HomeMy WebLinkAboutSWG2026-00206-ASBUILT - SWG As-Built - 8/21/2026 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
PermitNumber SVUG 'd0a( ' CU�UIa Parcel# 3' 33(Y5tQ(Z)'\O
Applicant Name (fir lru1'\ Occ Subdivision (Name/DivBlocklLot)
Applicant Address PC,
City, State, Zip -y ,ASOc.1A' `1 S4ç Installer Name QO\AckA F\uc ,-
SiteAddress 1k",)-k Li 1X5 tAJ U \ Designer Name t -y\okt r'
INSTALLATION CHECKLIST
❑ Full System Installation L}Tank(s)Only ❑Drainfield Only ❑Repair ❑Other
System Type k4✓i F — ----_— Pretreatment Type 4-'0 N r-
>5f1 from foundation? I1LLL cJ - ❑ WA BYES ❑ No
>50 ft. from wells? - ___ ___ r pr_ - ❑ E9 ❑
>50 ft from surface water? ------ _ _ ULE__yU - ❑ S ❑
Cleanout between building and tank?'-U - --�- �-..Q- -- -- --- ❑ ❑
a Tank bafes present? -- - - - - - - �.__._ _(_ -�1'�--`_ _ __ _ _ ❑ .l ❑
a24"access risers over each compartment?- -- - -- -- - -- ----- ❑ .S ❑
W Effluent fitter installed?--- -- - - --- -- - - --- --- - -- --- _ ❑ B ❑
to
Septic tank size 1`=J0O aal Manufacturer
0 D-box water level and speed levelers used? - ---- -- - - -- - -- - ❑ NIA ❑YES ❑ NO
�O Manifold/D-box accessible from surface?-- ---__ ----- ❑
QQ Checkves ta
val inslled7 - --_.--_ ---- - - - ---- - - ❑ ❑ ❑
2 Transport Line Size Schedule/Class
Bedrooms installed (check one) ❑ 2 ❑3 ❑4 ❑ 5 ❑6 ❑CommerciavOther
-10Rfrom foundation?-- - -------- - - ---- - -- -- --- - ❑ N/A DYES ❑ No
o >100 ft. from wells?-___ __ ___ _ __--- -- --- - -- --- -- - - -- -- -- --- - ❑ ❑ ❑
W >100 ft.from surfacewater? - - - -- - --- - --- ---- t " ❑
>10 ftfrom potable water lines?-- - -- --- - - --- - ---- - ❑ ❑ ❑
> 5 ft. from property lines and easerflents7 - - ,JJ�VL - - ❑ ❑ ❑
> 30 ft.from downgradientourfain/foundation drains? --- - - - - - ❑ ❑ ❑
G Drainfield level and observation ports present - - - - --- - - - -- -- 0 ❑ ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?--------- -- --- --- -- 0 El ❑
Pump tank setbacks consistent with septic tank? - - -- O WA ❑ yes ❑ No
zPump tank size gal Manufacturer
Q 24"access nser(s)and accessible from surface?-- ❑ ❑ ❑
Alarm or Control Panel Installed? - - - -- --- --- - --- -r ❑ ❑ ❑
Control Panel equipped - ❑ ❑
q pped with Timer I ETM/Countr-
- -
Pump installed in ❑ Bucket of.-QOn Block or ❑ Other
fPump Make/Model - / ❑ Floats or O Transducer
IL
Tank draw down in/min Pump capacity apm Pac tY Squirt Height ft
Pump on time Pump off time Daily flow set at apd
told&2121X8
•
Mason County OSS Installation Report pg. 2 Parcels kxr sTh
ABANDONMENT RECORD
Were eudsting septic components abandoned as part of this project? -- - ------ --- -- - YES ❑ NO
If yes, please describe: C iZtIS fl Jr ? McJr C L ,) 74 J IC
Were an components pumped out and property abandoned per WAC246-272A-0300? ------ -- Eryas ❑ tNO
RECORD DRAWING
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Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNERI 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 nd ails Record Drawing is accurate. form and attached Record Drawing is accurate.
D7Z3 Z6
siS1u Jinstafler Date
p �
�fIR//U 4, (/ /?c'ya / /
Printed Name of S.gnee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
Signature of Environmental Flea Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAWIBLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE upmMaemaoie
RECORD DRAWING (continued)
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