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Home My WebLink AboutSWG2024-00418 - SWG As-Built - 9/11/2026 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2024-00418 Parcel# 32104-50-00045 Applicant Name John Kilbourne Subdivision (Name/Div/Block/Lot) Applicant Address 611 Yakima Ave S Alderbrook Golf&CC,Lots 5&45 City, State, Zip Tacoma, WA 98405 Installer Name South Bay Septic&Excavating Site Address 71 E Country Club Dr E Union Designer Name Mow Septic Designs, Inc INSTALLATION CHECKLIST • Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair ❑Other System Type Shallow Pressure Bed Pretreatment Type >5 ft.from foundation? -- ----------- ------- -'-" - ❑WA AYES NO >50 ft.from wells? ----- - - ----- ❑ © ❑ Y >50 ft.from surface water? --- - -- - ' ^� " ATE ❑ o ❑ Cleanout between building and tank? - ---H -SEP t2026 ❑ ❑ U Tank baffles Present? -_ _ __ __ _ _ _ _ ____ ___ ____ ___ ❑ Q ❑ 24°access risers over each compartment?- - -- - ----- - - -� ❑ ® ❑ w Effluentfilterinstailed?-- - - - -- - - - - - - - - - -- ❑ ® ❑ Septic tank capacity(working) 1.250 gal Manufacturer Cuz Concrete Products 0 D-box water level and speedlevelers used? ------ --- --- - -- ❑ wA O NO DJ O Manifold/D-box accessible from surface?-- ------------- -- ❑ ❑ a9z Check valves installed? -- -- - - --- - - - ----- ------- ❑ ® ❑ 0< a Transport Line Size Y Schedule/Class 40 Bedrooms installed(check one) ❑2 S 3 ❑4 ❑ 5 ❑6 ❑Commercia&Other >loft.from foundation?-- -SCR--4 - - - - --- - - -- - ❑ NIA ❑ YES NO >100 ft.from wells?-_ ____ _ _ __________ _ _ ____ ____- ❑ s ❑ W >loo ft.fromsurfacewater?- - - - - - ---- - - - ---- ---- -- ❑ 0 ❑ a 10ft.frompotablewater lines?---- ---- --- --- --- - - --- ❑ I ❑ > 5ft.from property lines and easements?-- - ----- ------ - - ❑ ❑ W > 30 ft.from downgradient curtain/foundation drains?- -- - - - -- -- ❑ D ❑ Drainfield level and observation ports present - - --- - ----- --- ❑ © ❑ ❑ Graveless chambers or • Clean gravel used? (check one) Proper cover installed over drainfield?--- --- ---- -------- - ❑ ❑ Pump tank setbacks consistent with septic tank?------ - --- -- - ❑ WA ® YES fl NO Y Pump tank capacity (flood) 1.000 gal Manufacturer Cuz Concrete Products 4 24"access riser(s)and accessible from surface?------ -- - -- - - O a Alann or Control Panel Installed? -- - ----- - - ------"-- ❑ 2 Control Panel equipped with Timer/ETM/Counter-- - --- - -- -- ❑ ® ❑ n. Pump installed in ❑ Bucket or U On Block or O Other o- Pump Make/Model Liberty 280 ® Floats or ❑ Transducer Tank draw down 2 iNmin Pump capacity 44 gpm Squirt Height 6 ft Pump on time 2 min Pump off time 6 hr Daily flow set at 360 gpd U'mOBRRJIe Mason County OSS Installation Report pg. 2 ?arcelp 32104- - 0oo`4'S ABANDONMENT RECORD Were existing septic components abandoned as p�artt o°f°thiiss proojecctt?,,- - - - - -- - - - -- - - - YES ❑ No If yes, please describe:�+ _ "rte 1. --�� d'[�-0g ha-c-k�'Gl�`d� �Q1o4.r8.z Were all components pumped out and properly abandoned per WAC24o'-2/2A-0300? -- - - - - - ❑ YES ❑ NO RECORD DRAWING This is perTnanent record nd mtst b accurate and descriptive enousn to re-localethe ee of maintenance actNities end future develop Re;;,: Sracna Dra 6eaa manifold onentation&layout,Saptc/punp tankl n North arrow.relerue d,aineld.exisUfl5end proposed 6 local-On at etLs waterlines. wells.obsarvabon pons deanauts.and other meintenance access punts. Incomplete Record Urawnas may ve le seer anal delays nrnaLnraunon approval and related pemrrs. • Record Drawing Attached CERTIFICATION OF INSTALLATION INSTALLER DESIGNER/ENGINEER I certify that I installed the system in accordance with I certify that the system has been installed in actor- 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 hem have been cleared/approved by both the designer shown hem 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 and attached Record Drawing is accurate. - form and attached Record Drawing is accurate. 'fit c'tA— Sit Signature of Installer Date BbnIiBI111G@11ffin C 1, Printed Name of Signee MASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Report and sto Uns ` Record Drawing on behalf of Mason County Public PaAULA JOY�ONNsoN'S' Health Signature of Environmental alh Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Upeete08I1r/2°'B A ö F5 50 45 GO d/P G t .rd .}0 nl R be TPRC�t- f321R4-5p- 00045 y� ° �{ 1 � CCUNTet; CLugD2F H4ETf € VNrO} S ti�l� 95542 tees 5saeP =?EST }4dLE 3 ,r{D 4l, S ° 15 + vne₹5S 71 COdac([oc Grp #3 =51 .1 to 4 + ____fit-Gt: 3cug\S +r m'� y 1 r G Edo CZ)SX`f'S PR�HRR4 4 ID•F $ED W �'rr,• • . / T L YJ rmi FQ6SSuke TR SNGH k.E SE¢ul :. . i WR^rBR '+�Flcwca Q ?radio-V`s ?sr_+ ® lscs�W( 'f' stc. t•250 o f =sue^ ® Pew—<- UeA�9srP4K$g EeeL2-Canpart with qty Wuett Filter 13 c 5 r)c'fS vet-" b PAULA JOY JOHNSON'$ 'tC E .. O4 1000 Gallo Pump C1arbe ® TC e4 Haza d ea{f4 ) veNoteto installer** f,rd W Sleeve waterlmc whethinn wi 10' r� pes 74O°lo R t of septic transpoi line.Maintain V Buffer *°r lo'minimum between water line and septic tanl&dtainfield. Kayla Milam From: DO NOT REPLY <noreply@masoncountywa.gov> Sent: Saturday,August 29,2026 11:53 AM To: Environmentalhealth Subject: OSS Inspection request for John Kilbourne - SWG2024-0041 8 Submittal request for:John Kilbourne Site Address:71 E country club dr E Permit Number:SWG2024-00418 Parcel Number:321045000045 AUG 3 11016 'h1'I Installer Name: Ben Guffin installer Phone Number:3609705709 Installer Email Address:southbaysepticandexcavation@gmail.com 71 N SJPECT(Qe'J Designer Name:Paula Johnson Designer Email Address: paulaj@hctc.com Inspection Request Date:2026-08-31 Inspection Type:Full System Comment\Notes:There's a lot going on with this Install please call me and talk to me if there is a problem 360-970-5709 Ben Thank you for submitting your final install request.The install should be complete and ready to inspect on the'Inspectio Request Date'and remain uncovered for three business days to allow staff time to inspect. Poor weather situations may, be accommodated by contacting onsite staff. Installer is responsible for obtaining Septic Designer/Engineer installation .'approval prior to backfill of system components. If no contact is made by the health department within the three _ business days of notice,the installer may cover. Mason County Asbuilt Form, Record Drawing, and Installation fee must be submitted for final installation approval. 1 • 1 • , • I I 1 � If• 11 • 1 1 ' 1111 ' r / • 1 ' 1 . FE �Ft' �, Ar ° } s .a feyl r T3 r,Jf.. ? — F k e e' e *mac GalaxyS23 f' ` August 31 _ _ _ r r l LIIfl. ' r