HomeMy WebLinkAboutSWG2025-00229-ASBUILT - SWG As-Built - 8/24/2026 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2025-00229 Parcel# 22330-50-00307
Applicant Name Rick Atkinson Subdivision (Name/Div/Block/Lot)
Applicant Address 300 NE Haven Lake Dr _+_/
City, State, Zip Tahuya, WA 98588 Installer Name Jack Johnson
Site Address -j6 ALL Designer Name NIA tank only install
INSTALLATION CHECKLIST
❑ Full System Installation Q Tank(s)Only ❑ Drainheld Only ❑Repair ❑Other
System Type Pump tank to exsisting gravity system Pretreatment Type N/A
>5 ft.from foundation? - -- - - - -- - - - - - - - - - - - - --- - - - ❑ NIA ❑YES NO
>501t.from wells? - _ _ _ _ _ _ _ _ _ _ _ _ _r_ _ __ _ _ __,..— .--a_.: ❑
>50 ft.from surface watery - - - - I{ ` ❑ ❑
fCleanout between building and tank? - ❑ ❑
O Tank baffles present? - - - - - �j�� r f• 2e ❑ ❑
d24"access risers over eac in im. '. - - - -^- ❑ ❑
W Effluent filter' - 11J1�V-'s ❑, ( ❑ ❑
plic tank capacity(working) gel ufacturer
O D-box water level and speed levelers used? - - - - - - - - - - -- ❑ NIA ❑ No
0O Manifold/D-box accessible from surface? - - - - - - - ❑ ❑
f0= Check valves installed? - - - - -- - - - - - - - ❑ ❑ ❑
o¢
Tran a Schetlule/Class fr^
Bedrooms installed (check one) ❑ 2 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft.from foundation?- -- - - - - - - - -- - ❑ NIA ❑ NO
>100 fl.fromwells?- ---- -- - - - - - - - --- - - - - - ❑/� ❑ ❑
W >100 ft.from surface water? --- - - - - - -- - - i-�-� ❑ ❑
ty >10ft from potable waterlines?-- - - - -- - - - - ❑ ❑ ❑
aZ > 5 ft.from property lines and easements9 . - - - - - - - - - - - O ❑ ❑
> 30Th from downgradient curial ation drains? - - - - - - - - - - ❑ ❑ ❑
Drainfield levelando ion ports present -- - - -- - - -- - -- - ❑ ❑ ❑
❑ Grav ambers or ❑ Clean gravel used? (check one)r ✓t fO ❑
e cover installed over drainfeld?-- - - --- - - - - - -- - - - - - ❑ �r 0
Pump tank setbacks consistent with septic tank?- - - - - - - -- - - -- ❑ N/A E YES ❑ NO
1 Pump tank capacity(flood) 118 gal Manufacturer Orenco
6 24" access riser(s)and accessible from surface? - - - ❑ Q ❑
~ Alarm or Control Panel Installed? - - -- - - - - - - - - - - - - - - -- ❑ 0 ❑
Control Panel equipped with Timer/ETM/Gaunter - - - - --- - - - Q ❑ ❑
a Pump installed in ❑ Bucket or ❑ On Block or Q Other PVC Basin
Pump Make/Model Liberty Pumps LE50 Q Floats or ❑ Transducer
Tank draw down 160 in/min Pump capacity 115 gpm Squirt Height 25 ft
Pump on time Float Pump off time Float Daily flow set at Float gpd
addated XRV2➢18
Mason County OSS Installation Report pg.2 Parcel# 22330-50-00307
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - ---- - ------- - ❑ YES It NO
If yes,please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? ----- ' " ' ❑ YES 0 N
RECORD DRAWING
This ie.p.rmauenr rtcor4 end must b.accurate.nd dscrlWv.^n^.an to n.mczle In the need or mainmmfl<e aulmtief end more aevalopmem. Typ cal Record
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❑ Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER. DESIGNER/ENGINEER
I certify that!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 ail 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 a ched Record Drawing is accurate, form and attached Record Drawing is accurate.
Sig tune !"VInstaller Date Ni
JQy\ 21t956V V\`
Printed Name of Signed f
MASON COUNTY PUBLIC HEALTH /r� r,Yf u
The undersigned approves this Installation Report and V
Record Drawing on behalf of Mason County Public
Health:���/'/�Xy� �ryry������� `8 gg4
Signature of Environrn nta Health Specialist Date (stamp,signature and date)
THIS FORM MAY BE SCANNED ANDAVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE apd.l.0 erxrrxme
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