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Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG • Parcel# 32o.� ≤b -a/CoA'
•Applicant Name AJew pµ/r Subdivision (Name/Div/Block/Lot)
•Applicant Address // S/ G CI
City, State, Zip YentA, 4< 97y87 Installer Name
.Site Address s4 Designer Name
INSTALLATION CHECKLIST
❑ Full System Installation ❑ Tank(s) Only ❑ Drainfield Only ❑ Repair ❑Other
System Type Pretreatment Type
> from foundation? -- - - - - - - - - - - - - - - - - - - - - - - - - - ❑ NIA /E:] ❑ No
>50 . rom wells? - - - - - - - --- - ❑ ❑>50 ft. fr surface water? --- - - 1 -- 7 -- ❑ ❑Cleanout b een building an _ - - - ❑Tank bafflesp ent? - - - - - - - ._ }j(n_'{_htHli - _ _ a _ - ❑ ❑
I— 24' access risers er each compartrpaht?- - - - - - - - - - - - - 4-I - ❑ ❑ ❑
W Effluent filter installe - - - ❑ ❑
N
Septic tank capacity(wor ) gal Manvfactvler
O D-box water level and speed le \used? - - - - - - - - - - - - - - ❑ N/A ❑ YES ❑ NO
J
OIOi Manifoltl/D-box accessible from su - - - - ❑ ❑
mZ Check valves installed? - - - - - - - - - - - - - - - - - - - ❑ ❑ ❑
OQ
Transport Line Size Sched /Class
Bedrooms installed (check one) ❑ 2 ❑ 3 4 ❑ 5 E ❑Commercial/Other
,10ft. fromfaundation? - - - - - - - - - - - - - - - - - - - - - - - ❑ NIA DYES ENO
>100ft. fromwells?- - - - - - - - - - - - - - - - - - - -0 ❑ ❑
>100ftfromsurface water? - - - - - - - -- - - - - - - - - -0 ❑ ❑
tL >1oft. from potable water lines?- - - --- - - - - - - - - - - - -- - - ❑ ❑ ❑
Z > Sfl. from property lines and ease nts?- - - - - - - - - - - - - - ❑ ❑ ❑
> 30 ft from downgradient curtai oundation drains? - - - - - - - - - - ❑ ❑
Drainfield level and observaho ports present - - - - - - - - - - - - - - -C ❑
❑ Graveless chambers o ❑ Clean gravel used? (check one)
Proper cover installedov drainfield?- - - - - - - - - - - - - - - - - - - ❑ ❑ ❑
/accessris
nk setbacks onsistent with septic tank? - - - - - - - - - - - - - ❑ N/A ❑ YES ❑ NO
Ynk capa y(Flood) gal Manufacturer
. 24 access ris (s)and accessible from surface?- - - - - - - - - - - - - ❑ ❑ ❑
~
CrC trot Panel Installed? - - - - - - - - - - - - - - - - - - - -
❑ ❑aP nel ecuipped with Timer/ETM/Counter- - - - - - - - - - - ❑ ❑ ❑stalled in ❑ Bucket or ❑ On Block or ❑ Other
4ake/Model ❑ Floats or ❑ Transduceraaw down in/min Pump capacitygpm Squirt Heightn time Pump off time Daily flow set at gpd
uq.•4 emnnle
el he it,sign ID.i14FerF525A3-Fn 1-9833- orrydFl FezA
Mason County OSS Installation Report pg. 2 Parcel# cLa3U Sc -i cti q
. ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - -- - - - - - ' YES ❑ NO
If yes, please describe 6/71'ftt cqi Man ronnPS G
Were all components pumped out and pr party abandoned per WAC246-272A-0300? ' - - - - - - ' YES ❑ NO
RECORD DRAWING
This o a permanent record an must be accurate and escOYpva enough o reroceu In me nee or ma✓dada nce activities an uture are o mem. ca ewrij
Drawngs contain mmpela B ntanrmtoenramn 6l N�Septoumd rdek lo.ain,North ar.ow r wane drainrieliJ eesllho and proposed buildings location of wells.wasnne
ells,observation ports cleanours and other momlenenee access pointe incomplete deco,Uravnngs May create aidibonal delays in final installation approval and related permits
S' oJ1 Tula tz
/aIOV
II t -. ❑ Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER ESIGNER/ENGINEER
1 certify that/installed the system in accordance with I rtify that the system has been installed Ina or-
the septic design stamped APPROVED by Mason den with the septic design stamped"APP VED by
County Public Health and that any deviations shown Masol curly Public Health and that an evictions
here have been cleared/approved by both the designer shown h e have been cleared/approv by both
and Mason County Public Health and meet all State myself an ason County Public H Ith and meet all
and Mason County Codes. State and Me n County Codes
I further certify that all intonation contained on this I further certify t all inform on contained on this
fo qqqqqq-andn attached Record Drawing is accurate. ton and attache ecord yawing is accurate.
R10.h M;/]our, PR 08/28/26
Signat
ure oNrrsTalRr /1n0M-O Date
nn .t1 fi0ur P2
Printed Name of Si nee
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 WED SITE uiwawaemtgota