HomeMy WebLinkAboutSWG2004-00531 - SWG As-Built - 6/9/2005 AN
AS-BUILT FORM
Revised Januay 4, 19»
AI tEL -aim.FICATION .
r,Aans .bow
Assessor's
mber SWG Parcel # JyZ'Zdoo.�`D
- DD f.3 (Twelve-Olglt Number)
.
� 'YNoG�S Subdivision KS'
y. (Name/uivislon/Block/Lot)
D e s iLl ne r �,��,F.w�,a�J
INSTALLER CHECKLIST
Fl 7r: IC TANK NIA Yes Prior to Completion
A) .•?,5 ft. From foundation? : . . . D,I6w& � U — 9loQ_�
B) >4O ft from wells and surface water? • ❑ ❑
C) Bldg stub-out to-septic tank"icJean-out if not 1-2%? ❑ ® ❑
D) Baffles intact and clean? . ,; . . . . . . . . . . . . .• ' ' ' ' • • ' ' ' ' ❑ ❑
® C
E1 Dividing "all'intact? . . . . . . . . . .. , , ❑
❑
C
I'1 Risers installed for access? . . . . . . . . . . . . . .
G1 Tank Size gal.; Manufacture IS
II. D-Box
A) Leveled with water?
. �I ❑ C
B) Speed leveler used? . . . . . .
. . . . . . . , ...
:. . ... . . . . . . . . . . . . . . .
III. DRAINF'IELD �, w
A) >10 ft from foundation > t
' S ft from property lines? '. r.: ,�.� .� . . . . . . . . ❑ p .—
B) >100 ft from welts and glkaceuwater? , ,.:. . .
C) >l0 ft from potable water lines? . . . . ' ❑
❑ ® �.
D) Laterals level to± I inch& end caps present if not looped? . . . . . . . . . . . . . . ❑
E) Gravelless chambers utilized? ❑
F) System dimensions the samesign ? . . . . . . ' ' ' ' ' ' ' ' ' ' ' ' ❑ 1 ❑as shown on the design? . . . . . . i81
. . . . . . . . . . . . . ❑ ❑
G) Gravel clean, properly sized, and proper depth? . . . . . . . . .
H) PRESSURE SYSTEMS " " " " " ' ® ❑ Cl
1) Sand quality ASTM C-33? 40 ❑
2) Head height uniform and z24 inches? Actual head height 0," . . . . . . ❑ to ❑
3) Clean-outs and observation ports present? ❑
4) Mound: Side Slope 3:1? " " " ' ❑ ® C
19
5) Owner informed electrical connections must be made
by owner or licensed electrician and inspected by L&I? . . . . . . . . . . . . . . ❑
C
IV. PUMP/PU CHAMB
A) Scree basket effluent filte circle one) installed? . . . . . . . . . . . . . . . . . . . ❑
B) Riser insta ed for access? . ® ❑
C) Alarm installed? ❑ it7 CD
D) PUMP make��QS. . . . ,���t( �. . . . . . . . . . . . . .. . . . .. . . . . . . . . ❑ lfA ❑
' Pump model ,
E) Chamber size 000 gal; 22 b ga(/tnch; Chamber Mantlfacttire
F) Pump chamber draw-down T inches per minute; Height of pump off bottom of pump chamber_ inches
G) Pump controls: Timer(or)Elapsed Time Meter (circle If installed); If tuner is used: pump On uh pump Ofil 14
- Sys kv- Oao
�1��UIL7I�RAWING
y
CHECKLIST
® Drainfield& manifold _
orientation & layout
Trench bed dimensions
•b
and critical distances '��� G
within layout i Gio• r
® Septic/pump tank
placement.
%I Location of buildings. !
e
(W Observation port& clea - <
out location. e X
l� Location of wells &
L 4 �� b
roads.
10 Undisturbed native soil
between trenches. + Tn
JQ No
as• 7 � '
o o l
o y O
o �: Vk
t-ank location and
e t6
th the
crit
CAUTION:Minor adjustments �ems compromise the viability of the system.ld orientation mit ade isthe installer's e field responsib respe installer onsibility to obta n nor written`approval from eitherthe
and the designer,but could
health department or the designer before making any deviations from the design that affect the system viability. My deviations from the approved design muse
be
shown above.
CERTIFICATION OF INSTALLATION
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 certifythat all deviations from the design stamped
deviation from the design stamped"APPROVED"by "APPROVED"by MCDHS are shown above.
MCDHS t contact the designer
B. I certify that I contacted the designer and left the ❑ Ididno
waived the notification requirement ver because the
designer
system open for inspection up to 48 hrs prior to
cover.
I further certify that all information contained on this form is accurate. I understand that if the information contained herein is not
accurate,there will be just cause for imm di es us�ion of my installer rtification.
�� 5a`(�E �ntlaSolJ (�
��,G 3 .�, w.e.�5 i+tiSO. L 6�t ►�''' ►gnature o sta ate
(toe r L •� ariment f Health s.
The undersigned approves this installation on behalf of Mason County p
itanan Aiate