HomeMy WebLinkAboutSWG2023-00428/ASBUILT - SWG Application / Design - 9/4/2026 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANTI PERMIT INFORMATION
Permit Number SWG 2023-00428 Parcel# 22336-54-00046
Applicant Name Rob Miller Subdivision (Name/Div/Block/Lot)
Applicant Address 190 NE Tiger Way E Lynch Cove/ Div 4/Lot 46
City, Stale, Zip Belfair, WA 98528 Installer Name Shae Oien
Site Address 2i NG _#%4ayA L'VI Designer Name Tom Weaver
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type Gravity Sod 10'X 45' Pretreatment Type Septic tank
>5ft. from foundation? -----jo
-------- ❑ NWA •YES NO
>50 ft. fromwells? ----- - - - -l;- ;I-lyh�r -- ❑ ❑
>50 ft.from surface water? - _ _ ___ __ - ❑ ■ ❑
Cleanout between building and tAUG 2-)- ^B- jJ --- ❑ � ❑
U Tank baffles present? -__ _ __ _______ ___ __- ❑ 0 ❑24"access risers over each corn -_ ❑ U ❑
HEffluent filter installed?- -- - - - - - - - - - - -- -- - ❑ U ❑
Septic tank capacity(working) 1250 pal Manufacturer Infiltrator
O D-box water level and speedlevelers used? - - - - - ----- ----- ❑WA US No
Manifold/D-box accessible from surface?- - - ---------- - ❑ U ❑
0LL
Q Check valves installed? -- ------------------------ ❑ ❑
2 Transport Line Size 4" Schedule/Class 3034
Bedrooms installed(check one) ❑ 2 ■ 3 ❑4 ❑ 5 ❑6 ❑CommerciavOther
>10 ft.from foundation7 -- - - - - ------- - - -- ❑ Nu UVES ❑ NO
>100 ft. from wells?- __ _ _ _ __ _ _ ______ _ _ ___________ ❑ U ❑
W >100 ft.from surface water? --------- -- - ------------ ❑ ❑
M >10ft.from potable water lines?---------------------- ❑ � ❑
Z > 5ft.from property lines andeasements?-- -- - ----------- ❑ 0 ❑
> 30 ft.from downgradient curtain/foundation drains?---------- ❑ ® ❑
Drainfield level and observation ports present - -- -- ❑ ❑
❑ Graveless chambers or • Clean gravel used? (check one)
Proper cover installed overdrainfield?---- ❑ M ❑
Pump tank setbacks consistent with septic tank?- -- -- -------- - in ❑ YES ❑ NO
Pump tank capacity(flood) pal Manufacturer
2
R 24"access riser(s)and accessible from surface?-------- ---- - - 0 ❑
Alarm or Control Panel installed? - -- ------- - - U ❑ ❑
a
Control Panel equipped with Timer!ETM/Counter --- - -- - - - - • ❑ ❑
6. Pump installed in ❑ Bucket or ❑ On Block or ■ Other
9LPump Make/Model U Floats or ❑ Transducer
Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
ugNM 02,/2016
Mason County OSS Installation Report pg. 2 Parcel#22336-54-00046
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? --- - - - - - - - - - - - - ❑ YES NO
If yes. please describe:
Were all components pumped out and property abandoned per WAC246-272A-0300? ❑ YES NO
RECORD DRAWING
Tab Is e pxnNxnt road aid mlel M accords and dncnpllw ough to M.In the nwd ol m.lnYnanc.acuvltln and IUWn ErvNopment TYpul Re rd
Dr. gs0.MYer. orflff*Jd 81MNoI@ crania 181eyN.SepliWmp tank bcs4 ,No'n ru ..resew drarlteM.exaling and proposed Wtbyps,bulron of wefs wtedbea.
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® 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 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 Geared/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 Meson County Codes
I further certify that all information contained on this I further certify that all information contained on this
form d attached Record Drawing is accurate, form and attached Record Drawing is accurate.
(7 & 21/26
Signature of inArár Date
Shae Oien
Printed Name of Signee
t
MASON COUNTY PUBLIC HEALTH " it i `.
The undersigned approves this Installation Report and YH0UA5 EEWFAVFA•.
Record Drawing on behalf of Mason County Public Nssn NEA
Health: S)/ /%rtSignature of Environment Health Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated BQtam9
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Kayla Milam
From: DO NOT REPLY <noreply@masoncountywa.gov>
Sent: Thursday, August 13, 2026 10:43 AM
To: Environmentalhealth
Subject: OSS Inspection request for Rob Miller- SWG2023-00428
Submittal request for: Rob Miller
Site Address: 211 NE Barbara Lane Belfair, Wa 98528 f� ra p❑rte}
Permit Number:SWG2023-00428
Parcel Number: 22336-54-0046 AUG 1 3 226
Installer Name: Dien Construction Inc. B
Y
Installer Phone Number: 360 340-1981
Installer Email Address:oienconstruction23@gmajlcorn
Designer Name:Tom Weaver-Allied Designs
Designer Email Address: tweaver1431@gmail.com
Inspection Request Date:2026-08-14
Inspection Type: Full System
Comment\ Notes:
Thank you for submitting your final install request.The install should be complete and ready to inspect on the 'Inspection
1equest Date' and remain uncovered for three business days to allow staff time to inspect. Poor weather situations may
)e 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
'usiness days of notice, the installer may cover. Mason County Asbuilt Form, Record Drawing, and Installation fee must
e submitted for final installation approval.
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ai
MASON COUNTY
Public Health & Human Services
FINAL INSPECTION:
SWG2023-00428
ADDRESS: 181 NE Anchor Dr
PARCEL: 223365400046
DATE: 08/14/2026
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