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HomeMy WebLinkAboutSWG2000-00391 - SWG Inspections - 2/7/2001 ON-SITE SEWAGE INSTALLATION FINAL INSPECTION .}.,.{,..., :ji}`•.vv,:::;:{tit V,'• .�,,>.S r}.yvv'T�::f i ..:: •:.,::vv;},.. .... v{'•1k.''•':>'r,:;':>.:}:}::'�i`i:}:}:vii:;i::i'ii:::::i::�::v:•:v}:L;::i:•:{ v vi} �rc7� :: .,Y.:v}}S:•}}:•}k ,::::.:v v::n:'•.•v:.::?:ti:.}v:•:•v .•.vv{.::}}:{.}• .. .v - ;::i{'i}}}Y.•}:{;:::�:�iii::}ii:•}:-yip'�:}:}i: .\.Jn..n:}......:n. k:....:..¢•:i•::::.i..... :f• 4 •s.....:.f:.•e •`A...:2•i}•:ri-•y :..y,{ DATE CALL$D IN: TIME: 0 a w� INSTALLER: / t5 APPLICANf/OWNER: &Lr L- wa-r..SDlil CALLER: PHONE#OF CALLER: "L SWG#: PARCEL NUMBER: ZZ�-7- _00D g SUBDIVISION: Div:__ Lot: SYSTEM TYPE(CHECK ONE): PRESSURE GRAVITY INSPECTION SCHEDULE(CHECK ONE): APPOINTMENT PLUG IN AS-BUILT ON-SITE(CHECK ONE): Q YES No STAFF INITIALS: .................::::::::::::::::::nii::-}}i}i;vii}}}}}iiiiiit?iiiii:ii?i{J{}}}}:}ii}:i%•}}}}:-} ..... 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ON-STYE SEWAGE INSTALLATION STAFF INSPECTION REPORT ;ii`�i;::'::is:}ri=::::}::::?:.\.>+tiiYiy:ri?..{•vy}:.•.:'•:'-.y':.•i 4U:.,•.;.,:;....:v,::tv' {>x �•-'+ih:<?::ti:: .:a4:•i2:y?}:}:it•}}:�:tr::•:.::�::•• ' ...,t•rvM1 :r..:-:::errs}}•.}•;??: :....:..:::::::::::::...}...::.::::.�:::::...:.:::... :..::}:`�.t.:-:..::::::..;- ••-,'•••:fix... :•:-::::::.�.. .................................................::.�.�::.:::.�::::.:_:.:n�.�:i:i:.':::.�::::::ir.:.�:.�::..::.:v: : -.;. ' .. ..........::::.:.'.4i;:::^:•:}}:ti::...............,v::is}.n. :h,n:..:.p''rs•�?•..v:•:.:_.................:::.:_:::.�::•i:iiJ:Li'+1;;nh}>%+^i;:_�'ii?:•i}}i}..: :•r. ... ,:..::::.v::::::::•f::•'-:t....:.::. ...r::::......... ,..v 3. .. ::.. ..:,...::::.:. ::.::....................::::: ; L SEPTIC TANK Yes No Comments A) >5&from foundation? B) >50 ft from wells and surface water? ~ C) Bldg stub-out to septic tank:clean_O t if not 1 2%? 1 D) Baffles intact and clean? --��- E) Dividing wall intact? F) Risers installed for access? II D-Box beveled with water and/or speed leveler(circle)? �— I L DRwnv�,o A) >10 ft from foundation and>5 ft from perceived property lines? B) >100 ft from wells and surface water? C) >10 ft from potable water lines? D) Laterals level to±1 inch&end s J' cap present if not looped? _C E) Gravelless chambers utilized? F) System dimensions the same as shown on the design? G) Gravel clean,properly sized,and proper depth? ED PRUSURE SYSTEMS 1) Sand quality ASTTvi C-33? 2) Head height uniform and z 24 inches? 3) Clean-outs and observation ports present? f 4) Mound: Side Slope 3:1? r 5) Owner informed electrical connections must be made by owner or licensed electrician and inspected by L&I? IV• PEW/PUAw CMAhMER A) Screen basket or effluenof1jrDc Jele one)installed? B) Riser installed for access? C) Alarm installed? D) Pump on Winer or demand(circle)? V• AS-BDILTREQUUM? —� VI. OTHER COMMEMWOBSERVATIONS --� The undersigned has reviewed this installation and verifies these findings on behalf of Mason Count},Dcrutment of H th Services Sanitarian 2/7/g/ Date QWY1rleeTuWdwcL%pd Revised M/2 W . . ON-SITE SEWAGE SYSTEM PERMIT PERMIT NO. SWG — °' C N MASON COUNTY DEPARTMENT OF HEALTH SERVICES Q Z En [Date N. 2 426 W. CEDAR/ P.O. BOX 1666/SHELTON, WA 98584 Receipt No. /!�T 5 — ° `� PHONE (360) 427-9670 Amount$ z V � � �) �, CHECK APPLICABLE ITEMS �/ m < PROPERTY OWNER- ` DAT m NEW SYSTEM DAYTI� P ONE: MAILIN DDR S: REPAIR SYSTEM TABLE 6 REPAIR CITY: (� STATE, Z P' MAINTENANCE REVIEW SINGLE FAMILY CD c PROPERTY A DRESS: ` OTHER: R PRIVATE WELL ✓ m PECIFIC DIRECTIONS FOR LOCATING SITE: n_� COMMUNITY WELUPUBLIC SYSTEM �� \� CalE�S .�, ,C SYSTEM WFI# — ,���`�-�'.; SYSTEM NAME 0 a PP (CANT NAM i� —•c: �� I 1 ' w - aka MAILING ADDRESS 116 Name of Lot ��� ft.x l�� ft. Installer �,�� 'X ;,k i 4' e: acres TELEPHONE u I J Name of ( Number of X 3 '�- � �� 7 II�J Designer �� 7 --� C�k��` Bedrooms OFFICIAL USE ONLY BELOW THIS L _ I DEPARTMENTAL COMMENTS/CONDITIONS DEPARTMENTAL SOIL LOGS w o I�O {�1 L ��S�vJ SO i o TV� t A Soil �I� -o p+eta - S�•, �, `', ,' vaAwb' So%\ .. Q 2 g- 30• Tkj0t Sod 11 M i SOIL TEXTURE CODES: V=Very G=gravelly S=sand L=loam Si silt C clay E Extremely INSPECTOR(print name) IN CPECTION SIGNATURE DATE PERMIT EXPIRATION DATE 3 I-00 •All systems require ongoing Operation and Maintenance(0&M)as specified in Mason County On Site Standards. •All on-site sewage systems must be be installed fled by a Mason Coua Mason nty Certified In Certified Dstaller,unless prior approval iner or a Professional s grantedless prior otherw se.Pn such cases na preliminary on-site •All on-site sewage systems mu meeting between health department staff and the homeowner is required. •On-site sewage system design approval does not imply other building site requirements(i.e.RLC,Water Adequacy)have been met. •Any change from the specified use of the property or any site alteration affecting the system design may invalidate this permit. •This Permit expires 3 ears from the date of site review.Denial of this permit may be a Baled to the Health Officer wRhin 10 da s of denial date. PATE: DESIGN4! EW APPROVAL BY: DATE: INSTALLATIONrARO D BY: Z 7/� L , j TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTO : Applicant's Copy 1 ' CP O ' 14 d' 33 MASON"COUNTY DEPAARTMENT OF HEALTH SERVICES :� �";' ^•,'� 'ERM �8,66 0 - 584 9670 427-7798 APPLICATION FOR VARIANCE/APPEAL w:M Directions ss/STgNCt 1. Complete Part A and submit to the Director of Health Services, PO Box 186, Shelton, WA 98584, l jj'' with one of the following fees (as appropriate): $26 for appeal; $21 for staff review; $93 when Healt /F Officer review is necessary; or $113 when State Department of Health concurrence is necessary. 2. Staff and the director will make a recommendations to the Health Officer in Parts B and C. 3. The Health Officer will make an initial in-house determination in Part D. i j 4. The applicant, if unsatisfied with the initial Health Officer determination, can request a Health Officer Hearing. Findings and determinations of the Health Officer may be appealed to the Mason County Board of Health. Part A: Appeal/Request for Waiver • Applicant's Name: �ARR1S R�s�►1 • Address: X f � i • Telephone: t 3 W • Assessor's Parcel Number Subdivision Na the and Lot Number • Nature of variance or appeal: ❑ Reduce separation between rims reserve (circle one or both) drainfield area(s) and from feet to feet. El Appeal findings or conclusions of environmental health staff (please specify) : Other (please specify) C �3 SAS A • Applicant's Signature • Date x:1av-a:rrslVARXA?=.V Revised: 01107196 Part B: Staff Findings n r-I u Applicant owns the affected well u Soil texture provides for treatment of sewage n n LI Applicant does not own affected well, v Soil depth provides for treatment of sewage but owner has been notified M n LU Enhanced sewage treatment will be utilized. u Parcel cannot be developed without variance Specify type: n U Other: N ' \AAjU- Environmental Health Specialist Date Part C: Director's Recommendation - n v Director recommends approval of the variance or appeal, based on the following considerations: n u Director recommends denial of the variance or appeal, based on the following considerations: Director of Health Services Date Part D: Health Officer's Determination The Health Officer has determined that approval of the request for variance or appeal will not have an adverse effect on public health and the variance or appeal is hereby granted. This decision is based on the following findings: n u The Health Officer has determined that approval of the request for variance or appeal has a potential for an adverse effect on public health and the variance or appeal is hereby denied. This decision is based on the following findings: 1AAC V so Health Officer Da e x:%ON-srMvARZAMW.w Revised: 01107196 DESIGN EORIM - PAGE ONE 0 i1w, 14"1998 design will be reviewed when 3 conies of each of the following items are submi d: a Completed cieaign form that has berm signed and dated % Scaled layout sketch,including all applicitbr6 Items on checklist s Scaled plot plan,including all applicable items on checklist % Cross-section sketch,including all applicable Ite Vi PERMIT ASSISTAWrc_ --�•�/��PARCEL IDENTIFICATION Permit Number: sw-i )oco - ���Y'I I Designer's Name: Designer's Phone#: (SU917 Applicant's Name: ��E r i��� �jJ f+ Assessor's Parcel No.: a sip OCC�i3� Mailing Address: G-;&,x 1?;-1 (Twelve-Digit Number) ) IiM\uN }\, 5 � Subdivision: �l0 City State Zip (Name/DIvisio"lock/Lot) DESIGN PARAMETERS Treatment Device ❑ Glendon Biofiiter ❑ Sand Filter ❑ Mound )<Sand Lined Drainfield ❑ Aerobic Unit-Make/Modcl:_ --- ❑ Disinfection Unit - Make/Model: Drainfield Type Pressure Bed ODrainrock Gravity 19Trench U Gravelles Chambers Septic Tank/Drainfield Specifications Laterals ' `O Number of Bedrooms _ 3 Schedul Class `i' Daily Flow Length t L ft Septic Tank Capacity 11-3, gal Diameter in Receiving Soil Type(1-6) 114 Number Receiving Soil Appl.Rate I gpd/ft' Separation ft ` Required Square Footage lXZ ft2 Designed Square Footage ft2 Orifices Percent duction Taken L) % Total Number of Orifices Trench/gidth i U ft Diameter 3 i Trend See Length -�� ft Spacing oZ'1 in Elevation Measurements Manifold Original Drainfield Area Slope � % J(�Class Length ft ! New Slope if Altered % Diameter oL in Depth of Excavation from in Original Grade (Up-slope) Preferred Manifold Configuration Used? ❑ Yes ANo Designed Vertical Separation in Transport Pipe (Down-slope) ' c ed Class l in Length ft � Gravelless Chambers Required? 0 Yes�No ❑Optional Diameter in r Pump Required? �Yes ❑No Dosing and Pump Chamber I Number Doses/Day Pump/Siphon Specifications Dose Quantity al Difference in Elevation Between Pump Shutoff and Uppermost Chamber Capacity —P� Orifice: 7 Pump Controls: Timer(or) Elapse Time Meter(circle if required) 1f Timer: Pump On , Pump Off Uppermost Orifice is)�Higher, 0 Lower than Pump Shutoff a Capacity @Total Pressure Head: :',�•!off rpm Chec the followjrf omponents if they drain between doses: Calculated Total Pressure Head: °I `l ft Laterals anifold Transport (Attach Pump Curve) I i e. Y DESIG FORM - ,'. . ,,, TWO Revised February 1 g, DESIGN CHECKLISTS Scaled Plot Plan Scaled Layout Sketch Cross -Section Sketch Test ! . ;e locations Dwinfield orientation and layout \Referenced depth from original grade: Property lines '10 -l-rench/bed dimensions and critical Septic tank lid and drainfield cover Existing and nronosed wells +i'hin distances within layout I depth 100 ft of pn-i:, r ty Iines t7 D-BOV"f"P`l," locations Critical distance measurements to cuts, Septic tank/pump chamber location j Reference depth from original grade banks. rind surface water b Observation port location ►nd restrictive strata: Loc,:;ion and orientation, .,; curtain � Clean-out !ocation Laterals,trench bed top and bottom \ drain and all absorption components �\J Manifold placement I O Curtain drain collector b Location ;wri !imension of prim:T­ )XI Orifice Wacement I Sand augmentation system and n:erve area � Lateral placement, with distances to Buildings edge of bed `Other cross-section debit: Dirrrr,, of slope indic^ \ Al� !ible/visual alarm referenced Observation ports and clean-outs Waterlines 1 Scale of drawing shown on scale bar Roads/casements/driveways/ I- — _ _ __ ____ Cross-section information for mound parking j Lavout information for mound system Isystem: �O Critical resource lands(if appiicablc) j i0 Overa',1 fill dimensions 110 Settled cap depth at center and edge o b North arrow and scale of drnwing I r] Up_slo e downs!o e and cndslO e ' bed shc,,, a scale bar p , p p ! fill widt'.t j 10 Sidewal!slope ICY Up-slope and downslope bed elevaticu I Adt:Ntional Information 1 0 Lcsign staked out 0 Operation and Maintenznce Notice Attached I� O Waiver(s)Attached DLSIGN APPROVAL The undersigned designer(]floes,)�%e the requirement to be notified by the installer of the installation and given 48 hours to perforn. ' 'anal inspection pri( Signattnrc of Designer Date The undersigned has reviewed (his design on behalf of Mason County Department of Health Services and determined it to be in compliance Air!, .,,­i.e and local on-:,i: c,r,ulatio s: Environmental Health Specialist Date A 1 IQi DESIGN APPROVAL IS VALID ONLY UNDER TIIF,FOLLOWING CONDITION: ✓ The design is stamped "Approved"by Mason County Department of health Services. The On-site Sewage Permit has not expired,the Permit Expiration Date is: 03 ✓ The system is installed by a certified installer, unless prior authori7n!ion is obtained from Mason County . Department of Health Services. ✓ D: re!d site conditions have not been altered to adversely affect conditions of design approval r ' �12b �E RT� IJE SC R 1 pT I OA! HA�IPIS W AT501� LAKE LAND VILLAGE I'll so 000gj(p � LoT Flo >= ISSo OLD RANQ14 RD, ( GoLF 0-0QR5E r MENT pEJ � L0 'PE R' S CASE r m RESC-RVE T�2 to x So / BED o o / to S , r r ( 4 - Rv a pump 3 BED laousE r F-- r z9 _ Rv GARAGE a o= pRV i E QUA � I y I I - I I I 4 R tVC way � MMu R— - C o E - T v� R O HO 3roo -2 7 T- I If W S O►L LOGS SC �r PO BOX 3-7L ALE ► = zU PLLyA, wA r 1/ A to t'r 'V Al �A�,l•, M9 �p twt. 14;AL E Iwr1'� yrrstA I I oOTS A r ObSkAVATiOZ 0 SO Ids VIM 3a Flo �" � 1a I�-yy • FM qq- Ia' fS '' so' I AS Q3� �movuF fR� �Ara, ,��� • . ��a1� - fib - ����b I a p�9Gf„u lob S 1 ' SECURED LID WITH GAS TIGHT SEAL r 240 DIAMETER ACCESS RISER FINISH GRADE TO PUMP CHAMBER FROM SEWAGE SOURCE FLOATING MAT APPROVED EFFLUENT FILTER SEDIMENTS SEPTIC TANK ATYPICAL) SECURED LID WITH GAS TIGHT SEAL EO UNIO N N 0 1 24 DIAMETER ACCESS RISER FINISH GRADE FROM SEPTIC TO DRAINFIELD TANKri EMERGENCY STORAGE • r HIGH WATER ALARM LEVEL — INDEPENDENT `` WORKING VOLUME FLOAT STEM WI AvJ►b f vi, 11FOR FLOAT ' MOUNTING i x�� �+►� �'' CHECK VALVE SEDIMENTS SUBMERSIBLE CENTRIFUGAL PUMP l • PUMP CHAMBER • QxPICALI •AS NEEDED 1 Is'71 E Johns Pmlrie Road Shelton, WA 98584 60-426-6697 ROD Excava.Ling GENERAL NOTES 1. Rob's Excavating has designed this system in accordance with all-current state and county Health Department requirements and assumes no responsibility for its use or longevity. The owner therefore agrees to maintain and make all necessary repairs to the system at no cost to Rob's Excavating. 2. The contractor shall be certified and approved by the county to install septic systems. 3. The contractor shall field verify all contours, stub out elevators, and trench depths in drainfield areas before construction. 4. All construction materials and installation shall conform to al: applicable state and county Health Department requirements. S. It shall be the installer's responsibility to have a copy of this design onsite at all times during construction. 6. it shall be the owner's and/or installer's responsibility to notify Rob's Excavating and the county Health Department for the required inspections before backfilling. 7. All required tests shall be successfully run before calling Rob's Excavating for final inspection. All components, including all tank acces,; 'ids must be accessible for inspection. S. Rob's Excavating and the County Health Department shall first approve any variations to this design. 9. Owner/Installer shall not remove any topsoil in drainfield area. Removal of topsoil could render the site unusable. r 10. Existing utilities shown on the plans have been plotted from the best information available to the designer. Accuracy and completeness are not guaranteed. . . . . . . . . . . . . . . . . . . . . . . . . . . Have cr good Dt v! ROB'S EXCA VA TING 1871 E J01IN.S`PRAIRIE RD SIIE!TON WA 98584 (360-426-6697) INSTALLATION / MAINTENANCE PRESSURE DIS7'It1BU"PION SYSTEMS 1. Install laterals with contour of the ground. 2. Install trench bottoms level and at all times a minimum of six inches into the native soil. 3. Install locator tape on top of all drainfield laterals. 4. Install observation ports as indicated on the plot plan (minimum two per drainfield with bottom extending to the drain rock/native soil interface). 5. Install drainfield during dry weather and soil conditions, and soil smearing must be eliminated by hand raking. 6. Install threaded clean-outs at the ends of all laterals (cap must extend to within 6 inches of finished grade and be marked with locator tape). 7. Install audio/visual high water alarm. x. Install 1/8 inch mesh non-corrosive pump screen (min. 12-sq. ft. surface area, not to interfere with controls or floats). 9. Install check valve in pump outlet line to prevent system from draining back into the pump chamber. 10. Filter fabric required over drain rock prior to back filling. if the drain rock extends above natural grade, run the filter fabric at least 2 inches down the trench wall. 11. Divert all storm water run-oft away on-site sewage system. 12. No curtain drains allowed within 10 ft. or the up-slope edge of the drainfield and reserve area. 13. No curtain drains allowed within 30 ft. of the down-slope edge of the drainfield and reserve area. 14. Have the septic tank and pump chamber pumped or inspected every three to five years. 15. Inspect floats, clean pump screen and test water alarm every 6 — 12 months as needed. 16. All materials and workmanship must meet County and State regulations. 17. Septic tank risers to be at or above finish grade. iS. Deviation from this design without prior approval from the Designer and Mason County Health Department will make this design null and void. 19. Pump chamber lid to be above finish grade. 20. The on-site septic system owner is responsible for properly operating and maintaining the OSS and shall: a) Determine the level of solids and scum in the septic tank once every three years. b) 'Employ an approved pumper to remove the septage from the tank when the level of solids and scrum indicates that removal is necessary. c) Protect the OSS area and the reserve area from: 1. Cover by structures or impervious material 2. Surface drainage 3. Soil compaction by vehicular traffic or livestock 4. Damage by soil removal and grade alteration d) Keep the flow of sewage to the OSS at or below the approved design both in quantity and waste strength. 21. High strength waste will increase the depth of the biomat in a drainfield, causing a decreased flow through the biomat and possible ponding or flooding of the drainfield. High strength waste in a residence is usually related to the"lifestyle" or habits of the home, generally resulting from one or more of the following: i a) Excessive use of a garbage disposal b) Consecutive loads of laundry done all on one day c) -Excessive bleach or detergents with added whiteners d) Dishwashing, showering, and laundering all at the same time e) Medications— antibiotics can kill or impair the biological process in the septic tank. f) Leaky plumbing (hydraulic overloading) i I SI SKHD150 SP40 SP50 1 MAX.SOLIDS 3/4"SPHERE MAX.SOLIDS 1-1/4"SPHERE MAX.SOUDS 1-1/2"SPHI 1-1 /2 HP 4/10 HP 1/2 HP 3450 RPM 1750 RPM 1750 RPM j • Dual shaft seals standard. Seal • Available in automatic and manual • Available in automatic and me failure sensor capability available • Oil-filled ball bearing motor • Oil-filled, heavy-duty ball beari (to be wired to an alarm device) incorporates automatic reset motor • 1-1/2 HP, oil-filled motor thermal overload • Enclosed,two-vane cast iron • Rugged cast iron construction • Non-clog,two-vane thermoplastic sewage-type impeller • 1-1/2"NPT discharge sewage-type impeller • Automatics feature oil-isolatee • Spring loaded mechanical seal • Automatics feature reliable level control diaphragm switch with carbon and ceramic faces diaphragm switch with piggyback cast iron housing • Non-clogging semi-open plug-in • Rugged cast iron construction thermoplastic impeller • 2" NPT discharge • Mechanical shaft seal with car • Pump-out vanes on rear shroud of • Rugged cast iron construction and ceramic faces impeller • Stainless steel shaft • 2" NPT discharge(3"flange • For high head septic tank effluent • Completely field serviceable optional) applications • Residential sewage ejector or high • Completely field serviceable • 1-1/2 HP, 1 o 230V and 3o 200V, capacity sump pump • All bronze model(SP50AB1) in 230V,460V or 575V • 4/10 HP, 1 o 1 15V or 230V automatic, 1 o 1 15V • 1/2 HP, 1 o 1 15V, 200V,230V 3o 200V, 230V,460V or 575V 160 32 32 _ W r . - - W if 120 Q 24 R 24 t = x � 414 X.16 o - ' _ { � 40 � • ° 6 14 r 0 0 16 20 30 40 s0 60 0 0 40 80 80 100 120 0 0 32 64 90 128 160 CAPACITY-U.S.Q.P.M. CAPACITY-U.S.Q.P.M. CAPACITY-UA Q.I.M. MASON COUNTY DEPARTMENT OF HEALTH SERVICES PO BOX 1666 SHELTON, WA 98584 SHELTON (360)427-9670 FAX (360)427-7798 ELMA (360)482-5269 TO: Rob Goodwin BELFAIR (360)275-4467 SEATTLE (206)464-6968 RE: Design for WATSON Case No: SWG2000-00391 Parcel No: 122175000086 [X] Your design for the above referenced parcel has been review and is APPROVED. Please refer to the comments section of this letter for any additional information. [] Your design for the above referenced parcel has been reviewed and is NOT APPROVED. It does not meet the requirements or needs additional information. Please see the comments section of this letter for more information. Please call me at (360)427-9670, ext. 554 if you have any questions. Sincerely, Pam Denton Environmental Health Mason County Health Services COMMENTS: 1 of 1 SWG2000-00391 AS-BUILT FORM Revised Febr�y ta,199F Pt sT F# ' Iv Applicant .W► 994S O, - OA) Assessor's Parcel # l z Z Permit Number SWG?�& - dp 3 2 / (Twelve-Digit Number) Installer 904 's LX Subdivision �lC'- 4A.11c U, 1, f (Name/Dlvis n/Block/Lot) Designer INST�ILLR GHECKL.I3T N/A Yes Prior to Completion I. SEPTIC TANK 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 . . . . . . . .. . . . . . . . . . . . . . . . . . . c G Tank Size: f� al.;Manufacture S � d9 s e II. D-Box A) Leveled with water? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . B) Speed leveler used? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III. DRAINFIELD / A) >10 ft from foundation and>5 ft from property lines? . . . . . . . . . . .. . . . =4� B) >100 ft from wells and surface water? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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-33T 2) Head height uniform and 2:24 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 CHAA�IBER A) Pump make P jd OmAt�C Pump model 0 B) Chamber size l Z oU gal; Manufacture iry �S a e -*— C) Height of pump off bottom of pump chamber inches D) Pump chamber draw-down i gallons per inch E) Pump capacity .30 (o T gallons per minute F) Pump controls:Timer(or)Elapsed Time Meter (circle if ins ta led) If timer is used: Pumn On Pump Off G) Screen basket effluent filte circle one)installed? . . .. . . . . . . . . . . . . �— H) Riser installed for access? . . . . . . . . . ... .. . . . . . . . . . . . . . . . . . . . . . . . . ✓ I) Alarm installed? . . . . . . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . . . . . . .. . . As-euivr DRAW1N CHECKLIST ❑ Drainfield&manifold orientation & layout ❑ Trench/bed dimensions and critical distances within layout ❑ Septic/pump tank placement. ❑ Location of buildings. ❑ Observation port&clean- out location. ❑ Location of wells& roads. ❑ Undisturbed native soil l between trenches. ❑ North arrow i i r CAUTION:Minor adjustments to septic tank location and drainfield orientation made in the field by the installer are generally acceptable to both the department and the designer,but could in certain cases compromise the viability of the system. It is the installer's responsibility to obtain prior written approval from either the health department or the designer before making any deviations from the design that affect the system viability. Any deviations from the approve design must be shown above. CiRTIFiCATdON OF 1'NTA1�14TlOI+i Installer Check a box from Row"A"and`B",sign and date the certification A. ❑ I certify that I installed the system without any ❑ I certify that all deviations from the design stamped deviation from the design stamped"APPROVED"by "APPROVED"by MCDHS are shown above. MCDHS B. ❑ I certify that I contacted the designer and left the ❑ I did not contact the designer prior to final cover because the system open for inspection up to 48 hrs prior to signer waived the notification requirement. cover. I further certify that all information contained on this form i ccurate. I and d that if a information contained herein is not accurate,there will be just cause for immediate suspension of installer ce ' is ' n. ature o In to er Date The undersigned approves this installation on behalf of Mason County Department of alth ervic a4:e�g 217101 Sanitarian Date ,I On-Site Sewage Systems (Chapter Request For Waiver From State i SECTION 1. ;COMPLETED BY APPLICANT , �t _ ` Name: (1) �'1':n�15 W F Tsoj LocalpRlff 09Address: © 7C -Z�n J Telephon : 140 �1>- �'-) 4M Signature. Property Identification:(3) ID AN YA �Ayu,\A 1h ViI�9��2✓ SECTION II. 1!COMPLETED BY APPLICANT , WAC Number:(4) WAC Requirement:(5) Waiver Soughf�(6) \ "i�e SieewAllo�J ��ve, i11� ZNSZA\1 URAio �c�c7( �►J 246-272- I - D� K 1�✓ ��, �►�Cr:a6v�.a �,� 1S USiNo �-33 SPt� �+ I�c ,SS Subsection• Rn4\ra� 0 a h+St'AbJ Justification(Mitigation measures to be provided):(7) C'.�� 5n� will caRa'ylo� �N1,auc� 'Ena,�'nn�►►� � �1ltr�v�ov �u,�S CQm Zi� "S Tc4v \\ ,� o T • � SECTION 111. COMPLETED BY HEALTH OFFICER Review Criteria(8) Mitigation Measures(m addition to those proposed):(9) Comments/Conditions:(10) Type of Waiver:(11) OClass A OClass B )(Class C-Request DOH review AC&mgranting? Yes_ No_ Neighbor Notification:(12) Required? Yes_No_ Ifneeded are agreements,easements,etc.properlyfiied? Yes_No_ SECTION IV. COMPIEI FD BY HEALTH OFFICER !This Request For Waiver From State Regulations has been reviewed according to the provisions of Chapter 246-272 WAC On-Site Sewage Systems The review criteria applied,and the mitigation measures proposed and/or required,have been evaluated for their ability to provide public health protection at least equal to that provided by this chapter WAC. Approved/Granted-Subject to all comments,conditions and requirements noted in Section II and III. ❑ DeRied Local Health Officer 1 Date: