HomeMy WebLinkAboutSWG2004-00594 - SWG As-Built - 11/30/2004AS -BUILT FORM
Revised February 18, 1998
Applicant
Permit Number
Installer
Designer
SWG O - c dIL1
AsParceT ���.' � L� - � I � � � i
�Y •, y e �g(Twelve-DigItNumber)
Subdivision
(Name/Division/Block/Lot)
N/A Yes Prior to Completion
I. SEPTIC TANKli/
A) >5 ft. From foundation?
B) >50 ft from wells and surface water?
C) Bldg stub -out to septic tank: clean-out if not 1-2%?
D) Baffles intact and clean?
E) Dividing wall intact?
F) Risers installed for access?
G) Tank Size: \aCc gal.; Manufacture
t�S
II. D -Box
A) Leveled with water?
B) Speed leveler used?
III. DRAINFIELD
A) >10 ft from foundation and >5 ft from property lines? /
B) >100 ft from wells and surface water? V
C) >10 ft from potable water lines?
D) Laterals level to ± 1 inch & end caps present if not looped?
E) Gravelless chambers utilized?
F) System dimensions the same as shown on the design?
G) Gravel clean, properly sized, and proper depth?
H) PRESSURE SYSTEMS /
1) Sand quality ASTM C-33? /) �✓ J
2) Head height uniform and z24 inches? Actual head height .. ✓✓/
3) Clean -outs and observation ports present?
4) Mound: Side Slope 3:1?
5) Owner informed electrical connections must be made by
owner or licensed electrician and inspected by L&I?
IV. PUMP/PUMP CHAMBERI
A) Pump make V\ '0' ; Pump model S C ) )
B) Chamber size \ 1, ';') gal; Manufacture 'iJ MS
C) Height of pump off bottom of pump chamber (0 inches
D) Pump chamber draw -down ?,Z/ gallons per inch
E) Pump capacity 4 (' gallons per minute
F) Pump controls(or) Elapsed Time Meter (circle if installed)
If timer is used: Pump On ,,V -z.., Pump Off
G) Screen basket orffluent filtc (circle one) installed?
H) Riser installed for access?
I) Alarm installed?
7 7
3b.
CRITICLIFT
O Drainfield & manifold
orientation & layout
O Trench/bed dimensions
and critical distances
within layout
O Septic/pump tank
placement.
O Location of buildings.
O Observation port & clean-
out location.
0 Location of wells & �t
roads.
O Undisturbed native soil
between trenches.
O North arrow
OP°
CAUTION: Minor adjustments. W septic tuck location and drainfeld orientation made in the field by the installer aro generally acceptable to both the department
and the designer, but could in certain cases compromise the viability of the system.Itis the iastaler's responsibility to obtain prior written approval from either the
health or the designer before makhtg any deviation= the dolga. system viability Any deviations from the approved design must be
shown above. .10e)41 6 fi ir;�i �r, i`e:
Installer Check a box from Row "A" and "B", sign and date the•cert ' op
A. 0 I certify that I installed the system without any
deviation from the design stamped "APPROVED" by
MCDHS
B. 0 I certify that I contacted the designer and left the
system open for inspection up to 48 hrs prior to
cover.
I further certify that all information contained on this, fooni;is accurate. I
accurate, there will be just cause for immediate suspension of my install
❑ I certify that all deviations from the design stamped
"APPROVED" by MCDHS are shown above.
❑ I did not contact the designer prior to final cover because the
designer waived the notification requirement.
d that i the information contained herein is not
on.
v '//-0 5 CLI
. _S
ignature of Installer Date
The undersigned approves this installation on behalf of Mason County De ret of Heal ices.
12_13/ °y
Date
Sanitarian