HomeMy WebLinkAboutSWG2026-00103 - SWG As-Built - 9/4/2026 P4aso;County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG.Ua- (&W2 Parcel# d3OCO \ CY)
Th
Applicant Name {(ktt,1 /( r h Subdivision (Name/Div/alock/Lot)
Applicant Address St N L' _,-,mA „ ¶c -�"City, State, Zip ,t1 Installer Name Cup\ {=\y y
Site Address 31 N 1.- X Wi0.ln Designer Name Pcdpxvvm \Arc* r
INSTALLATION CHECKLIST
❑ Full System Installation $Tenk(s)Only 0 Drainfield Only ❑Repair ❑Other
System Type Aga-v1 TY Pretreatment Type flab
>5 h. Rom foundation? ----- -- -_____ V ,y ❑ NIA DYES jiO
s.Cg e. ro Gn wnlle9 rr+ 11��
Z >50 ft. from surface water? - __ _ __ __ 1 -r " ❑ ❑
Cleanout between building and tank? •-- {� 84 ❑
o Tank baffles present? --- - ____ ____ 1 ❑
24"access risers over each compartment?- y s,p ❑
u Effluent filter installed?.- BY ❑ 0
N
Septic tank size /anal Manufacturer .,Z-NFn_7,ria,To2
OO D-box water level and speed levelers used? -_____________- ❑ WA ❑yam ❑
NO
OLL Manifold/D-box accessible from surface?-----___-_ r
r z Check valves installed? -- - - - - - ___ �O ❑ ❑ ❑
Transport Line Size Schedule/Class
Bedrooms installed (check one) ❑2 ❑3 04 ❑ 5 ❑s ❑Commercial/Other
>10ft. from foundation?--_______________________- NIA DYES ❑ NO
13 >100 ft. from wells?- ---- ------------------------ ❑ ❑ ❑
W >100 ft. from surface water? - ______________ _ ❑ ❑
Z >10 ft. from potable water lines? _ ❑ ❑ ❑
>5 ft. from property lines and easements?-- ❑
>30 ft. from downgradlent curtaln/fou d on drains?- ----- -_ _- ❑ ❑ ❑
Drainheid level and observatlo , rts present - --- - - - - - -- - --
❑ Graveless chambers,of ❑ Clean gravel used? (check one) ❑ ❑ 0
Proper cover installed over drain!ield?-- - - - - __ __ ________- ❑ ❑ ❑
Pump tank setbacks consistent with septic tank?-- -- --------- 0 WYA ❑ YES ❑ No
ZPump tank size gal Manufacturer
24" access riser(s)and accessible from surface? ❑ ❑
Alarm or Control Panel Installed? . . . . . . . .
❑ ❑ ❑
Control Panel equipped with Timer/ETM!Counter ❑ ❑ ❑
Pump installed in ❑ Bucket or ❑ nBlock or ❑ Other
Pump Make/Model
❑Floats or ❑ Transducer
0. Tank draw down n/min Pump capacity a i gpm Squirt Height it
Pump on time Pump off time Daily flow set at
tkaklttltlaNa
Mason County OSS Installation Report pg. 2 Parcel# ?z,3 3051 at CC)
ABANDONMENT RECORD
Were existing septic components abandoned as pan of this protect? --------------- —Y-- ❑ NO
If yes, please describe: Cef US N E r1 ii) YA-NK M
Were all components pumped out and properly abandoned per WAC246-272A-030D?•------- 1n`eEB fl No
RECORD DRAWING
This Is a permanent record and must be accumta and descdptiva enough to re-locate In the leeti or mainstream activldes and future davetopment Typkal Record
Universe contain: Dmhiled&manrold alentalon&layout,Seplidpumptenk heating,North snow,reserve drainield,existing and proposed buildings,Iccalion otwells,waterlines.
words,observalbn polls,cleanouls,and oNermelntenance access points. Incomplete Record omwlgemay create adddional Delays In final installation approval and related pemlls.
ea: ✓ ��l S /9In
r/ ✓'n,0
❑ Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that)installed the system in accordance with I certify that the system has been installed in accar-
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/appmved by both
and Mason County Public Health end meet all State myself and Mason County Public Health and meet all
and Mason County Codes. State end Mason County Codes
I further certify that all information contained on this /further certify that all Information contained on this
form an -a ch Record Drawing is accurate- form and attached Record Drawing Is accurate.
O723 26
Sig Installer
,��///�/� �/ro�j��
77//�ir✓ A V/�CJ
Printed Name of Signee 9/41/26
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and ': -
Record Drawing on behalf of Mason County Public rrgf
Health:
l'IV
Signature of Environmental Health Specialist Date (stamp, signature end date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE WtWed Belrx
\ )
) ) � \
z �
(_
) ��.
| Z ;
; | \\
\\
( `
, t
\
El -s
N �
±333@@3333
C' ii 0 ) ) C)
! ` mriC) < § §
o ` \ 4 fl\ § )
\ 8 \
/ Z
. ; ! !
` z § }
\ | ) m
90ni
k � �
; \ )
I
i