HomeMy WebLinkAboutSWG2011-00081belongs to parcel #32309-53-00042 - SWG Application / As-Built ONSITE SEWAGE SYSTEM APPLICATION
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MASON COUNTY PUBLIC HEALTH Official use only CO)
426 W. CEDAR STREET PERMIT NUMBER: SWGC;-)O/ 000 / a
PO BOX 1666 � 0 �
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SHELTON,WA 98584 DATE RECEIVED: AMOUNT RECEIVED:$t 1�
(360)427-9670, Ext. 352 -
APPLICANT DATE CHECK APPLICABLE ITEMS Z :E
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i� .��Z�� E3 NEW SYSTEM 3 <
A,-_'REPAIR SYSTEM m Mi
MAILING ADDRESS DAYTIME PHONE 0 TABLE 9 REPAIR .
O TANK REPLACEMENT
JF 77— aES
O RV HOLDING TANK ONLY
CITY STATE 9 ZIP �,�(requires waiver) M
L r � INGLE
A ' L ASS-Y
tN'� p OTHER FAMILY
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SITE ADDRESS Please describe: Z
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Sr4-f✓1 lys Note: 3
Record Drawing(Asbuilt)required for all Q
NAME OF DESIGNER PHONE NUMBER m
/ installations.
N l A DRINKING WATER SOURCE
NAME OF INSTALLER O PRIVATE INDIVIDUAL WELL �p
0 PRIVATE TWO-PARTY WELL O
s�Z� .k COMMUNITY/PUBLLIIC,W/ATER SYSTEM I
NUMBER OF BEDROOMS LOT SIZE: ACRES FT X FT SYSTEM WFI#: Ioi
SYSTEM NAME: ! IO
SPECIFIC DIRECTIONS FOR LOCATING SITE. ! hz
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74) 'A` 1lU
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Site must be flagged from main road and test holes must be flagged with test hole numbers
Official use only below this line
SOIL LOGS
COMMENTS/CONDITIONS
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&u-� l'G�, ��/1�LL^ �. Cry � .1 �J - 6Lw+7 1"i
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SOIL TEXTURE CODES: u�
V =very G=gravelly S=sand L—loam Si=silt C=clay E=extreme)
INSPECTOR SIGNATURE DATE DESIGN EXPIRATION DATE DATE
Revised 4/4/200
RECORD DRAWING (ASBUILT) Mason County Public Health
PARCEL IDENTIFICATION
Assessor's Parcel# 20200 7 —St7— e�85'
Permit Number SWG goo-7 --001y3 (Twelve-Digit Number)
Subdivision
Applicant's Name ,5fe v e_ "'n-F,,// (Name/Division/Block/Lot)
Applicant Address 17 71 E Ti n�be��ke_ Ne31�P^ Installer's Name Ra„ /,k,.,Cr��stg-1,c
OF
City, State,Zip S 1e/4,1 +-✓ Designer's Name
INSTALLER CHECKLIST"
N/A Yes Prior to Completion
I. SEPTIC TANK
>5 ft. From foundation'?............................................................. ❑ ❑
>50 ft from wells? ................................................................... ❑
>50 ft surface water? ................................................................ ❑ ❑
Building stubout to septic tank: cleanout if not 1-2%? ................... ❑ Ey ❑
Baffles intact and clean?............. .............................................. ❑ 9 ❑
Dividing wall intact?.................................................................
Risers installed for access?........................................................ ❑ d ❑
Screen basket or effluent filter installed?(circle one) ..........._........_ ❑ p� ❑
Tank size: . I Jg gal.; Manufacture: 9,, +s p,e_c4st—
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?........................... ❑ ❑ ❑
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? ............................................. ❑ ❑ ❑
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 ❑ ❑ ❑
Chamber size gal; Manufacture ❑ ❑ ❑
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 ❑ ❑ ❑
apply). If timer: Pump On Pump Off
Riser installed for access'?......................................................... ❑ ❑ ❑
Alarm installed?........................................................................ ❑ 0 0
CHECKLIST RECORD DRAWING
�
❑ Drainfield& Ke- --`
manifold orientation
& layout
❑ Trench/bed
dimensions and
critical distances
within layout
li� Septic/pump tank
� placement
EY/Location of
buildings
Observation port&
clean-out location
�r
Location of wells& ,n K �Mpa ►i
roads
❑ Undisturbed native - - - K"It 's ��
soil between �` pt"F itd
trenches
❑ North arrow
Ggr4'�
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CAUTION:Minor adjustments to septic tank location and drainfield orientation made in the field by the installer are generally acceptable
to obtain prior wr tten approval fronn eithert could in the health depin cases artment o�the cleszgneli bef �naki the
d n rations front the clesi�e��Trat responsibility
to the system viability. Any deviations from the approved design must be shown above. If
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 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 filial 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/le info- iat'o cont fined herein is not
accurate,there will be just cause for immediate suspension of my installer certification.
Signa -e of nstaller
Date
The undersigned approves this installation on behalf of Mason County Public Health, L IIJ
1
Revised January 20U8 F_nvirOnnrental Health Specialist Date
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SEPTIC JaNK
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