HomeMy WebLinkAboutSWG2004-00292 - SWG Application / Design / As-Built - 6/14/2004 SON I;OUNTY DEPARTMENT OF HEALTH SERVICES PERMIT NO. SWG -e _
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426 W. CEDAR/P.O. BOX 1666/SHELTON, WA 98584 Date N, o
PHONE (360)427-9670 ReceiptAmount
PROPERTY OWNER: DATE: - C ABLE I MS �/ H
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MAILING ADDRESS: ^ DAYTI R P
C7
CITY: S ,ySAT_- 83 AY 2 TABLE 6 REPAIR
�J E REVIEW m
PROPER DR S: SINGLE FAMILY Z
OTHER: 3
CIFIC D ECTIONS FOR LOCATING SITE: FRIKML m
O _h$ MUNI-FY WELLIPUBLIC SYST
_ >�e u � SYSTEM WFI#
SYSTEM NAME I
APPLICANT
NAME L..
Name of a Lot -17,rx'+ /4oi ex NGADDRESS
Installer �d�r- -- Lit" MAI
Size: 1 i CYF, acres o
Name of TELEPHONES
Designer ® Number o SIGNATIJR AT o
, (� Bedrooms �/ X
OFFICIAL USE ONLY BELOW THIS LINE 11
DEPARTMENTAL SOIL LOGS DEPARTMENTAL COMMENTS/CONDI
Tea �
SQL- ���200�- � I �� w�0% � q�?
itaij v%�
Say\ �.(S�• Cad. �� p.�,�� � ��,
P.�,.. .Qev,'r ars•
SOIL TEXTURE CODES:
V=Very G=gravelly S=sand L=loam Si=silt C=day E=Extremely
INSP CTOR(print ame) INS CTION SIGNATURE DATE PERMIT PIRAT ON DATE
� I
•All systems require ongoing Operation and Maintenance(O&M)as specified in Mason Cou On- fte Standards.
•All on-site sewage systems must be designed by a Mason County Certified Designer or a Professional Engineer,unless prior approval i 3 granted otherwise
•All on-site sewage systems must be installed by a Mason County Certified Installer,unless prior approval is granted otherwise.In such ses a preliminary on-site
meeting between health department staff and the homeowner is required.
•On-she 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 eyes 3 years from the date of site review.Denial of this permit my be a to the Health Officer within 10 days of denial date.
DESIGN R EW PPROVAL BY: DATE: IN TION RO BY: DATE:
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TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTO .Applicant's Copy
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A&BUILT FORM
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c o d Parcel# 3 D-s -OOa�2
PermitNumber
lnstailla �[ Bw•-J' Subdivision vt
NIA Yes r to Completlon
1. SEPTIC TANK
A) >5 ft From famdaticn?.......................................... ❑ i
t--
B) >50 ft ftom walls and surface water? ............................... ❑ ' 13Q Bldg emb-oat to septic tank clean-cut ifnot 1-2%? .................... ❑
D) Ba11Iea intact and clean? ..............................:......:.. . ❑ ❑/
B) Dhiding wall intact!....................... ....................... ❑ lY' ❑
F) Risers installed for access? ..... ....:. ❑ G� ❑
() Tank Sias:/ K-c/ QC.G.�.
gal.;Manufacture
11. D-BOX
A) I evened with water? ............................................. �" Q ❑
B) Speed levelarused? ......................I...................... B" ❑ ❑
III. DRAINFWAM
A) >10 it from foundation and>5 ft fmm property lines? .................. ❑ Cam' ❑
B) >100 ft fiom wells and surface water? ............................... ❑ 03 ❑
C) >10 A$om potable water limes? :.................................. ❑ ❑-- ❑
D) laterals Ievelto±I inch&end caps present if not looped? .............. O ❑
B) Gravellm chambers utilized?
F) System dimensions the same as shown on the design?.................... ❑.-_ 0`7 ❑
.... G)..(italic!clean,ProPaIY sized,and proper depth? ....................... ❑ EF � ❑
H) PRE8fiURES"Tems
1)--isamd quality ASTM C•337 .............. ............. @ ❑ ❑
2) Toad height uniform and z24 inches? Actual head height. ..... ❑ ❑ ^ ❑
3) Clean-outs and observation parts present? ........................ ❑ 0 ❑
4) Mound: SideSlope3:17 ................................. ..... ❑ El-- ❑
ed
echons must be me&
5) byth owner vn mfa li electrician and inspected by I.&I7 .............. ❑ fl— ❑
IV. PUMPIPUMP C O �/ I
A) Stxem basket or ent Sl circle one)installed? ! E? KY[...... ❑ ❑'� " ❑
B) .Riser installed for access? .......................................... ❑ a—= ❑
C) Alarm installed? ...................................... ❑ ❑ 0—
D) Pumpmake Z44daz }:um Pumpmodel S17
E) Chamber size lr�60 Sal;t�pVm* ClimberManuffictme rrt s /ti
1� Pump chamber draw-down�, inches per mimrie; Height ofpmmp offbottom of pump j,;I- inches
O) Pm*controls:Timer(or)Elapsed Time Meter (circle If in$WleM; If fterr is used:Pump Pump Off
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nMICUW or VVA(Vf-S
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dimand
7mda== F C�1µ
w1�iplsyro�
PI Sqd*Wtank /
O Location of buildings.
O Otservation port&clean-
O Location of wails&
roads. �. <
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bednative soil --5 If Qc--o k
between treachea.
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kntatler--Check a box from Row"A"and"B",•aign and date 8te,,dfication. . . - ...
A. I that I installed the system without any O I certify that all deviations gore the derign pad
=On from the design stamped"A"ROVEbD"by "Arrxov� by MCDHS are shown above.
MCDHS
B. I certify that I contacted the designer and left the b/JI did not conmet the designer prior to gnat cov because the
system open for inspection lip to 48 lus prior to /`"` designer waived the notification requirement.
cover.
I fu ther certify that all information contained on this form is accurate. I understand that if the information contained I ersin is not
accurate,these will be}test cause for'immediate suspension of my installer cerffical
tgnatme o err
The undersigned approves this installation on behalf of Mason County Deppronent of Mm
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