HomeMy WebLinkAboutSWG2026-00221 - SWG As-Built - 9/4/2026 Docusinn Envelope ID'.5968FOA1-2D53-BB37-BOD.5-F6CA4BAA199e
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2026-00221 Parcel # 123055200015
123055200015
Applicant Name SKINNIER SAMI IFl Subdivision (Name/Div/Block/Lot)
Applicant Address R21 IIAVCRFST non/E SE
City, State, Zip OI YMPIA WA 9A513 Installer Name SAMI IFI SKINNER
Site Address 70 NF I Al IRFI RD RFI FAIR WA Designer Name CAMI IFl SKINNER
INSTALLATION CHECKLIST
❑ Full System Installation X❑Tank(s)Only ❑ Drainfield Only ❑ Repair ❑Other
System Type PRFSSIIRF Pretreatment Type NI IWATFR WI TRASH TANK
>5 ft from foundation? - - - - - - (} 4 r f�� N/A O YES ❑ NO
>50 ft.from wells? - - - - - - - - - - - - - �Itr - - �Iil� ❑ ❑
Z >50 ft.from surface water? - - - - - - - - - - - - -41St � �6 � - I /I' lO ❑ ❑
HCleanout between building and lank? - - - 4 - - - - - - --- - - - - - L1 ❑ x❑ ❑
O �_Tank baffles present? - - - - - - - - - - - - mss'- -, {R=Qi- - - /O x❑ ❑—_
C24"access risers over each compartment? - - - -_= — ❑ ® ❑
W Effluent filter installed?- - - - - - - - - - - - - - - - - - - - - - - - - - - 0 ❑ ❑
rA
Septic tank capacity(working) snp / 1060 gal Manufacturer INFIl TRATOR IM-540 & CM-10A0
O D-box water level and speed levelers used? - - - - - - - - - - - - - - - ❑ NIA ❑ YES fl NO
OJ
O Manifold/D-box accessible from surface?- -- -- - - - - - - - - - - - - ❑ El ❑
mz Check valves installed? - - - - - - - - - - - - - - - - - - - - - - - - -- ❑ ❑ ❑
OQ
� Transport Line Size 91N (FXISTI NI`\ Schedule/Class S(`HO 40
Bedrooms installed (check one) 2 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10ft. from foundation?- - - - - - - - - - - - - - - - ❑ N/A DYES NO
>100 ft. from wells?-- - - - - - - - - - - - - - - - - -- ❑ ❑ ❑
J >100 ft. from surface water? - - - - - - - - - - - - - - - ❑ ❑ ❑
ILL >10 ft.from potable water lines? ❑ ❑ ❑
Z > 5 ft. from property lines and easements?- - - - - - - - - - - - - - -- ❑ ❑ ❑
fY > 30 ft.from downgradient curtain/foundation drains? - - - - - - - - - - O ❑ ❑
Drainfield level and observation ports present ❑ ❑ ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed overdrainfield?- - - - - - - - - - - - - - - - - -- ❑ ❑ ❑
Pump tank setbacks consistent with septic tank? -- - - - - - - - - - - - ❑ NIA x❑ YES ❑ NO
Pump tank capacity (flood) gal Manufacturer EXISTING ('nNCRFTF
Q24" access riser(s)and accessible from surface?- - - - - - - - - - - -- ❑ O ❑
~ Alarm or Control Panel Installed? - - - - - - - - - - - - - - - - -- - - ❑ O ❑
a
Control Panel equipped with Timer/ ETM /Counter- - - - - - - - - - - ❑ ® ❑
rl Pump installed in ❑ Bucket or ❑ On Block or O Other 191N BASIN
[L Pump Make/Model I IRERTY 9g0 X❑ Floats or ❑ Transducer
a� Tank draw down 4 in/min Pump capacity BS gpm Squirt Height N/A ft
Pump on time 49 SFr Pump off time A HRS Daily flow set at ?4n gpd
updated arzv20IH
Docusign Lnvelope ID:5960FDA1-2853-8837-8005-F6CA4BAA199B
Mason County OSS Installation Report pg. 2 Parcel# 123055200015 an
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - --- 0 YES D NO
If yes, please describe;
Were all components pumped out and property abandoned per WAC246-272A-0300? - - - - - - -- 0 YES NO
RECORD DRAWING
This is a wrmanent record and must bn accurate and descriptive enough to re-locate in the need of manrmunce atlNnlee and future development. Typical Record
orawings contain Draineeld d manamd orientation a layom.Septic/pump tank incatgo.uortb arrow,reserve dramnem,a 1s ng and proposed builaings iocation of wells,waterlines,
wells,olrsavalan ports cleannuts,and other maintenance access paints. Incomplete Resod cravings may create additronal delays in final nslallalinn approval and related permits.
El Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that I installed the system in accordance with 1 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
f�t4 d Record is accurate, form and attached Record Drawing is accurate.
6"� nAf1enma
z.,Edrre of
f Installer
Signature o/Installer Date
S'AMI IPI CVIMMPP
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health.
eNwp`6M 9(L U7
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 anrrzole
m +- ] 20 }
{ �f
_ v1
} : >
,
@
Ca
Cl)C-D > ` m
CD 2 \ ' _0
« )
o + ; c)
OO
O O O
. �
@Ag
_+« Aaso m
0 . n
m
+/- 120' : E I
M
\ \ NORTH z
0 \ c
)
` , m
CD
. �
ncl)K c \ \ k \ (
mmo > o = > O = m »
) \ $ \ > ` G - Z
{ ) O = a2 \ § \
� f ) ` \ � ) ) }
§ \
G � H
? \\ }
x 9 \
i : }2 \
! \ »\ § / &
(Ill fli `
. rM j ! 2a
C } ) i ( ( ` ` , -