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HomeMy WebLinkAboutSWG2002-00213 - SWG Application / Design / As-Built - 5/30/2002 MASON COUNTY DEPARTMENT OF HEALTH SERVICES PERMIT NO. SWG — N N d N 426 W. CEDAR/P.O. BOX 1666/SHELTON, WA 98584 Date y o ReLso ceipt No. 5 v; PHONE (360)427-9670 Amount$ Z f w P ERTY OVyNER: DATE: _ _ CHECK APPLICABLE ITEMS �/ 10 M LIN ADDR SS: S NEW SYSTEM o DAYTIME PHONE: ' 4!j s _ REPAIR SYSTEM -i-.J STATE: ZIP: TABLE 6 REPAIR m MAINTENANCE REVIEW m PR�VOPE TY A RE,54_SS: SINGLE FAMILY c D L OTHER: 3 SPECIFIC DIRECTIONS FOR LOCATING SITE: PRIVATE WELL m r+ I �UMCI fLACOMMUNITYWELL/PUBLICSYSTEM (� p SYSTEM WFI N Q � ICI�q�f on [ Ll9lllot l8�ue c�n CTO Q�MO`l 3 l NSIGNA ST ANT EM ME I" 1 r Na of Lot ft.x ft. DRESS Iw I e Se: 3 ry acres E o N e of E um er o0 Designer — Bedrooms 0 L OFFICIAL USE ONLY BELOW THIS LINE DEPARTMENTAL SOIL LOGS DEPARTMENTAL COMMENTS/CONDITIONS 00 3( '7 -sy Z_J' to 10 uIIG► D ,/ q G fc D 'o u0 o m N o N Q SOIL TEXTURE CODES: m t♦ V=Very G=gravelly S=sand L=loam Si=silt C=clay E=Extremely C INSPECTaR( int n e) IN ECTI SIGry�� DAT PERMIT EXPIRATION DATE (� Al r u L W u� 6 u 6 •All systems quire ongoing Operation and Maintenance(O&M)as specified in Mason County On- ite 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 •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 permit expires 3 years from the date of site review.Denial of this permit may be eal to the Health Officer within 10 days of denial dale. DE N. VIEW AYRROAL BY: DAT IN ALLA N A D BY: r, -2 y DATE: �0 6 Z� �j TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM: Applicant's Copy MASON COUNTY DEPARTMENT OF HEALTH SERVICES June 14, 2002 PO BOX 1666 SHELTON, WA 98584 SHELTON (360)427-9670 FAX (360)427-7798 Mason County Septic ELMA (360)482-5269 PO Box 1341 BELFAIR (360) 275-4467 Shelton WA 98584 SEATTLE (206)464-6968 RE: Design for LAWIN Case No: SWG2002-00213 Parcel No: 321367590093 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: 6/14/2002 1 of 1 SWG2002-00213 DESIGN FORM-PAGE ONE Rewa,t�ai A design will be reviewed tWhen,�ggof each*(the following Items are su{xttld : wk pkltPl�an,�kwluG4WaUappYoabIs le onq=ieeldld 42ti�ons Y�okid aI1 P4able o�a� Permit Number. SW Designer's Name: bf4120 t Designer's Phone f: L5c6-44eYo Applicant's Name: LS6 rf-L, t r\ Assessor's Parcel No.: 94J9 .3 MaitingAddress: eC R (twetro• 61tNumbod 'D-hm Subdivision: OW Sure Zip D Treatment Oevice G G LLja Filter G Mound O Sand Lined Dnk&.Jd 13 Aero U G Disinfection Unit - MakeRrW&' Drainfield Type O &WALT SERVICESa GGm uesve ambers Septic Tank/DralnfieldSpecifications / Laterals Number of Bedrooms 3' SchedulclClass o2 p0 Daily Flow 'S gpd length Septic Tack Capacity /�nD _gal Diameter Receiving Sou Type(1-0 3 Number Rooetving Soil Appl.Rate Separadoa 9 ' Required Square floatage AAA P P'R Designed Square Footage P Tota!)vumb§ Percent Reduction Taken Diameter ' Spacing JUN 112002 Sevatlon Measurements EW Manifold SchedulcACInss �>o 0 Original Draiafield Area Slope 4• •/ th New Slope if Altered % �. Diameter Depth of Excavation from Original Onde $ in Preferred Manifold Configuration Used? ®Yes (up•doa) in Transport Pipe -too (Down-slope) Length /Class Designed Vertical Separation �� in r Gmvetless Chambers Required? ❑Yes ❑No C9 Optional DDiame.ter Pump Required? 0 Yes O No Dosing and Pump Chamber Pump/Siphon Specifications Nuiiiber of Doscs/Day Dole guantityaatiry Difference in Elevation Between Pump Shutoff and Uppesost Chamber Capacity Orilice: '4 A Pump Controls: Tiow(or)Elapse Time Meter(ewe It rcq if Tuner. Pump Oa Pump Off Uppermost Orifice LM Higher, O Lower tiu p Shutoff Capacity Q Total Pressure Head: ( q! (L)q Qom Cheek the following components If they draht between dose Calculated Total Pressure Head: C� 4 2rf rt ❑ Lawals ❑Manifold 0 Transport (Attach Pump Curve) DESIGN FORM.PAGE TWO rScaled .Plot Plan Scaled Layout Sketch Cross-Section Sketch gr Test holellocationsPro * Drainfteld orientation and layout Referenced depth from original grs Ir ly � Trenehlbod dimensions and critical Ot Septic tank lid and drain&ld eov. ting and proposed wells within distances within layout depth 100 B of property lines O D-BoxP"[`mn locations $ Critical distance measurements to cuts, W Septic tank/pump chamber location Reference depth from original grad banks,and surface water Q Observation port location and restrictive strata: O Location and orientation of curtain 19 Clean-out location & Laterala,aeaehAwd top and boas Min and all absorption components 0T Manifold placement O Curtain drain ooUeetor Location and dimension of primary li OdrWo.placement O Sand wgmwtation 3 system and reserve area 17 Lateral placement,with distances to Buildings edge of bed Other cross-section detal; Z DUCCUoa of slope indicator 0 Audtbk/visuai alarm referenced ® Observation ports and clean-outs ® Waterlines jR Scale of drawing shown on scale bar ® Roads/easementsldriveways/ puking O Critical resource lands(if applicable) 81 North arrow and scale of drawing �� shown on scale har sio Additional lnfolmation a Design Sawa" . O Optxation and MaWau noa Notice Attached O Waiver(s)Attached The undersigned designer does, 0 does not,waive the mAuireraent to be notified by the installer of tier installation and given 4; hours to perform a final inspection prior to cov Signature of Designer Date The undersigned has reviewed this design on behalf Mason County Department of Health Services and dowmiaed it to be in compliance with state and local on-site regulation . 6 ly/oz • Environmental earth Special'i;t at Caution- DFSICNAPPROVALISVAUDONLYUNDERTHEFOLIAWINGCOMMON: The design is stamped"Approved'by Mason County Department of Health Services The On-site Sewage Permit has not expired,the Permit Expiration Date Is: 6 / The system is installed by a certified installer,unless prior authoriadon it obtained Mason County Department of Health Services. Drainfield site conditions have not been altered to adversely affect conditions of design approval re e IC_ —may W e 11 1�rPc,., (`d2SPS�Q 1-' �r- ------ Zoo POss, \c 1 An rH sites f v � C � Ca , Lo�ro.ls �n�a�iow-CQniz�r ,Q�_graLLr& . MgY 3 o 2002 �3 WR SERVICES � APPR MC HEAl, €i CEPT o , JUN 11 2002 l�ane�__------- D ao � i 1 i 80o Gn - Grp L i ud[6I/ / c Y� o� tO` MD � � � ad � Q MAY 3 0 2002 HEALTH SERViCES APPROVE® MC HEALTH CREPT JUN 1 1 200? �n I/ CEW � I 1 = 10 SECURED LID WITH GAS TIGHT SEAL / 24•DIAMETER 1 ACCESS RISER \i FINISH GRADE - - - - - PUMP CHAMBER FROM SEWAGE SOURCE FLOATING MAT APPROVED EFFLUENT FILTER SEDIMENTS SEPTIC TANK (TYPICAL) SECURED LID WITH GAS TIGHT SEAL THREADED UNION 240 DIAMETER ACCESS RISER FINISH GRADE SERVICE VALVE FROM SEPTIC TANK -�TO DRAINFIELD EMERGENCY STORAGE /� ANTI SIPHON E NIGH WATER ALARM LEVEL - - - - - - - A OVED EAL.TH DEPT WORKING VOLUME INDEPENDENT NORMAL TIMER OFF LEVEL _ _ _ _ _ _ - 1 O �T ENCLOSED PUMP ^g�� UNTING SEDIMENT SHROUD' CF) CK VALVE ]$ I SEDIMENTS SUBMERSIBLE CENTRIFUGAL PUMP PUMP CHAMBER (TYPICAL) -- •AS NEEDED RISER WITH LOCKING LID tREERA aLOW CONTROL VALVE SLOTS AS REQUIRED ECKELONG SWEEPp90 DEGREE \ \ pp ELBOW SECTION A-A WASHED ROCK DRAIN SUMP TRANSPORT PIPE FROMAPPROVED PUMP CHAMBER MC HF.ALTH DEPT JUN 112002 CEW DRAINFIELD CONTROL BOX (SLOPING GROUND: MANIFOLD BELOW LATERALSI DETAILSENGINEERING d° Performance Data Pump Characteristics 32 Pump/Motor Unit Submersible Manual Models SP4011111 I SP401112 24 Automatic Models SP40A1 I SP40A2 °a 4/1oHP Horsepower 4/10 = cr Full Load Amps 9.4 4.7 16 Motor Type Split-Phase 'o J R.P.M. 1750 o a Phase 0 1 ~ Voltage. 115 1 230 Hertz 60 0 0 20 40 60 SO 100 120 Operation Intermittent CAPACITY-U.S.G.P.M. Temperature 140OF Ambient HEMA Design A Total Head (feet) 4 8 12 16 20 24 28 Insulation ants A GPM 1 4/10 HP 120 108 90 68 42 20 0 Discharge Size 2"NPT SaBdsHandling 1-1/4" Dimensional Data Unit Weight 60 lbs. Power Cad 18/3,S1TW,IISV=10'std. 3-15/16 6-13/16 I.ADdllmmiueinWan s-1 a (20'opt.) 2 Canpomm ammvan may 230V=20'std. 2NPT wryt1/3M 4-5/16 DISCHARGE 3.No for mthone puryw undw anifid 4.Dimensions and wegm an Materials of Construction S.We mareapproximate`aerve° 3-3/4 110 rMM to 18 ache re mad la ear their Handle Steel prdam and their Lubricating On Dielectric Oil ueafaalamvida�ul^aqa,oa Mates Housing Cast Iron A P P R a.I V M MC HEALTHEVT Pump Losing Centimes J U N 1 1 20 2 Shaft Stainless Steel Mechanical Seal Faces:Cabon/Ceramic 4-v1s Clatsr Shaft Sec Sec Body:Brass Sp in Stainless Steel 13-1/16 Bellews:Buna-N 12-1/4 _ DISCHARGE PUMP Impeller Thermoplastic HEIGHT ON Upper Bearing Single Row Boll Bearing 16 Lower Bearing Single Row Ball Bearing PUMP OFF a v Fasteners Stainless Steel z c LL f Z Q AURORA/HYDROMATIC Pumps, Inc. C 1840 Haney Road,Ashland, Ohio 44805 (419) 289-3042 QwIVU 3ac� �Z Loose ue� e�-O_L�el"_l14'�4N_ .orb -r!Jro 3 ro<k- do Uri -: ---- 07�1 PV �cao &POf0 h0� APPROVED MC HEALTh DEPT JUN 1 1 2002 CEW n MASON COUNTY SEPTIC SYSTEMS Diana Field P.O.B. 1341 Shelton, WA 98584 (360) 426.8642 INSTALLATION/MAINTENANCE Pressure Distribution Systems 1. Install laterals with contour of the ground. 2. Install trench bottoms level. 3. Install locator tape on top of all drainfield laterals. 4. Install observation ports as indicated on the plot plan. (Minimum two per drainfield with the bottom extending to the drainrock/native soil interface. 5. Install threaded cleanouts at ends of all laterals with cap extending to within 6 inches of finished grade and be marked with locator tape. 6. Install audio/visual high water alarm. 7. Install effluent filter on outlet of septic tank and/or 1/8 inch mesh non- corrosive pump screen. (Minimum 12 sq. ft. surface area, notA E® with controls or floats. MC J4r-AL.TN DEFT .JUN 1 1 2002 8. Tee to tee construction between laterals and manifold with orifices oriented to the 12:00 position. Orifice shields are required. (UnlesscEW design specifies 6:00 orientation.) 9. Geotextile (filter fabric)required over drainrock prior to backfilling. If the drainrock extends above natural grade, run the filter fabric at least 2 inches down the trench wall. 10. Install drainfield during dry weather and soil conditions. Any soil smearing must be eliminated by hand raking. 11. Divert all storm water run-off away from on-site sewage system. 12. No curtain drains allowed within 10 feet of the up-slope edge of drainfield and reserve area. 13. No curtain drains allowed within 30 feet of the down-slope edge of drainfield and reserve area. 14.A cover of between 6 and 24 inches of mineral soil containing no greater than 10%organic content shall be placed over the entire drainfield area and shall be graded in such a manner as to preclude accumulation of water over the drainfield. Backfill and grade the site to prevent surface water accumulation over any component of the on-site septic system. 16. Installation of drainfield on a sloped area should have check valves installed in the manifold to prevent hydraulic overload of the lowest elevation lateral and also to enhance rapid pressurization of the system. 16. This system has been designed in accordance with all current state and county Health Department regulations and this designer assumes no responsibility for its use or longevity. The owner therefore agrees to maintain and make all necessary repairs to the system at no cost to MASON COUNTY SEPTIC SYSTEMS and Diana ESeld. 17.All materials and workmanship must meet County and State regulation. MC Fr7A1.TX DEPT JUN 1 1 2002 CEW 19.Deviation from this design without prior approval from the designer and Mason County Heath Department will make this design null and void. The On-site Septic System owner is responsible for properly operating and maintaining the OSS and shall: a.) Determine the level of solids and sewn in the septic tank once every three years. b.) Employ an approved pumper to remove the septage from the tank when the level of solids and scum indicates that removal is necessary. - c.) Protect the Oss area and the reserve area fro m 1. Cover by structures or impervious material 2. Surface drainage 3. Soil compaction by vehicular traffic or livestock 4. Damage by soil removal and grade alteration d.) Keep the flow of sewage to the Oss at or below the approved design both in quanity and waste strength -e.) Direct drains,such as footing or roof drains away from the area where the Oss is located f.) Inspect and clean pump screen every 6 . 12 months g.) Inspect floats and test high water alarm every 6 to 12 months . High strength waste will increase the depth of the bicmat in a drainfied,causing a decreased flaw through the biomat and possible ponding or flooding of the draixdleld. High strength waste in a residence is usually related to the 7lfestyW or habits of the horns, generally resulting from one or more of the followings 1. Excessive use of a garbage disposal APPROVED 2. Consecutive kxrds of laundry done all on one day MC F9 FA A_TN' CI E PT 3. Excessive bleach or detergents with added whiteners JUN 1 1 2002 4. Dishwashing,showering,and laundering all at the same time 6. Medications • antibiotics can kill cr impair the biological C: EW process in the septic tank B. I.ealw plumbing (hydraulic overloadf ng) a 3� f2s quo 93 ed 5 LS Cr Ni d _ Date Called In: Caller Phonv. II #: , © 1 Time: II pp `- (� Installer: 4 l[Z S 0 q _ , a a�" " !] LParcel#: Designer. Q Subdivision: } Applicant/Owner: SLLZ2 j Q(a7 i n Site Address: "eTeckaR.iliata Gravity ❑ Sandfilter Messure ❑ ATU/Proprieti Filter Mound ❑ Glendon Biofilter ❑ Sub-Surface Drip Inspection Schedule:(check one): YES ❑ NO As-Built On-Site?(check one): YES ❑ NO Staff Initials: E/I Staff�Jse tnlyr Appointment Date: Time: Comments: Is building present? z YES ❑ NO Does necessary soil depth appear to have been altered since design approval? YES NO System appears to have been installed under suitable soil moisture conditions? YES ❑ NO System has been sited/constructed to prevent surface/groundwater infiltration? j� YES ❑ NO If gravel and/or spec sand has been used,is it clean and of proper size/grade? rX YES ❑ NO YES 0 NO Have all horizontal setbacks been maintained? l` Disposal 100'from wells/surface water? Tanks/TransportlFilters 50'from wells/surface water? Have waivers been applied for? Cl YES NO If so,have all waiver criteria been met? El YES D NO Has the system(layout(components etc.)been installed as-per design? YES ❑ NO If NOT, has designer concurred with changes? ❑ YES ❑ NO Tanks watertight(all openings w/cast-in fittings or ez Risers to grade&watertight? < equivalent?) Lids secure if contractor not resent?Please secure lids! a• ERTIC TANK.. „ .w... LJMP TANK: ; �leanout installed? ump on block or in vault? atlles intact with adequate clearance for inlet pipe? Discharge line as per design(check/ball valves, etc)? Outlet filter as per design and accessible? lost position correct for dosing&to prevent hang-ups? utlet piping sufficiently stabilized to prevent settling? ,l I Floats on separate tree,not attached to discharge? ❑ imer, ETM, Counter present if required? Tran rt line correct&install to revent settling? Pagel of2 tIOVcEl vcf) 426 bV C'er Sr. ❑ Lateral&orifice placement/shielding as per design? lfSandfilter has a Pump Well. ❑ Squirt height uniform and adequate for orifice size? ❑ Lid of primp well vented? ❑ Cleanouts present,accessible and anchored propedy? ❑ 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 pumpwell= in. ATUJPROPRIETARY FILTER: ❑ Treatment unit present? ❑ System appears to be installed coaectly? ]]❑ Unit installed by mt. certified representative? ❑ Disinfection unit present and as per design requirements? o ❑ D-Box accessible from finished grade? ❑ Trench/Bed width&length correct? ❑ Speed levelers used? ❑ Lateral/Trench 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 as desi and anchored? ❑ Gravelless chambers present if required on deli ? Preferred manifold configuration used? leanout ports as per design and anchored? 'fold length correct? Trench/Bed width&length correct? Valve box for manifold accessible from surface? Lateral/Trench separation adequate? eral pipe diameter/class correct? Arenches/Bed bottoms appear level and in contour? Orifice spacing/diameter correct? KI Trench depth correct? ❑ Orifice shields resent if required on design? ❑ Graveness chambers present if required on design? ❑ MOUND: In addition to pressure checklist: ❑ 2' minimum from edge of gravel bed to side slope edge? ❑ Side slope 3:1 ❑ Monitoring 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: 1 Comments: The undersigned has reviewed t Ilation and verifies these findings on behalf of Mason County Department of Health Services: Sanitarian Signature: CbJa Date: 1 r�Q Z Page 2 of 2 AS-BUH,T FORM Revlaed Immmy 4.19W ..Im'e ; °£ 3 Applicant ti I\e:y, u \_aw t o Assessor's �QQ^ Parcel# 30213 -?S 9 6 64 3 Pe 't Number SAG ol_ Q (Twelve Oigit Number) al ler Subdivision (Name/DivisloNBlocklLot) Designer —�W wA P,� .` )NSTALikROH�CMIST " r fi NIA Yes Prior to Completion 1. SEPTIC TANK A) >5 ft.From foundation?........................ .. ................ ❑ la ❑ B) >50 R from wells and surface water? ......... ....... ... ... ...... ... ❑ ❑ C) Bldg stub-out to septic tank:clean-out if not 1-2%? . .. .. ... ... ... . . . .. . ❑ la ❑ D) Baffles intact and clean? .. ... . ...... .... . .. . . . .. . . . . .. ... .. . .. . .. El ❑ E) Dividing wall intact?. . . . . . . .. . . ...... . ... . .. .. .. .. . . .. . .. . . . .. . .. ❑ a ❑ F) Risers install foraccess? .. . .. . . . ... . . . ... . ... .. . . ❑ IR ❑ G) Tank Size: WO gal.;Manufactureegra t�C A t 1Ee II. D-Box A) Leveled with water? . . . . . . . . . . . . . .. . . . .. . . . . . . . . . . . . . . . . . . . . . . . .. 8 ❑ ❑ B) Speed leveler used? . . . . . . . . . . ... . . . . . . .. . . . . .. . . . . . . . . . .. . . . . . . . x, ❑ ❑ 111. DRAINFIELD A) >10 ft from foundation and>5 ft from property lines? . . .. . . . .. . .. . .. . .. ❑ J& ❑ B) >100 ft from wells and surface water? ....... ... . . . .. . . ... . .. . .. ... . . ❑ K ❑ C) >10 ft from potable water lines? . ........... ... .. .. . . .. . .... ... ... . ❑ oil D) Laterals level to±I inch&end caps present if not looped? . ... ... . ... .. . ❑ � ❑ E) Gravelless chambers utilized? ...... ........... ... .. ......... ... .. . ❑ ❑ F) System dimensions the same as shown on the design?...... . ...... ...... ❑ Ir ❑ G) Gravel clean,properly sized,and proper depth? .... ... .. ... ... ... . ... . ❑ ❑ H) PRESSURE SYSTEMS 1) Sand quality ASTM C-33? .... ............ .. . .. .. .. . ...... . .. . 5t ❑ ❑ 2) Head height uniform and z24 inches? Actual head height .. . .. ❑ 5k ❑ 3) Clean-outs and observation ports present? .. . . . .. .. . . . ... ...... . .. ❑ � ❑ 4) Mound: Side Slope3:1? ........ .... .... .. .. . .. .. . ... . .. . .. .. r ❑ ❑ 5) Owner informed electrical connections must be made by owner or licensed electrician and inspected by L&I? . .. . .. . . .. . . . . ❑ $ ❑ IV. PUMP/PUMP CRAM A) nl effluent r (circle one)installed? ... . . ....... ....... ❑ 9r ❑ --B) Riser edforaccess? .. .... ........ .......................... . ❑ 6t ❑ C) Alamxinstalledl . ... ....... ............. .. ............... ❑ ❑ D) Pump make tl/27 i 114 Pump model Se 40 E) Chamber size gal; gal/inch; Chamber Manufacture_96Ada_ ef1f1fAbik, F) Pump chamber draw-down inches per minute; Height of pump off bottom of pump chamber inches G) Pump controls:Timer(or)Elapsed Time Meta (circle If installed); If timer is used:Pump On_Pump Off ...... .. ....... .......... W ......... ... WM U A Nan- ME CIWXKLLW 13 Drainfield&manifold orientation'&layout • Trench/bed dimensions and critical distances within layout • Septic/pump tank • Location of buildings. placement. • Observation port&clean- out location. Ll Location of wells& roads. 0 Undisturbed native soil between trenches. E3 North arrow CAUTION:Minor adjustments to septic tank location and drainfield orientation made in the field by the installer ale F gn5gly acceptable to both the department in and the designer,but could in ctitain cases compromise the viability of the system it is the installa's responsibility to o In prior written approval from either the health department or the d=iW before making any dcrinflons from the design that affect the system viability. Any deviations from the approved design must be shown above. .......... OF INSTALLATION �x ........ . .... Installer Check a box fforn Row"A"and"B",sign and date the certification A. >W:, I certify that I installed the system without any 0 1 certify that all deviations from the design stamped deviation from Jhe design stamped"APPROVED I by "APPROVED"by MCDHS are shown above. MCDHS B. 0 1 certify that I contacted the designer and left the )iV,I 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 cilmained on this form is accurate. I understand that if the info ion con herein is not accurate,there will be just cause for immediate suspension of my installer certificali I L16-6, W Hgow ate The undersigned approves this installation on behalf of Mason County De 41,nt oMServices. /0 banitanaill ate