HomeMy WebLinkAboutSWG2008-00351 - SWG Application / As-Built �- -;N� ONSITE SEWAGE`SYSTEM APPLICATION
MASON COUNTY PUBLIC HEALTH Official use only co m
426 W. CEDAR STREET PERMIT NUMBER: SING -�A0$-00351 a m
PO BOX 1666
SHELTON, WA 98584 DATE RECEIVED: (�!✓ D AMOUNT RECEIVED:$ 0
(360)427-9670, Ext. 352 S" v ? 1
APPLICANT DATES CHECK APPLICABLE ITEMS Z f
E3 NEW SYSTEM m
MAILING ADDRESS 6 REPAIR
\\ DAYTIME PHONE 0 REPAIR SYSTEM O
�aa SV{J `1\ \ O TANK REPLACE
r _ C7 TANK REPLACEMENT �
CITY STATE ZIP Y1 b O RV HOLDING TANK ONLY T
(requires waiver) y
` Ow& S O INSTALLATION PERMIT ON Y
SITE ADDRESS w O SINGLE FAMILY
OTHER C
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Please describe: m a rw\ 3
NAME OF DESIGNER PHONE NUMBER
\ Note: m
�.1 A Asbuilts required jar all instal ations. C
NAME OF INSTALLER < I�
^ DRINKING WATER SOURCE F
0N O PRIVATE INDIVIDUAL WELL j If1
NUMBER OF BEDROOMS LOT SIZE: ACRES FT X FT O PRIVATE TWO-PARTY WELL 17''
O COMMUNITY/PUBLIC WATER SYSTEM
SYSTEM WFI#:
SYSTEM NAME: I�CN
SPECIFIC DIRECTIONS FOR LOCATIN
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Site must be flagged from main road and test holes must be flagged with test hole numbers I
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Official use only below this line Kl I
SOIL LOGS COMMENTS/CONDITIONS I�
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SOIL TEXTURE CODES:
V =very G=gravelly S=sand L—loam Si=silt C=clay E=extreme)
INSPECTOR SIGNATURE DATE DESIGN EXPIRATION DATE DESIGN APPROVED BY DATE
DATE INSTALLATION FEE PAID INSTALLATION EXPIRATION DATE IN 4L ION PROVED BY DATE
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Revised 4/92007
RECORD DRAWING ASBUILT) Mason Count Public Health
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--- Assessor's Parcel# l3 -Vk-...qv 3 0
Permit Number SwG2U, OU,?-/ (Twelve-Dig t Number)
Applicant's Name 1— `Na N-t AV\Aa Subdivision
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(Name/Divisio lock/Lot)
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Applicant Address �\aa 5yN p�tt����t\1 A Installer's Name
City, State,ZipSr`�\�b`� WAS "\�S>ol Desi er's Name
�i~� �rs';t 'ems �� �-,� �T'a��.'��c�rx>>:,;�3;��''ST�AIfiL�r`"ER CI�'C, ,:ISTr.+'�'".�:�?,.uu. +�'r �4�.�'"�zs•��`2 s�
W utv.:?N :§�'.� '&:�,....n; 'a e..t'd-..n....i', YE'F..,- .,..d+,.>. ---.�-..aweae::;•'',a,. ram:.r.,ek..r.e+{-.:ru;. _.aw� '�:::
N/A Yes rior to Completion
I. SEPTIC TANK
>5 ft. From foundation?............................................................. ❑ ❑ 13
>50 ft from wells? .................................................................. ❑ ❑
>50 ft surface water? .............................................................. ❑ ❑
Building stubout to septic tank: cleanout if not 1-2%? ................... ❑ ❑
Baffles intact and clean?............................................................ ❑ ❑
Dividing wall intact?............................................................... ❑ ❑
Risers installed for access?....................................:..........:....... ❑ ❑
Screen basket or effluent filter installed?(circle one) ..........._........ ❑ ❑
Tank size: gal.; Manufacture:
II. D-BOX.
Leveled with water? ................................................ ...... ❑
Speed leveler used? ............................................ ...... ... .. .
III. DRAINFIELD
>10 ft from foundation?................................. ........ . .. ...... ❑
>5 ft from property lines and easement lines?....... ........ ........... ❑ ❑'
> 100 ft from wells?.......................................... . ............ ❑ ❑
> 100 ft from surface water? ................................................. ❑ ❑
>10 ft from potable water lines? ............................................. ❑ ❑
Laterals level to±1 inch&end caps present if not looped? .............. ❑ ❑
Gravelless chambers utilized? ................................................ ❑ ❑
Gravel clean,properly sized, and proper depth?........................... ❑ ❑ 3 _
PRESSURE SYSTEMS
Sand quality ASTM C-33? ................................................ ❑ ❑
Head height uniform >24 inches? Actual head height ❑ ❑
Clean-outs and observation ports present?......................... ❑ ❑ .
Mound: Side Slope 3:1? ............................................. ❑ ❑ m
Owner informed electrical connections must be made by
owner or licensed electrician and inspected by L&I?............... ❑ ❑
IV. PUMP/PUMP CHAMBER
Pump make ; Pump model ❑ ❑ 11
Chamber size gal; Manufacture ❑ ❑ 11
Height of pump off bottom of pump chamber inches
Pump chamber draw-down gallons per inch per minute
Pump capacity gallons per minute
Pump controls: Timer, Elapsed Time Meter, Counter? (Circle all that ❑ ❑ 11
apply). If timer: Pump On Pump Off
Riser installed for access?.......................................................... ❑ ❑
Alarminstalled2....................................................................... ❑ ❑
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e,,. ..,wa.�?��k�:-w�:.��5�."._.�?•.r_.e�...-�-c�ac:i�.r...�RECORD�DRdW,ING`�',`�,�-,� -�� .�1.�.�:���.1'����w_ ,�r'�`.�_z�r"Jk�,r`��'
CHECKLIST
❑ Drainfield&
manifold orientation
& layout j
❑ Trench/bed u
dimensions and
critical distances
within layout
❑ Septic/pump tank
placement
❑ Location of
buildings
❑ Observation port&
clean-out location S�mb
❑ Location of wells&
roads
❑ Undisturbed native
soil between
trenches \
❑ North arrow �J�
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 ins ller's responsibility
to obtain prior written approval from either the health department or t e designer before ma ng any deviations from he design that affect
the system viability. Any deviations from the approved design must be shown above.
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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 designs amped
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 requiremen
I further certify that all information contained on this form is accurate. I and rstand that a infog lion wntaine herein is not
accurate,there will be just cause for immediate suspension of my installer cent do \ `
Signature of Installer Date
The undersigned approves this installation on behalf of Mason County Public Health. /1 101
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EnvironmenJ Health Specialist Date
Revised January 2008 - -