HomeMy WebLinkAboutSWG2008-00341 - SWG As-Built - 6/1/2009 - �"`-' th�+�v■+�� mason uounty uotic LYCQIUb
Assessor's Parcel# �(� �%
Permit Number SWG ? -- LO7 w (Twelve-Digit Amber)
Applicant's Name Subdivision
(Name/Division/Block/Lot)
Applicant Address r'- -- - ,installer's Name
Ci ,State,Zip e ' Desi er's Name '
N/A Yes Pr r to Completion
I. SEPTIC TANK
>5 ft. From foundation?............................................... ❑ U/ ❑
..............
>50 ft from wells? ............... ❑ a/ ❑
....................................................
>50 ft surface water? ................................................................ ❑ ❑/i ❑
Building stubout to septic tank: cleanout if not 1-2%? ................... ❑ (+� ❑
Baffles intact and clean?............................................................
Risers
wall intact?
fora..ess?....................................................... ❑ � ❑
Dividing
Risers installed for access?............................................
Screen basket or effluent filter installed?(circle one) ..........._......._ ❑ ❑
Tank size: 6c al.; Manufacture:
II. - D-BOX
Leveled with water? ........................................................... ❑ 03-, ❑
Speed leveler used? ............................................................ ❑ ❑
III. DRAINFIELD /
>10 ft from foundation?....................................................... ❑ L9 ❑
>5 ft from property lines and easement lines? ............................ ❑ ll[-/' ❑
> 100 it from wells?......:...........
.......................................... ❑ Ey, ❑
> 100 ft from surface water? ................................................. ❑ ❑
>10 ft from potable water lines? ............................................. ❑
Laterals level to+I inch&end caps present if not looped? .............. ❑ LA-/ ❑
Gravelless chambers utilized? ................................................ 0 ❑/ ❑
Gravel clean,properly sized,and proper depth?........................... ❑ PX ❑
PRESSURE SYSTEMS
Sand quality ASTM C-33? ............................................... C� ❑ ❑
Head height uniform >24 inches7 Actual head height !r ❑ ❑
Clean-outs and observation ports present?......................... ❑1// ❑ ❑
Mound: Side Slope 3:1? ............................................. hd ❑ ❑
Owner informed electrical connections must be made by ,
owner or'licensed electrician and inspected by L&I?..............
W ❑ ❑
IV. PUMP/PUMP CHAMBER
Pump make ; Pump model ❑ ❑
Chamber size gal; Manufacture ❑ ❑
Height of pump off bottom of pump chamber inches
Pump chamber draw-down gallons per inch per minute RECEIVE
Pump capacity gallons per minute RECEIVED
Pump controls: Timer, Elapsed Time Meter, Counter?(Circle all that 2 ❑ ❑
apply). If timer:Pump On Pump Off
Riser installed for access?.......... ElE_p�; .
............................................... /
Alarm installed?......................................... ltY ❑ ❑
I
CHECKLLST
ElDrainfield&
manifold orientation
&layout
❑ Trench/bed
dimensions and
critical distances
within layout
❑ Septic/pump tank
placement
❑ Location of
buildings �/"
❑ Observation port&
clean-outlocation
❑ Location of wells&
roads
❑ Undisturbed native
soil between
trenches
❑ North arrow
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 ofthe system..It is the installer's responsttable
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 approved design must be shown above.
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 MCPH are shown above.
MCPH
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 cover. designer waived the notification requirement.
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 immediate suspension of my installer certification.
SignaturInstaller Date
The undersigned approves this installation on behalf of Mason County Public Health.
� 1
Revised January 2008 Environment 1 Health Specialist Date