Timer/ETM/Counter- - - - - - - - - - - ❑ ❑ ❑
a_
Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
a Pump Make/Model ❑ Floats or ❑ Transducer
• Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
uodma erzuvme
Mason County OSS Installation Report pg. 2
Parcel#
ABANDONMENT RECORD
YES NO
Were existing septic components abandoned as part of this protect.
If yes, please describe: yE. No
Were all components pumped out and properly abandoned per WAC246-272A-0300? " - -- - - -
RECORD DRAWING
descriptive enough maecae in the need of maintenance activities and.lure development Typical FecoN
This is a permanent record end must be accurate end eescrl to
Draw are came n Dlas.OeWo maoand mammain a lance a ceprdwmp.nx location North Draw.resor'Iegs may a additional delays irilield,existing and ^�•linetall lion appmeaI and eleted permits.
wells,obOll an pons.daanoNs,and other maintenance access pants. Incomplete Record Drawings may create
Record Drawing Attached
CERTIFICATION7State
ALLATION
NER/ENGINEER
INSTALLER
I certify that I installed the system in accordance with that the system has been installed in accor-
the septic design stamped "APPROVED"by Masonwith the septic design stamped"APPROVED"by
County Public Health and that any deviations shown County Public Health and that any deviations
here have been cleared/approved by both the designer here have been cleared/approved by both
and Mason County Public Health and meet all Statean Mason County
mysf and Mason
County
Coubli Health and meet all
and Mason County Codes.I further certify that all information contained on thiser certify that all information contained on this
farm and attached Record Drawing is accurate. nd attached Record Drawing is accurate.
Signature of Installer Dale
M
of Signee
UNT'PUBLIC HEALTHned approves this Installation Report anding on behalf of Mason County Public/ -3�'5'� b 7 E (stamp, signature and date)
Environmental Health Speclahst Date THIS FORM MAYBE SCANNEDAND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE UpeWea N=nAra
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