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HomeMy WebLinkAboutSWG2002-00390 - SWG Application / Design / As-Built - 9/17/2002 PERMIT NO. SWG _ CDMASON COUNTY DEPARTMENT OF HEALTH SERVICES C N d N 426 W: CEDAR/P.O. BOX 1666/SHELTON, WA 98584 Date <: u PHONE (360) 427-9670 Receipt No. Amount$ z F PROPERTY OWNER: DATE: CHECK APPLICABLE ITEMS 3 m LA - - a2— MAILING AD RESS: DAYTIME PHONE: NEW SYSTEM ✓ tJ !J FOL gil 49117 REPAIR SYSTEM CITY: STATE: ZIP: TABLE 6REPAIR 1: m P U kr p ca A l 1N A �%�3 MAINTENANCE REVIEW PR ..3O ERTY ADDRESS: SINGLE FAMILY ✓ Z M u OTHER: 3 SPECIFIC rrDI--R''ECTIONS F_OR LO/GATING SITE: PRIVATE WELL C'J/ ' �d �fi -. L O�'1 L�c�1l S LA/ (6kW •ip COMMUNITYWEWPUBLICSYSTEM SYSTEM WA# l`t L CN E A L- L . U IF. h SYSTEM NAME ML-i-Pi e (Ira APPLICANT suu S I" S ch le f_+ s, .4 a t " '),narked " IA t q NAME GL-- T6hn5 ,jj Lot ft.x ft. Name of MAILING ADD W Installer /4.rA t y C -1- . Size: acres g TELEPHONE Name of I um er o SIGNAT E Designer : L _Trjt� Bedrooms - OFFICIAL USE ONLY BELOW THIS LIN DEPARTMENTAL SOIL LOGS DEPARTMENTAL COMMENTS/CONDITI NSco Zit" a2 �G ,r `1S 21V(33:) ` 9Zb 7 T -Q SOIL TEXTURE CODES: V=Very G=gravelly S=sand L=loam Si=silt C=clay E=Extremely INSPEGTOR rint na e) l I PEC ON SI T RE DATE PERMIT EXPIRATION DATE r rz;TC ' Gw{o q 3u JUL 30 K •All systems Alquire ongoing Operation and Maintenance(O&M)ass ecified in Mason County On-Sfte Standards. •All on-site sewage systems must be designed by a Mason County Certified Designer or a Professional Engineer,unless prior approval is ranted otherwise •All on-site sewage systems must be installed by a Mason County Certified Installer,unless prior approval is granted otherwise.In such cases a preliminary on-site meeting between health department staff and the homeowner is required. •On-site 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 pernnit expires 3 years from the date of site review.Denial of this permit may be appealed to the Health Officer within 10 days of denial date. D GN VIEW A DIP14AL BY,: DAT : I LLATION APPR V&D BY: DATE: � . G i� z uz, 03 TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM: Applicant's Copy MASON COUNTY DEPARTMENT OF HEALTH SERVICES November 08, 2002 PO BOX 1666 SHELTON, WA 98584 SHELTON (360) 42 -9670 FAX (360)42 -7798 Arrow Construction ELMA (360)48 -5269 230 E Warren DR BELFAIR (360) 27 -4467 Union WA 98592 SEATTLE (206)46 -6968 RE: Design for HINCKLEY Case No: SWG2002-00390 Parcel No: 321347590081 Your design for the above referenced parcel has been review and is APPROVED. Please refer to the comments section of this letter for any additional information. Please call me at(360) 427-9670, ext. 353 if you have any questions. Sincerely, Cindy Waite Environmental Health Mason County Health Services COMMENTS: 11/8/2002 1 of 1 SWG20Q-00390 DESIGN FORM- PAGE ONE Revised Joinery 4.1999 A design will be reviewed when S copies of each of the following Items are submitted: Bedid pot P t h�sdl�q� kii Kam an eh been slilned and�soltWt 0& Cirws-tasol scaled�ion kieMarutq so MtP Ron son checklist �X. `>z S ' rS*� y .�. use Permit Number: S WG _ Designer's Name: - Designees Phone#: -4.o - CA,I - ass Applicanes Name: t-A 4 L 5T G Assessoes Parcel No.: Mailing Address: /n,� E Poi.K AVE; aweivaDi It Number) pOQT 0f7G14 A ki), WA 9836E Subdivision: AT A - chy state zip (NomdDivis loeka ot) L y5 UE:SIGIJ PA>7AIVl��1 Treatment Device 0 Glendon Biofilter 0 Sand Filter O Mound cam le' O Aerobic Unit-Make/Model: O Disinfection Unit - MaketModel: Drainfield Type 9 Pressure 0 Bed 0 Drainrock NOVO4 2002, 0 Gravity R Trench 0 Gravelles Chambers Septic Tank/Drainfield Specifications Lateral#26 : CEDAR M Number of Bedrooms 3 Sch__edule/Class jo Daily Flow 366 d Length Diameter Septic Tank Capacity 00 al 35 n Number Receiving Soil Type(1-6) 61 z Separation ft Receiving Soil Appl.Rate h O epd/ft Required Square Footage 'O ftZ Orifices Designed Square Footage 3 6 O ft' Total Number of Orifices (Uct Percent Reduction Taken 3 oft �� t Trench/Bed Width Diameter Trench/Bed Length / ao ft Spacing y �� Elevation Measurements Manifold ch IdClass Original Drainfield Area Slope O % Length ft New Slope if Altered % Diameter in Depth of Excavation from (,v in Preferred Manifold Configuration Used? 91 Yes ❑No Original Grade (up-lope) Ufa` Transport Pipe (Down-slope) Schedule/Class Designed Vertical Separation f a� in Length er No✓ ii - TOOp Gravelless Chambers Required? ❑Yes ®No 0 Optional Dosltt Sump Chair ber Pump Required? ®Yes ❑No Number of Doses/Day w Dose Quantity / Pump/SiphonSpecifications Chamber Capacity O o gal Difference in Elevation Between Pump Shutoff and Uppermost Pump Controls: Tinter(or) Elapse Time M (circle B required) Orifice: If Timer. Pump On ,Pump Off Uppermost Orifice is O Higher, ❑Lower than Pump Shutoff Check the following components if they drai2 between doses: Capedty®Total Pressure Head: 3S [I'Iatersls GUsaifold ❑Transport Calculated Total Pressure HVIII& / L U 7 F K /a D = f 34, x 9 = GS -S z (Attach Pump Curve) 't y' 3 o - 5: a k - 36 / ✓� C>[r % o � (s iAr;L I'; ' v c. 2002 DESIGN FORM- PAGE TWO _ RevbeaApru zA.149a �MWF����Mt�.�� ��'�;>a:$ b���� � S J#: ``^` X� b.�3 ✓'8 t� Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch 9--Tea hole locations a-Drainfield orientation and layout Referenced depth froi a original grade: erpmpe ty lines Cl.—Trench/bed dimensions and critical O'Septic tank lid and drainfield cover 0--Existing and proposed wells within distances within layout depth too ft of property lines O D-Box/"T"/"L"locations O-Qrftical distance measureme is to cuts, 0- Septic tank/pump chamber location Reference depth from original grade banks,and surface water A '�- C"liservation port location and restrictive strata: Cf—Location and orientation of curtain Cl--Clean-out location 9'�Laterals,trench/be top and bottom and all absorption components D�Manifold placement O Curtain drain collector f!Lom cation and dimension of primary O-Orifice placement O Sand augmentation system and reserve area a-1 ateral placement,with distances to IY rldings edge of bed Other cross-section detail: fT D'aedion of slope indicator EYAudibletvisual alarm referenced O Observation ports dclean-outs erl , erlines fyScale of drawing shown on scale bar d Roads/easements/driveways/ Cross scctton inform tion for mound parking A LaSnut information for mound system: system: f�Critical resource lands(itapplicable) Q Ovtrall fill dimensions © . Settled rap depth a center and edge of fYgorth arrow and scale of drawing 0 up-slope,downs lope,and endstope bed shown on scale bar fill width © Sidewall slope O Up-slope and do lope bed elevation A40itionalInformation Er Design staked out p O Operation and Maintenance Notice Attached O Waiver(s)Attache DESIGN APPROVAL' The undersigned designer Erdoes, ❑does not,waive the requirement to be notified by the installer of the installation and given 48 hours to perform a final inspection prior to cov i/ gn re of Date The undersigned has reviewed this des i on be alf of M n County Department of Health Services and determit ed it to be in compliance with state and local on-site regulatiZIL4 cwQo Environmental Health Specialist D to Cayttow DESIGN APPROVAL IS VALID ONLY UNDER THE FOLLOWING CONDITION: d The design is stamped'Approved"by Mason County Department of Health Services, 3U lor The On-site Sewage Permit has not expired,the Permit Expiration Date Is: 01 Of The system is installed by a certified installer,unless prior authorization is obtained fio Mason County Department of Health Services. Drainfield site conditions have not been altered to adversely affect conditions of design approval i p a i i I i 7 f, J: 1 \� ` LII 11 0 jO Qo a li d O/ r �V c _ 002 ") V 11 (0o` a� +y �•25 " &0 LATF-kALS 7 /s"o.es-F eCL-Lsa-aFe"OM n/aul�o%u C�'pJ� - SCREW ON CAP 45 DEGREE ELBOW NOTE, LATERAL O=OBSERVATION PORTS--TO BE 4" - pKfice 1 PVC PIPE FROM BOTTOM OF TRENCH END OFit TO FINISHED GRADE. REMO ABLE DZTCH DETAIL CAP SHALL BE INSTALLED 014 CLEAN OUT \ OBSERVATION PORT PIPE. NOTE, CLEANOUT TO BE FROM 0 TO 6� INCHES BELOW FINISHED GRADE. MARK ENDS WITH REBAR: CLEAN OUT REQUIRED AT END OF EACH LATERAL. o vL o V, 1 - A�s_KADE of s E a,, ��` uzlG�Nn� reAo� �— 2 0�2 uu xA G �w DRRIro�icLi � VJ��L FAA G� of !c P4- GL s NOV ?N •/.py..y(1./IRNWAM/Wl - 1N.40.s 111110.1 ' IIIOM.MR YNY.• rN.flnM MO,.wI.Re TI1M1 Y.wOer ROY.. YI,/11M0, '. YLLY.• MN.NA.MM.\I/l IMO.NMO.M � .we11 YLLR• ..wrwnwLL �Y J•aR. L.a.. .�'V4 ./.n.wu.wnww wwr./rl d.wR lop dw•Tune Or r.n�rm..a .RMwr. truia r+ n.nn azenc TAm mmeeu DETERMINE THE TOTAL DYNAMIC HEAD: Selected residual pressure: 2.00 ft. Transport pipe friction lossess: 8a ft. yr M A M fzLX5 Line # I _60 ft. ......... 4 ,5a R. Line #2 6 6 ft........... Line#3 ft........... ft. Line#4 ft............ ft. .:R Line#5 ft............. ft. Total elevation lift................ _� ft. TOTAL DYNAMIC HEAD:...... /V O G FT. PK�� t f DETAILSENGINEERING • Performance Data 32 Pump Characteristics ►wp/Mqw lket Sdkelwslkls Moedel Al " OSP33M1 OS►33111 w 24 AdlWedkNo" OS►33AI OS►33A2 I/3NP x Hww►owW 1/3 is FoR tod AoNs 7.1 4.6 u iff MMw Type i 17SO o s ►kew 8 1 Vd" 115 230 0 Nerlt 60 o so zo so a so eo CAPACrTY-U.S.G.P.M. 0►wMlw kddroilleM Tso*erolws 140°F AsiMdt Total Noes(foot) 4 8 12 16 20 24 25 NtMADdslp R GPM 1/3 NP 60 55 48 39 28 7 0 i s !s11w Doss F DhdarRe Size 1.1/2-N" Ji sd ws"Willis 5/8• Dimensional Data UsR Wow SO Nlf. [+A 3.7/B d-3/4 618 ►eww Cord ,4 SJTW 18/3 S1TW 10'aL(20's►t.l 0 st1 t. ew.N A In ON 1-1/2 NPT p.( AN ON 1*rtlnY.6 Materials of Construction '" """"�°" Hens Sled 3-3 44. rdwo" aprwl.d. Ukko""ON DWKkk 01 L— 5.W ' ...d.'g6110 Mew Homing Cal kw F dwh OW ow au ►wT ca1101 cat kw ilk.A.n.Ahan Skoh Sled F Mother" Sal Fares:Cwiso/Coradit 1 Skoh Sod Sod 11F:Bross f_Lii "stowas Stool ¢. 9.1/4 10 Polar .Nno2e 113/4 POMP �. .-... . . ON UMW Iswlws Sh*Row Nd Rowkg tower RMM! Sk*Now Rd Iswing sell (all Iron 2-314 3 ZLA Fostesws sh""s Steal PUN P oFF AURORA/HYDROMATIC Pumps, Inc. 1840 Gantry Road, Ashland, Ohio 44805 1 ) 289-3042 P 4-c L s o-F 6 PAo, F s NOV 2 �'• o�r/''nsor� �es� Installation/Maintenance Pressure Distribution Systems 1. Install laterals with contour of the ground. 2. Install trench bottoms level. 3. Install locator tape or rebar on top of all drainfield laterals. 4. Install observation ports as indicated on the plot plan (minimum-2 per drainfield with bottom extending to the drainrock/native soil interface). 5. Install drain field during dry weather and soil cpnditions, any soil smearing n ust be eliminated by hand raking. 6. Install threaded clean-outs at the ends of all laterals ( cap must extend to within 6 inches of finished grade and be marked with locator tape or rebar.) .R: Install audio/visual high water alarm. 8. Install 1/8 inch mesh non-corrosive pump screen (min. 12 sq. ft surface area not to interfere with controls or floats.) Or Pump screen may be substituted with B o tube in septic tank. 9. Install check valve in pump outlet line to prevent system from draining back into the chamber. 10. Tee to Tee construction between laterals and manifold with orifices oriented at 6 O'clock. Install laterals to the manifold with orifices at 12 O'clock, (do notglue). after pressure test and Health Dept. approval , turn orifices down (6 O'clock) and glue laterals to manifold. W. Filter fabric required over drain rock prior to backfilling. If the drain rock extends above natural grade. run the filter fabric at least 2 inches down the treench wall. 12. Encase all water lines within 10' of drainfield area. 13. Divert all storm water run-off away from on-site sewage system. 14. No curtain drains allowed within 10' of the up-slope edge or 30' of the down slope edge of the drainfield and reserve area. 15. have the septic tank and pump chamber pumped or inspected every 3 to 5 years. 16. Inspect and clean pump screen every 6-12 months as needed . Inspect floats and test high water alarm every 6-12 months as needed. 18. All materials and workmanship must meet County and State regulations. 19. Deviation from this design without prior approval from the Designer and Ma.,on County Health Department will make this design null and void. 20. All manhole lids and access, sampling, or inspection ports must have locking covers. 21. All pressure systems with pump chamber higher than drainfield must have a /8" hole drilled in the discharge pipe above the pump to prevent siphoning. 22 . All transport lines under driveways must be encased to Drevent crushing. 23. OWNER IS RESPONSIBLE FOR ALL PROPERTY LINES. d��2 PAGE of (, PAGES i 1l I - - _ I i �lL ��\�" Date Called In: U- Cane[ m Phone: TiTime:e: 4 �7 SWG#: �- Z)D3 O Zd-0003 cc - p installer. � vv7 I;n Parcel#: 8AV Designer. Subdivision: Applicant/Owner: t,.t/t, / Site Address: S tem. ceck'ill,diat' ❑ Gravity ❑ Sandfilter Nvr Pressure ❑ ATU/Proprietary Filter Mound ❑ Glendon Biofilter ❑ Sub-Surface Drip Inspection Schedule: (check one): ❑ YES ❑ N As-Built On-Site? (check one): YES ❑ N Staff Initials: EH Staff Me.OWY. Appointment Date: Time: Comments: ..y.- 4 � .y��ra ' r .r' °`iy.`., •x ,".'i^ `>'s'" ��;.:�e�aw .*:u*«-Gx °.`,?"�=SwS; - Is building present? (t)uw lc�t, t5 i ✓� ❑ Y S O Does necessary soil depth appear to have been altered since design approval? El Y S Cl7'NO System appears to have been installed under suitable soil moisture conditions? ❑ NO System has been sited/constructed to prevent surface/groundwater infiltration? 1& S ❑ NO If gravel and/or spec sand has been used,is it clean and of proper size/grade? ❑� S ❑ NO Have all horizontal setbacks been maintained? Disposal 100'from wells/surface water? Tanks/Transport/Filters 50'from wells/surface water? ❑ Y S ❑ NO Have waivers been applied for? ❑ YES ❑ NO If so, have all waiver criteria been met? Has the system(layout/components etc.)been installed as-per design? CXY' S ❑ NO If NOT,has designer concurred with changes? ❑ S ❑ NO Sam ❑ Tanks watertight(ali openings w/cast-iit fittings or sers to grade&watertight? uivalent? ❑ Lids secure if contractor not present? lease secure lids! SEPTIC TANK: ., �kUMP TANK: Cleanout installed? ❑ Pump on block or in vault? Cafiles intact with adequate clearance for inlet pipe? ❑ Discharge line as per design(check/ha 1 valves,etc)? ❑ u et filter as per design and accessible? ❑ Float position correct for dosing&to Prevent hang-ups? !,Outlet piping sufficiently stabilized to prevent settling? ❑ Floats on separate tree, not attached to discharge? ❑ Timer,ETM, Counter present if required? ❑ TransDort line correct&installed to pi event settling? Pagel of 2 e ❑ lateral&orifice placement/shielding as per design? IfSandfilter has a Pump Well: ❑ Squirt height uniform and adequate for orifice size? ❑ Lid of pump well vented? ❑ Cleanouts present,accessible and anchored properly? ❑ Discharge line as per design(check/ball valves,etc.)? ❑ Observation ports to proper depths and anchored? ❑ Float position correct for dosing&to prevent hang-ups? ❑ Air coil present if specified on design? ❑ Floats on separate tree,not attached to discharge? ❑ Float level prevents bottom of filter sand from flooding? Overall depth of pump well= in. Top of underdrain pipes to bottom of pump well= in. ATU/PROPRIETARY FILTER: s,_ . ❑ Treatment unit present? ❑ System appears to be installed correctly? ❑ Unit installed by mfg. certified representative? ❑ Disinfection unit present and as per design requirements? ❑ D-Box accessible fiom finished grade? ❑ Trench/Bed width&length correct? ❑ Speed levelers used? ❑ LateraVTrench separation adequate? ❑ Grade of distribution pipe appears correct? ❑ Trench/Bed bottoms appear level and in contour? ❑ Lateral pipe diameter/class correct? ❑ Trench depth correct? ❑ Observation its as desi and anchored? El Gravelless chambers resent if required on desi ? ❑ PRESSURE: ❑ Preferred manifold configuration used? WO ❑ Cieanout ports as per design and anchored? ❑ Manifold length correct? ❑ Trench/Bed width&length correct? ❑ Valve box for manifold accessible from surface? ❑ Lateral/Trench separation adequate? ❑ Lateral pipe diameter/class correct? ❑ Trenches/Bed bottoms appear level and in contour? ❑ Orifice spacing/diameter correct? ❑ Trench depth correct? ❑ Orifice shields present if required on design? ❑ Gravelless chambers present if required on design? ❑ MOUND: In addition to pressure checklist: ❑ 2'winimum from edge of gravel bed to side slope edge? ❑ Side slope 3:1 oring ports to gravel/sand/soil interfaces present'? ❑ Mound constructed perpendicular to slope&in contour? ❑ GLENDON: ❑ Is control panel a`Glendon' authorized panel? ❑ Stand pipes present and accessible from surface? ❑ Shape and layout as per design? ❑ If slope>5%is absorption area on downslope only? ❑ Square footage of sand areas correct? Do not walk on Glendon! ❑ SUB-SURFACE DRIP: } Comments: The undersigned has reviewed this installation and verifies these findings on behalf of Mason County Department of Health Services: Sanitarian Signature: Date: Page 2 of 2 AS-BUILT FORM Rcviscareeuary4.19" x c 1 1 PAiit31 L ICSENT EI(iAJh4i Applicant 1 1 N C) lf-V Assessor's 2 Parcel# 3 l q 'I 5 goo g (Twelve-Digit F4 umber) PermitNutnber SWt*,��� �173 0 Installer VAYVIIa /C2urve Subdivision CA 'SM g I (Name/civisio lock/Lot) Designer TovCE S0 �+NS0A) INSTALLER CHECKLIST NIA Yes Pri rtoCompletion I. SEPTIC TANK A) >5 ft.From foundation? .. . . .... . ... . . .. . ..... . . . ... .. .. . .. . . .... . 0 ❑ B) >50 ft from wells and surface water? . . . .. . . ... . . . . . ... ... . . . . . ... . . C) Bldg stub-out to septic tank: clean-out if not 1-2%? . . . . . .. . . . . .. . . . . . . . ❑ ❑ D) Baffles intact and clean? . . . . . . . . ... . . . . . . . . . . . . . . . . . . . ... . . . . . . . . ❑ ❑ E) Dividing wall intact? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . .. . ❑ ❑ F) Risers installed for access? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ ❑ G) Tank Size: I ao O gal.;Manufacture IGc�r�X 5 cA S 11. D-Box A) Leveled with water? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ` ❑ ❑ B) Speed leveler used? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . JAY ❑ ❑ III. DRAINFIELD A) >10 ft from foundation and>5 ft from property lines? ❑ ❑ B) >100 ft from wells and surface water? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ ❑ C) >10 ft from potable water lines? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ ❑ D) Laterals level to+ I inch&end caps present if not looped? . . . . . . . . . . . . . . 0 E) Gravelless chambers utilized? Cl❑ ❑ F) System dimensions the same as shown on the design? . . . . . . . . . . . . . . . . . . . ❑ / ❑ G) Gravel clean,properly sized,and proper depth? . . . . . . . . . . . . . . . . . .. . . . . ❑ ❑ H) PRESSURE SYSTEMS 1) Sand quality ASTM C-33? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ ❑ 2) Head height uniform and z24 inches? Actual head height ` 6°. . . . . . ❑ )r!r ❑ 3) Clean-outs and observation ports present? . . . . . . . . . . . . . . . . . . . . . . . . ❑ 11 ❑ 4) Mound: Side S1ope3:1? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .®- ❑ ❑ 5) Owner informed electrical connections must be made by owner or licensed electrician and inspected by L&1? . . . . . . . . . . . . . . ❑ ❑ IV. PUMPIPUMP CHAMBE �;� �yo� " TAB) - A) Screen basket o uent filter ircle one)installed? ❑ ❑ B) Riser installed for access? . . ... . .. . ..... . ... . . . .............. . .... . ❑ ❑ C) Alarm installed? . ... . . .. . ... .i. ..... ....... ..........P.... . ... . ❑ rr ❑ D) Pump make LxI- n.o m A*Ti�_ • Pum mode) O 5 P so U o � E) Chamber size l o0 o gal; c;[-S— gaUmch; Chamber Manufacture ! S D Lti 4 F) Pump chamber draw-down 1/2- inches per minute; Height of pump off bottom of pump ch _� inches G) Pump controls:Timer(or)Elapsed Time Meter (circle If Installed); )f nmmer u used: 'p Own Pump Off No, CHECVLLST 0 Drainfield&manifold orientation &layout (3 Trench/bed dimensions and critical distances within layout • Septic/pump tank placement. • Location of buildings. L3 Observation port&clean- out location. Q Location of wells& roads. /> (3 Undisturbed native soil between trenches. Cl North arrow 69W O. (00 I 4P 0 '0 VO 0 CAUTION:Minor adjustments to septic tank location and dminfield 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 installer's responsibilityto lain priorwritten approval from cit he 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. 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 0 1 certify that all deviations from the design stamped deviation from the design stamped"APPROVED"by "APPROVED"by MCDHS are shown above. MCDHS B. Q I certify that I contacted the designer and left the V 1 did not contact the designer prior to final cover because the system open for inspection up to 48 hrs prior to designer waived the notification requirement. 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 immediate suspension of my installer certification. Signature of installer Date The undersigned approves this installation on behalf of Mason Counqb*rtment of Health Services. _Vj t'OL- S-a—rutanan 'Date,