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HomeMy WebLinkAboutSWG2000-00478 - SWG Application / Design / As-Built - 11/21/2000 .. ¢ � r � MASON COUNTY DEPARTMENT OF HEALTH SERVICES PERMIT NO. SWG , • V N a $ 426 W. DAR/P.O. BOX 1666/SHELTON, WA 98584 PHONE (360) 427-9670 Date' ( y: o Receipt No. N �. Amount$ Z �01(VNER: DATE: 3 F 1�1,t Av h Z I — d� CHECK APPLICABLE ITEMS MAILING ADDRESS: DAYTIME PHONE: NEW SYSTEM q 'Z CI�IC 2(� (e�"1 REPAIR SYSTEM CITY: f STATE I TABLE I NTENANCIR v MAINTENANCE REVIEW PROPERTY ADDRESS: SINGLE FAMILY c OTHER: 3 SPECiR11PJRECTIONS FOR LOCATING SITE: PRIVATE WELL COMMUNITY WE UPUBLICSYSTEM " —7-�P'W d ^ V V , 0 ON NA SYSTEM q QQ'>t�z- l C Z-7 � SYSTEM NAME pnl APPLICANT IN NAME jkgnrTrpAvkF ^� Name of Tt{ylr J Lot x 44" ft. MAILING ADDRESS Ul. InstallerNameof TELEPHONE (pp 7./{/ t7 ' Size: e} L�o.LtulYacres Designer S A-n Number o SIG RE N 0 Bedrooms X OFFICIAL USE ONLY BELOW THIS LINE I"' DEPARTMENTAL SOIL LOGS DEPARTMENTAL COMMENTS/CONDITIONS T,� l , - h L/ Gs w l� l� N U4U M M -' m U�+u f -i rn SOIL TEXTURE CODES: P0 V=Very G=gravelly S=sand L=loam Si=silt C=clay E=Extremely INS CTOR(print narrJe) N�SPECTION SI PRE DATE PERMIT EXPIRATION DATE (�J C +w �(A-)cw?o 11 z tv / t Z (3 •All systems reEluire ongoing Operation and Maintenance(O&M)elUspecified in Mason County On-Site Standards. •All on-site sewage systems must be designed by a Mason County Certified Designer or a Professional Engineer, unless prior approval is granted otherwise •Al 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-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 expires 3 years from the date of she review.Denial of this permit may be appeqW to the Health Officer within 10 days of denial date. DES N REV EW A V BY: D TE: IN AL ION RO D BY: DATE: 11 z. 00 LAJr YJ vl TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM: Applicant's Copy MASON COUNTY DEPARTMENT OF HEALTH SERVICES November 29, 2000 PO BOX 1666 SHELTON, WA 98584 SHELTON (360)427-9670 FAX (360)427-7798 ELMA (360)482-5269 BELFAIR (360) 275-4467 TO: Greg Walterick SEATTLE (206)464-6968 RE: Design for ROHRBAUGH Case No: SWG2000-00478 Parcel No: 321361290060 [x] 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. 0 Your design for the above referenced parcel has been reviewed and is NOT APPROVED. It does not meet the requirements or needs additional information. Please see the comments section of this letter for more 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: I added observation ports. 11/29/2000 1 of 1 SWG2000-00478 MASON COUNTY DEPARTMENT OF HEALTH SERVICES EhvlronmenfalHed Pere th 666 SHBL 98584 �L(360)427-9670 (360)427-7798 Application for Waiver/Appeal llV////vvap " Amount Pald. Receipt Number. Instructionsr T PART 1: Applicant/Parcel Identification Name of Applicant Date Mailing Address S-70 �. it)ffNLCftWV— Telephone (4V, /vo7J S G-� WA, Assessor's Parcel Number 5 a-t 34 ^ I Z— eloo &0 Subdivision Name and Lot ► 3tsw pp2e ;S a'-7 Z iM PART 2: Nature of Waiver/Appeal ❑ On-Site Sewage Requirements ❑ Food Sanitation Requirements o BuUdingpermitreviewpolicies ❑ Solid Waste Requirements a Location, WAC 246-272-09501 ❑ Group B Water System Requirements a Holding tank WAC 24&2 72-12 50 1 �K Water Adequacy Requirements a On-Site Standards ❑ Enforcement Timelines a Certification contractor(pumper, ❑ Departmental Determinations designer, installer, O&Mspec)requirements ❑ Other Description of Waiver/Appcal(include justification,additional material may be attached): T 1,¢Q ✓LR �,� 4� f�� wec 2�oa - uo2�3 w Applicant Signature: �'-e� 1 titVV . U u pRsxrtr- Date: N..IWDAr,(uBCf11V61WArVFA WP Gpdae:Nav=Lba 23.199e PART 3: Health Department Evaluation(Staff Use Only) IA.Type of Determination Requited: I B. Type of On-Site Waiver(if applicable): ❑Appeal )(Waiver 13 None required 0 Class A ❑ Class B ❑Class C 2. Identificaton of Specific Code/Standard/Determination(include date of determination or latest codelstandard revision): 3. Nature of Appeal: G�� AI19 psy PV\or 4. well - 4. Hearing Official: ❑Board of Health 1f Health Officer ❑Pollution Control Hearing Board ❑ Health Services Director ❑ Certified Contractor Review Board ❑Environmental Health Manager 5 Mitigating Factors: _ o,.e 9✓� �� �o4S $O w4`�-i i5 h✓4�l�Abla Iy.L4 (A.ysj�&_(Aqp4\�ed 1Car iA1 ell :6 1 _� �'✓� ✓} AUK t f �+�,y VF tr.cl I l7/1�� 6. I have reviewed this waiver/variance request. It is complete, and mitigation required by state and local policy has been submitted. Staff: Date: Q ( _ PART 4: Determination of the Hearing Official The hearing official has determined that approval of this request will not adversely affect public health and is hereby granted. ibis decision is based on the following findings and conditions: ❑ The hearing official has determined that approval of this request could potentially have an adversely affect public health and is hereby dented. This decision is based on the following findings: Hearing Officia Datc Z� H.-IWD.fTAURC/OMWA1VEKWP Update:November 23,1999 D ' 1�iE Revised spa zs,i99s A d � �tadsrctpned each of the following Items are submitted: elbRevised w. �Ing kA sPPle Mama on �Pikablo Hftaw omit xt permit Number Designer's Name: �nis�(A tic" p�� Designer's Phone#: 360 t{J,rot[34q Applicant's Name: S k raAr� ?Ate WW4� Assessor's Parcel No.: 3 a t 3(o—t L— QCQ(o0 Melling Address: V?0 � 00"-CA9AW—I�rQ (rwetve-Digit Number) !Sjw" wx LJA 9"P(/ Subdivision: (NamdDiv4iea/13lacka'ot) pry state ZIP n'J per„ rf reatment Device O Gleadon Biofilter O Sand Filter (3 Mound )%tSSand Lined Drainfeld O Aerobic Unit-MakelModeL — O Disinfwdon Unit - MakdModeL• Dreinfield Type Pftssurc 10 O Gravity �OTrench esChambers septic TankfDrainfield Specifications, Laterals �O 7j• ` ch ass Number of Bedrooms d Length ft Daisy Flow ( ibb cal Diameter I• in Septic Tank Capacity / Number 3 Receiving Soil Type(1-6 I B Separation '� a e-' ft Receiving Soil Appl.Rate 1._ t•o to aca gp�/ft Required Square Footage v Orifices Designed Square Footage Total Number of Orifices 36® Lao Percent Reduction Taken ye LIDft Diameter yZa v.c• l ' Tench Bed L cage 3(.- tv ft spacing Elevation Measurements pppE kilo �O Original Dainfeld Area Slope p ye .ong& � MC NO 2000. ft % New Slope if Altered Diameter `l+ 9 in Depth of Excavation from 0 Al µ D Preferred Manifold Configurq(j(yi jised? Yes ❑No Original Grade i +w S m C�r,�� (up-stoPe) Transport Pipe .% a (Do t 8 q � Za"sa✓o wy in r!D wn-slope) chedule/ s Designed Vertical Separation (2 +ZV SAoDtu Length O ft Diameter e2 in Graveness Chambers Required? ❑Yes )RNo ❑Optional Yes ❑No Dosing and Pump Chamber '/ Pump Required? Number of Doses/Day 7 PumplSiphon Specifications Dose Quantity al .' a Difference in Elevation Between Pump Shutoff and Uppermost Chamber Capacity Orifice: te ft Pump Controls: Timer(or)El se Time Meter(circle ifrequired If Thuner. Pump On NNE ,Pump Off Uppermost Orifice is0Higher. 0 Lower than Perm Shut Capacity @ Total Prizure Head: Check the following components if they chin between doses: Calculated Total Pressure Head: Laterals @3 Manifold ❑Transport (Attach Pump Curve) r5� DESIGN FORM- PAGE TWO RevheaA"24 1 pqglx , '; . Scaled Plot Plan Scaled layout Sketch Cross-Section Sketch Test hole locations Drainfield orientation and layout Referenced depth from original grade: Property lines Trench/bed dimensions and critical 91, Septic tank lid and drainfield cover Existing and proposed wells within distances%yyithin layout depth 100 ft of property lines �Oq D-Box/7111/to locations 19 Critical distance measurements to cuts, Y Septic tank/pump chamber location Reference depth from original grade banks,and surface water Observation port location and restrictive strata: I� Location and orientation of curtain Clean-out location tf Laterals,trench/bed top and bottom t drain and all absorption components AT Manifold placement O Ci collector IF Location and dimension of primary Orifice placement JX Sand augmentation system and reserve area Lateral placement,with distances to Buildings edge of bed Other cross-section delDirection of slope indicator Audtbl&Msual alarm referenced Observation ports and clean-outs Waterlines Scale of drawing shown on scale bar Roads/easements/driveways/ parkingult ff rdtlDua �tystems' 3 O Critical resource lands(if applicable) � �tlfI ns at. gr North arrow and scale of drawing shown on scale barpu NOW w Additional Information O Design staked out O Operation and Maintenance Notice Attached O Waiver(s)Attached IN The undersigned designer❑does, does not,waive the requirement to be notified by the installer of the installation and given 48 hours to perform a fatal inspection prior to cover: �+ //—/b—OLD Signat re ohomigner Date The undersigned has reviewed this design on behalf of Mason County Department of Health Services and determined it to be in compliance with state and local on-site regulation 7 Environmel Health Specialist Date Caution: DESIGN APPROVAL IS VALID ONLY UNDER THE FOLLOWING CONDITION: ✓ The design is stamped"Approved"by Mason County Department of Health Sell C/� ✓ The On-site Sewage Permit has not expired,the Permit Expiration Date is: / Z Fi a ✓ The system is installed by a certified installer,unless prior authorization is obtained from Mason County Department of Health Services. ✓ Drainfteld site conditions have not been altered to adversely affect conditions of design approval �,sPri Pf,A+� ; ��� 3Z131,� /2— y'GcloD N -vutr�Nb I VF a �v rO V a . z --1 �y4 ON ID � M� 4pO p ao yo OV 9 W v5cu,ay •�top05SV ww JOCKLS �� x riwite, �} "" �sss��a� 1-p,F, �� A-afa • � gp NA .1 hHh L� N y 4 = � a r w r� S �2 4 N J -� n O M I� P pjp j J Sz i � •- � - E `9 r� mN %A b s v b 'ti Z VL e ve - N � a � Nf J J .1 IDEp'f W 10 'J � 03 10 J z o Ito i Cl V m s — � CV ,y; O , SECURED LID WITH GAS TIGHT SEAL ZC DIAMETER 1 ACCESS RISER FINISH GRADE — — — — — TO PUMP CHAMBER FROM SEWAGE SOURCE FLOATING MAT APPROVED EFFLUENT FILTER SEDIMENTS SEPTIC TANK (TYPICAL) SECURED LID WITH GAS TIGHT SEAL THREADED UNION 24'DIAMETER ACCESS RISER O FINISH GRADE ptGO. Nod �' 9 2000 FROM SEPTIC DRAINFIELD TANK `` EMERGENCY STORAGE ANTI SIPHON VALVE' HIGH WATER ALARM LEVEL — — — - — — — — WORKING VOLUME INDEPENDENT FLOAT STEM NORMAL TIMER OFF LEVEL _ _ _ FOR FLOAT ENCLOSED PUMP p±lo.t A ( MOUNTING •SEDIMENT SHROUD' CHECK VALVE' y`it- p /'(TW L1.Y4'1� CN Q 10 SEDIMENTS �1;;[fi;, SUBMERSIBLE CENTRIFUGAL PUMP P�U TY�P CHAMB PICAL) ER O�'E7 or' - `AS NEEDED FIGURE 2 11 Pure Performance The OSI Biotube-Effluent filter is the most advanced in the industry, engineered to provide maximum 'A"- Extundatih! PVC Ila! protection for your septic system. L PVC Cap Features and Benefits Air Vcrit5 • Improves effluent quality. Average Total Suspended Solids (TSS)is less than 30 PPM, nearly 2-1/2 times lower tnan a non- screened system! • Allows for smaller diameter drainfield pipe. Lowers drainfield matena cos: • Superior patented design. Extends drainfield life. Reiiaix-<, corrosion-proof construction. • Easy installation. Installs in minutes in new or existing tanks. D • Simple, hassle-frok, pEpT maintenance. VAG NO 2 9 ZOOp 4- PVC 1 • Available alarm. a�E Indicates when mainten needed. • Ideal for variable-grade sewers Allows reduction of the transpc^ line size and associated cost, • Custom sizes. Call for availability. Irq-,T -Lt.- P-T (9 f It:� O1= Z t=- CO-,P. OF soli t N T•�v 1� 4- diameter mcdcl FT0435 o t ■■�■■■■■■■■■MEN■■■ENO ■■ ■■■■■■■■■■■■NINE■■■mom ■■ ■■■B■■■■■■■■11■■■■■MEN .■ • ..■A..■■■■■■U■■■■■■■■■■ ■■1Ww■.■■■■■■1m■■■■■■.■■■ ■■■IE■.■.■■■.mom..■■.■.■ ■■■1/.■■■■■■ ■■■■■.■ ■■■1�ONE■mom ti.■.■■.■.■■■ ■.■M■■■■■.■��■■.■■..■■.. ®eye - SEE N:::::::::::::::::: mom® ■MERE ii i::a■i::::::: AN:: :::::::::::::::::: Uid ME 0 MEN Bill ■ OMMENNEM ■■■��■..■r�■.....■.■.■■■ .■.■��r.M■A■■■■■■■■■■.■■ ©�a ...■MW■■ERNE.mom ....... ...■E...,...■.■.. ::::::: :::::::: caste ■■■■■1\!/■■NEON■. . . . ■.■:,..■■■■.... ■■.■■r.U■■ENE■■■E ...■WA�■.■E■■EN■ ■■■ENOMME■■■■N■■ ■■OEM■■■■■■■.■■■ ■E■WEEN■E■■E.■E. . . . ■........■..NEON ■■EEE■ENNEEE■■■■ E.■E■■■E■■■■■■■■ _ ■■■■N■■■.■.■■■.■ ' .■■■■■.■■■■■■■■■ Construction Notes 1. If the site Is too wet to prepare, do not proceed until It Is properly dry. The soil MUST be properly dry before Installation can proceed. Do no install the drain field while the soils are wet. 2. Use EXTREME pre in site preparation. Remove"NO"top soils. Use ore in tree and stump removal. leave root systems intact. 3. Trench bottoms must be level. Follow contours of the slopes. 4. If a"D"box is used, speed levelers are required. 5. Brush piles and debris are not to be burned on top of the proposed drain fields sites. 6. Do not use the drain field areas for storage of excavated dirt, parking areas, lumber packages,or anything that will disturb or destroy the areas. 7. Do not deviate from this design without permission from the designer. 8. Drain fields sites are to be roped off,for the protection of the sites, prior to and during the construction of the home. No traffic of any type is allowed on top of the drain field sites. Soils can be damaged easily and the Infiltration rate can be lost, making the proposed sites unusable for a drain field. 9.Z101tration the trenches are excavated,the sldewails and bottoms are to be raked to open the surfaces. able effluent screens are to be used. 11. Construction and materials for this system shall conform to the latest regulations and requirements of the County Health Department. 12. Topography, benchmark, stub-out and Invert elevations are based on assumed data. 13. Ascertain location of underground utilities before digging. 14. Edge of drain field trenches to be a minimum of 5 feet from any property and/or easement. 15. Encroachment of house and/or driveway Into drain field or reserve area may render the site unusable, requiring a redesign at additional costs, or even totally unusable. 16. All roof drains and surface water run off shall be directed away form the drain field. 17. Sewer lines under roadways shall be encased in pipe rated at 1000 lb. crush strength. 18. This system is not designed for use of a garbage disposal. Use of such may cause system failure. 19. Where sewer and water lines cross, water lines must be a minimum of 18 inches above sewer lines and encased in another pipe for a minimum of 20 feet. Crossing must be at center of encasement pipe. G 20. Where a good off site sandy cover is placed over an installed drain field, the sandy soil H extend ten feet beyond drain field and be feathered to match existing terrain. �p IP ID 21. Installation and use of this septic system without a tee filter looted in the oud rd j*VAe 2000 septic tank may cancel any warranty, expressed or implied. MMMM"``"'' 22. This system requires a proper degree of maintenance. Certification of the design an� Installation does not Insure trouble free service. 23. Keep septic components a minimum of 10 feet from any water line under pressure, unles�` sleeving of water line is provided, per codes. 24. A curtain drain (if required by designer or health department) is to be installed a minimum of 8 inches Into compaction and tight lined to daylight, meeting all county codes. Down slope side is to be lined with black plastic. XCAVATING PENINSULA W Highland Rd. Shelton, WA. 98584 1. hsstall laterals with contour of the grotmd 2 /Install trench bottoms level and at all times a Minimum of six inches into We native soil. Install locator tape on top of all drainfield laterals. �. Install observation ports as indicated on the plot lam(minimum-two per dntnlield with bottom extending to the drattvock/native soil m erface). 5. Install dr - i Iddttring dry weather and soil conditions, dd any soil smearing must be ralant 6. hwtall threa4ed clean-outs at the Ca of all laterals(cap mast extend to within 6 inches of hCd Cads of be marked with locator tape)' Install audiovisual high water alarm- Install V6 inch mesh non-corrosive pump screen(min. 12 sq. ft. surface area,not to interfere with controls or floats). ee+ sib-rueW EGft O V-yr F t t-TPW 9. Install check valve in pump outlet line to prevent system from draining back into the pump chamber. 10. Tee Tee c9nettoaw�Cn laterals�qd manifold�woitchko eaq entedtt 6 o'clock. Imtall laterals to the manifold witheo turn orificesdown(6 oclock)(andttela)orals opressure m o fo d. test and Health Dept. approval, 11. Filter fabric required over drain rock prior to backfillmg. If the drain rock extends above natural grade, run the filter fabric at least 2 inches down the trench wall. 12. Divert all storm water run-off away from on-site sewage system. 13. No curtain drains allowed within 10 ft. of the tip-slope edge of the drainfield and reserve area. ��,�ED 14. No curtain drains allowed within 30 ft. of the down-slope edge of t�� Ep'C reserve area. MC HEp� 15. Have the septic tank and pump chamber pumped or inapccted every ft"lave yeatss. 16. Inspect and clean pump screen every 6-12 months as noodai CON 17, 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. Install septic tank and pump chambers so that insp�on lids are at finished grade. If tank tope an set deeper than frudshed grade, risseprpsrowiilall be required. 20. � m�i wd9illt3talc�e tlwutdesigo m111 and from �Designer and Mason County ON-SITE SEWAGE INSTALLATION FINAL INSPECTION sFf .. .cst . ¢..'�>'�Z@'u^�tn.•KL'2 nn a, ua.¢,°..?�,:>>.\2;.i. :.� .,x.�3>�.sw �+y�'+2�.6� DATE CALLPD IN: TIME: rnJ INSTALLER: rN /C�fii1 LA APPLICANT/OWNER: CALLER: PHONE#OF CALLER: SWG#: Y dG - A/3 L112, / PARCELNUMBER: SUBDIVISION: Div: Lot: SYSTEM TYPE(CHECK ONE): PRESSURE GRAVITY INSPECTION SCHEDULE(CHECK ONE): APPO,INNT,`MENT PLUG IN AS-BUILT ON-SITE(CHECK ONE): Es NO STAFF INITIALS: ff MUMMER LTiSTAF� 51i{)NL APPOINTMENT DATE: TIME: :. COMMENTS: ! 1 i 4: ON-SITE SEWAGE INSTALLATION STAFF INSPECTION REPORT N714�•bl:a m .'� s .p.s a .y.. r �-. >a.ca Yes No Comments .. I. SEPTIC TANK A) >5&from foundation? / 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? IL D-Box Leveled with water and/or speed leveler(circle)? _ III. DRADWIEM A) >10 R from foundation and>5 It from perceived property lines? B) >100 ft from wells and surface water! C) >10 ft from potable water lines? D) Laterals level to±1 inch&end caps present if not looped? ,L E) Gravelless chambers utilized? F) System dimensions the same as shown on the design? G) Gravel clean.properly sized,and proper depth? H) PRESSURE SYST Ara 1) Sand qualityASTMC-337 2) Head height uniform and x24 inches? 3) Clean-outs and observation ports present? 4) Mound Side Slope 3:17 5) Owner informed electrical connections must be made by owner or licensed electrician and inspected by L&I? IV. PUI"/PMW CHAME / A) Screen basket uent filter ircle one)installed? B) Riser installed for s 7" C) Alarm installed? -� D) Pump on timer ideman ircle)? V. As-BUrLTREQUmm? VI. OTHER COMIENrS/OBSERVATIONS The undersigned has reviewed this installation and verities these findings on behalf of County Dent o,Pglealth Services. Sanitarian �� /uj Date C-WY1rdaVuWc axk wpd Revised9f" .� U= UIU �- LU AS-BOLT FORM _ Revised)aauery 4.19" .:�:. gy .'r: •. .rxa':a:: nxx:.na::nn..Y:nw�: . Applicant tl.ei Vl ll?/sad L'f!/l Assessor's Parcel# / 3 Z fat) la O � II'' Permit Number SWQ: q,�n &P`C 7 (rwewe-o19H Number) installer -0" "—J(I& S"t Subdivision (Name/Oivisbn/elocklLot) Designer �FRhIa�A� ( A. H /iE" toJS""i NIA Yes Prior to Completions I. SEPTICTANK A) >5&From foundation? ..................... ..................... ❑ 81 ❑ B) >50 ft from wells and surface water? .......... .. .... . .............. ❑ ❑ C) Bldg stub-out to septic tank:clean-out if not 1-2%? . ................... ❑ ❑ D) Baffies intact and clean? ....... ......... . . . .. .... ... .. ......... .. ❑ ❑ E) Dividing wall intact?...... .... .... ... . .. .. ..... . .... . . ........... ❑❑ ❑ ❑ F) Risers installed for access? . .... ....... ....... .. . ..... ............. G) Tank Size: gal.;Manufacture 11. *D-Box 11 A) Leveled with water? .. . . . . ... . . ... . . . . . . . . . . . I . . . . . . .. . .. .. .... . . ❑❑ ❑ B) Speed leveler used? . . . . . . . . . . . . . . . . . . . . ... . . . . . . .. . . . . . ....... .. I11. DRAINFIELD ❑ A) >10 ft from foundation and>5 ft from property lines? ❑ B) >100 R from wells and surface water? . ... .. . . .. . .. . . . .. . .. . . ...... . . ❑ C) >10 ft from potable water lines? .. . .... . .. .... ... ..... . . ........... ❑ D) Laterals level to±1 inch&end caps present if not looped? pr ❑ .............. E) Gravelless chambers utilized? ... .............. ... . . .......... ..... ❑ ❑ 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 .... . ❑ PI 11 ❑ 3) Clean-outs and observation ports present? ❑ 4) Mound: Side Slope3:1? . ... .. ... ...... . .. . .... .... .......... PS 5) Owner informed electrical connections must be made ❑ by owner or licensed electrician and inspected by L&I? ........ . ... . . ❑ IV. PUMP/PUMP CHAMP ❑ A) Screen basket or vent filte (circle one)installed? ................... ❑ B) Riser installed for access? ......................................... ❑ ❑ C) Alarm installed? ...................... ❑ ❑ ........... D) Pump make ( rQp�. Pump model SP 3 E) Chamber size _ gal; Ilto gdrmch; Chamber Manufacture 01-L A 3 F) Pump chamber draw-down c9- inches per minute; Height of pump off bottom of pump chamber—�R—inches G) pump coatr&r Timer(or)Elapsed Time Meter (circle N Installed); If tinier is used Pump On P — a,. CHECKLIST ❑ Drainfield&manifold orientation &layout ❑ Trench/bed dimensions and critical distances within layout ❑ Septidpump tank placement t�t3��— a e�t� eA . ❑ Location of buildings. ❑ Observation port&clean- fie, out location. j ❑ Location of wells& r roads. moo• i —t ❑ Undisturbed native soil t �� between trenches. ❑ North arrow _� p 1 1 Srg .ter 3 �apicM 91 2 W ge CAUTION:Mimr adjustrtienu W optic tank location a of meentarion I 8artrneat e i sully i reWns ft lInstaller to obWn pnorrwwntt�le�b�frroomeleither Lu and the desiAter,bm could in cation eases compromise viability tYstem• :with deparbmm lthe designer beforo malting any dcviatiens from the design that affect(he system viability. My deviations from the approved design must be shown above. W-il }00'* �nrr�� � 1 . °4asi' :. . - x a � x yA �� pp/fy� _: 'N •l�t�t �. F � '3 .Y�is"T'r� ::fi r:�:..ir�s:�u.1 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 desiga stamped"APPROVED"by � "APPROVED"by MCDHS are shown above. MCDHS g, � 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 bra prior to designer waived the notification requirement- cover. I further certify that all information contained on this form is aceurate. I understand that if the information contained herein is not accurate,there will be just cause for immediate suspension of my installer certification. o a ate The undersigned approves this installation on behalf of Mason County t of H ces• T I.l I 1310