HomeMy WebLinkAboutABANDONMENT RECORD - SWG Photos - 9/14/2026 \uthentisign ID:314F82F5-25A3-F111-9B33-000D3A4FF82A ABANDONMENT R E C O R D
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG • Parcel # 3Z.O3 I D -a/Q7I
•Applicant Name u✓" Subdivision (Name/Div/Block/Lot)
•Applicant Address 8 7/$5/ ecncA/G C-/
City, State, Zip Y2meA, 4 Q7yS7 Installer Name
•Site Address Designer Name
INSTALLATION CHECKLIST
❑ Full System Installation ❑Tank(s) Only ❑ Drainfield Only ❑ Repair ❑ Other
System Type Pretreatment Type
>\risers
foundation? - - - - - - - - - - - - - - - - - - - - - - - - - - - ❑ N/A ❑ Y ENO
>
wells? - - - - - - - - r, T;: T1 ❑ Li
Z > surface water? -- - ' - r - ----- - - - --r-\- - ❑ ❑
C een building and tank? - - i - - ❑ ❑ ❑
U Ts p ent? - - - - - - - - , � ��}17 t� 1 - ❑ ❑ ❑
F- 2s risers ver each compartrhthit?- - - - - - - - - - - - - ❑ ❑aW Eter installe - - - - - - - f .- - - - - - - - -Sk capacity (wor ) gat Manufacturer
O D-box water level and speed le rs used? - - - - - - - - - -- - - - ❑ NSA ❑ YES ❑ No
�O Manifold/D-box accessible from su e? - - - - - - - - - - - - - - - ❑ ❑ ❑
mz Check valves installed? - - - - - - - - - - - - - - - - - - - - - - - - ❑ ❑ ❑
6 Q
E Transport Line Size Sched /Class
Bedrooms installed (check one) ❑ 2 ❑ 3 4 ❑ 5 ❑6 ❑Commercial/Other
>10ft. fromfoundation? - - - - - - - - - - - - - - - - - - - - - - - - ❑ N/A EYES ❑ No
>100ft. fromwells?- - - - - - - - - - - - - - - - - - --Li ❑ ❑
W >100ft. fromsurfacewater? - - - - - - - - - - - - - - - - - - - - - - ❑ ❑ ❑
i >10 ft. from potable water lines?- - - - - - - - - - - - - - - - - - - ❑ ❑ ❑
? > 5ft. frompropertylinesandease nts?- - - - - - - - - - - - - - - ❑ ❑ ❑
> 30 ft. from downgradient curtai oundation drains? - - - - - - - - - - ❑ ❑
Drainfield level and observatio ports present - - - - - - - - - - - - - - ❑ ❑
❑ Graveless chambers o ❑ Clean gravel used? (check one)
Proper cover installed ov drainfield? - - - - - - - - - - - - - - - - - - ❑ ❑ ❑
Pump tank setbacks onsistent with septic tank? - - - - - - - - - - - - - ❑ NIA ❑ YES ❑ NO
Pump tank capa i y (flood) gal Manufacturer
Q24" access ris (s) and accessible from surface?- - - - - - - - - - - - - ❑ ❑\Transducer
AlarmorC trolPanelInstalled? - - - - - - - - - - - - - - - - - - - - - ❑ ❑aControl P nel equipped with Timer/ ETM /Counter- - - - - - - - - - - ❑ ❑D
ii - Pum nstalled in ❑ Bucket or ❑ On Block or ❑ Other
P p Make/Model ❑ Floats or ❑
a
ank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 8/21/2018
kuthentisign ID:314F82F5-25A3-F111-9833-000D3A4FF82A
Mason County OSS Installation Report pg. 2 Parcel # & -t 3C) so / Gay
• ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - - C YES ❑ NO
If yes, please describe: Ir' Vcid "
Were all components pumped out and pr perly abandoned per WAC246-272A-0300? - - - - - - - - X YES ❑ NO
• RECORD DRAWING
This Is a permanent record and must be accurate and descriptive enough to re-locate in the need of maintenance activities and future development. Typical Record
Drawings contain. Drainteld&manifold orientation&layout,Septic/pump tank location,North arrow,reserve drainfield,existing and proposed buildings,location of wells,waterlines,
wells,observation ports,cleanouts,and other maintenance access points. Incomplete Record nraviings may create additional delays in final installation approval and related permits.
, s. '2-i- i
❑ Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ ENGINEER
!certify that t installed the system in accordance with I rtify that the system has been installed in a or-
the septic design stamped "APPROVED"by Mason dan with the septic design stamped "APP VED"by
County Public Health and that any deviations shown Masot ounty Public Health and that an eviations
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 Ma n County Codes
I further certify that all information contained on this I further certify t all inform on contained on this
fo ,aatldtattached Record Drawing is accurate. form and attache ecord rawing is accurate.
Alah to l'oUe, PR 08/28/26
• WI
Signature oflnst�r �'W4'' -D Date
!ah ryIi/tor PR
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.'
9/14/2026
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