HomeMy WebLinkAboutSWG95-0483 - SWG Application / Design / As-Built - 7/11/1995 MASON WLINT1 DEPARTMENT OF HEALTH SERVICES PERMIT NO. SWG 7!_M1
426 W. CEDAR/P.O. BOX 1666/SHELTON, WA 98584 Date — I'
PHONE (206) 427-9670 ReceAmoulnt$pt o 'g o
Z,^ F
3
CHECK APPLICABLE ITEMS ✓ m
MAILI "D YAYTIME PHONE. INSTALLING NEW SYSTEM _o
REPAIRING OLD SYSTEM I f°
CITY: STATE: Ip; EXPANDING SYSTEM V w
SINGLE FAMILY
PROPERTY ADDRESS: OTHER Z
SPECIFY: 3
SIDE FI IRECTIONS FOR LOCH ING SITE:' PRIVATE WELL or
PUBLIC SYSTEM rJ
SYSTEM ID NUMBER
P
SYSTEM NAME
AP CANT r
NAM I
Name of Lot � ft.x �1f1 ft. AILING ADDRES
Installer
Size: �,�c Zacres TELEPHONE
Name of Number ot S TURE
Designer (n Bedrooms Ix Vn
PLOT P I�
LAJ
Draw a d�4��t4p�� nat plan
including�J W '9
❑Precis ion of.iest LLI
cSE�KA I g r
mewholes, 9
measur istanc�to r
prope ndalfg.
❑Entry=_her roads, —J L v �Y V u ^ ,ids _ 1 /O
drivew � �.4h. �`
NOTE: 1QTL% 19 x \ f
SYSTEM DESIGN VA
OFFICIAL USE ONLY. DO NOT WRITE BELOW DOUBLE LINE.
SOIL LOGS
aw Qwr 1.51 '9 t
/ N Yy
,2-1r7 �Fo�PaC'f6� L
Depth from Original
Grade to Restrictive
Layer or Water Table: (7 In.
DESIGNER DESIGNATION SCORES MINIMUM SYS EQUIREMENTS
Finding Score Designer Lev ❑One TW
Soil Type 1
Vertical Separation n. Septic Tank Daily
Capacity: /160 Gal. Flow: j6a GPD
Slope p�% _� APPI %� / Infilt. /
Parcel Size �,f0 Ac. Rate t/ c GPD/FT2 Area O� FT'
Distance to Shoreline ft. Total T Inspector Date
COMMENTS/CONDITIONS FOR APPROVAL
Any than a fro the specified use of the property or any site aQaffecting the system design may invalidate this permit.
This Permit expi from date of site inspection.Denial of this p m be appealed to the Health Officer wit ' 1 s of denial date.
SITE:O Approved red ❑Not DESIGN: ppro%DATE
U Not Approved INSTALLATION ed ❑Not Approved/
BY: DATE: BY:BY: : -Plr ,, BY: DATEVZ ?pI,
TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTTOM:Applicant's Copy
y
I I
Go
I I
(FOUND 3/4" IRON PIPE
NO PLUG (UP 0.5')
7.82' SOUTH OF LINE
S 89'36'14" E 393.76' 9.58'
�358.92 34. 5
9 97' S 89'39'57" E 358.74'
I I
2 40'0 �
OO 0 o� s OLD POLE �14
BUILDING 100' R I '.
OW
N POSSIBLE
p WELL SITE
1.719A LOT
ZI a
(INSIDE FENCE) �1//
1.72 ACRES (PER DEED) �c
p pp I I
nul
OO I
Y I
N 89'20'19' W I w I
W /BLUE SHED 354.83 w I co
! 100' R I rn o I M
,o
EXISTING WELL HOUSE i of z a
n I
b CONCRETE POND I ZIw W
o z
z 0�1 RED SHED 2' X 2' CHIMNEY
�- 1.57 ACRES NI
FOR& NORRISCAP �COVERED PICNIC MI I � o
PER VOLUME 20 PAGE 30 AREA I z o
OF SURVEYS.- I I N z
N 89'37'32" W I W PROJECI
64.76' C N 1/
FENCE ,� WOOD
21.81' WEST) u�' w SHED / . . � . . _ . . - . . _ . . ._ . . _ . ._ _ - A3:
rr�5III /
N 2'39'25" E.... SHED
� . . .c,101.67" . . .M ,�
_A BEING USED p r ( EXISTING SEPTIC y�l
GREENFIELD� o o POWER POLE SYSTEM �I y RISER EHONI
NEW FENCE z WITH METER o
POSTS o SHED E POWER POLE
(NO WIRE)/// I oo N 86'14'49" W � . . - _ . . - . . - . . . . - . . I 4.17'
SIGNS OF OLD N 15.43' 284.52'
FENCE POSTS .� - -x�c-x"x-x-'�`-x�`-x
& WIRE ` 17.34' S 86'49'37" W N 89-50.59" W 229.76' 45.00' 19.95'
39.43' 283.72'
25.46' N 89'37'32" W
11.74'
FOUND NORRIS BAR & CAP (/ 19.79'
PER VOLUME 20 PAGE 30 DEED LINE-' \ BOUNDARY UNE PER
OF SURVEYS BOUNDARY LINE
AGREEMENT PER
MASON COUNTY
DEPARTMENT OF COMMUIVITY.DEVELOPMENT
RESOURCE LANDS AND CRITICAL AREAS CHECKLIST
Permit Number �/w�y�� //�� �� rtLC Rle
A �✓ �' QS
rcel
Parcel Number ��I l �nl.cio
❑. 1. Saltwater shoreline or lake 20 acres or larger?
Name of Water Body
❑ Z Rivers,streams_or creeks with year round flow?
Type of Other Water
❑ 3. Rivers,steams or creek with intermittent flow but are within a dearly defined channel? (�
❑ 4. Lakes or ponds less than 20 acres in size?
❑ 5. Wetlands: Areas that are inundated or saturated by surface water that under normal
circumstances support vegetation adapted for life in such conditions,such as marshes,bogs,
and swamps_ r\yo
❑ 6_ Slopes greater than 15% (8.5 degrees)? On Landslide Hazard Map?
of Slopes
❑ 7_ Floodplains? rD
❑ 8. Seismic Hazard Areas? 1""
❑ 9. Agricultural Open Space Taxation Program?
❑ 10. Open Space Timber Taxation Program, or Designated forest or Classified Forest?
1_ Site has no Resource Lands for Critical Areas_.
Comments:_. y /l � l �' ✓! �'✓� ,
�, � �,, l
y
�� ��
Z�� �� 2 C► l ooP Kam• MASON COUNTY
DEPT. OF HEALTH
Field Sheet for SWG# �6—' (OY-09y
Applicant Name: 6 `�o r 10
Absence of critical area verified on subject property:
Yes No
1. Steep Slopes >
15%
2. Water
a. Wetlands
b. ' Streams
C. Lakes 6�
d. Ponds
e. Saltwater _ - -
7�y
Sanitarian's Signature Date
MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
MASON COUNTY BLDG. 111, 426 W. CEDAR
P.O. BOX 1666, SHELTON, WA 98584
(360) 427-9670, FAX. (360) 427-8425
=_ =_
. .
DATE. / /
FROM: ~ ~ ~ G rpyson N N N-
FOR: .c a-a-4,tz 4So.14-c(
PARCEL: 3 Z-d 4
'1ta�vc dealq�c �ac the a6eue j jww4; d �t"e-ce 4"
to
'I�e aeaaoaCm�
1) EXTREMELY GRAVELLY COARSE SANDS
REWIRE SAND AUGMENTATION.-G.G.
fF a
•'r._'._':.
.:.iG: .iT ..
title
1).ESION 1,'0101 - 11A(,V ONl? ,lnn,h,
A deFign �yi}� eviewad when 3 _copiet of. each of the following items, are submitted:
\\��j, d dcrngn fain; t_hnL hi ; 1, rn �iryied and d11rd
Vr9n , ,•d ttb:niuc , rand; uid Critical Area , CherkIIst attached
rated t,l ui plan, including all applicable item, on checklist
v Clad Inl, nL f;ket_ch, inc-ludinrt all applicable af< ns on checklist
t
;e,li oil Yetch inclndin all applicable items on checklist
� - 9 PP
PARCEL IDENTIFICATION II
II ti - p II
II ' - nit: Number _�_.,v (ram-Ut(S� Des
igner' s Name _�/N Vl•.r �t�rzj __ II
II n�
II Apl,I i c•ruit
Na
Nae /Q4,j,1,j('.-- Prop. Owner' s Name _
II Mnilinq Addres^ 20.r�_ �V _Ci � tcF___ Mailing Address
7.i1'
II Assessor's Parcel No. 32U6 - 2/ -�/J d Subdivision
-('i•wsTv1_ i s i i r 7 II
Mason
----'I
if
DESIGI7 PARAAfETE y
ais ✓ . . il.
II I r-1 rl, � Designed Vertical II
II r t r� tJ J Separation II
II Mound. Subsurface Pressure Gravity Bed Trench �?c!in II
II Septic Tank/Drainfield Specifications I f1 II .
II No. Bedrooms -__ I Pressure Distribution? 64 Yes l.J No
II Daily Flow _ 36U gP� 12::iEEEEE6:9:::Eie:c:EEE (If yes, Proceed. . . ) ........................
....................
II Septic TaA Capacity -- I—LUd gill_ I II
II Receiving Soil Type (1-G) - 11t I
II Receiving Soil Appl . Rate = 1 • Z and ft' I Laterals IL N O II
'french/Bed Bottom Area goo ft, I Schedule/Class
Wrench/Bed Width _ 3 ft I I..ength Ls ft
II
II Trench/Bed Length — /0o ft I II
I Diameter
II Elevation Measurements I Number y
II Orig, Drainfield Area Slope U t I Separation ft
II Final Drainfield Area Slope -- %- I orifices II
II Depth of Bottom of Trencli/Bed I Total Number of Orifices 31 11
,fl fr.ont.Original Grade _ Z 7 in I Diameter J/rl in
per' opt— I Spacing J6 ' II
II
Z 7 in I Manifold II
I' owns ope I Schedule/Class Zoo- P4_r ft II
f1 r-1 I Length
II Infiltrator 13sed? I-1 Yes tJ No I Diameter
m --�- In II
II Q'1 (—j I Transport Pipe
II Pump Required? ✓J Yes U No I schedule/Class 20 u ►�S r II
(If yes. Proceed. . .) iicE6cici.:Sicciiici.i.iicl Length 10 - _ft 11'
119E:ciE:c3:::SiE3E I Z II
II. Diameter in
Pump/Siphon Specifications I Dosing and Pump Chamber
II Di.fference in Elevation Between Pump Shutoff I fl Doses/Day
II and Uppermost Orifice N ft I Dose Quantity q O 3a1_. 11
II �} Chamber Capacity 35Z0- 5111- II
uppermost Orifi.r, is fNI i g)1e r, IJ lower _ I�
11 than Pump Shutoff I Check the following components if they drain 11
II (,-tparit:y to Tot. Pres. Ileld ___ Z71 qpm I between doses: II
calculated Tot. Piero. Head Q _ Ll_ I n
II (Attach Pimip Curve) I L I Laterals tJ Manifold Ld Transport 11
—mil
DE,S4GN 3,'OKM - PAGE•'[ WO
,II DESIGN Clit CKr ISl
f
IIScaled Plot Plan Scaled Lavout Sketch I Cross Section Sketch II �
I I II
II I I .I Reference depth from orig-- II
'7•est hole locations t�4 Drainfield orientation I inal grade: II
and layout I X,;
lI Property lines I D Septic tank lid and II
Z• Trench/bed dimensions and drainfield cover depth II
Existing and proposed I critical distances within I II
wells within 1,00 ft I .- layout I Reference depth from or;g- II
of •property Iif,&s inal grade and restrictive
locations I strata: II !
r{�l Critical distance I .I II
measurements to cuts, I L" Septic tank/pump chamber I Laterals, trench/bed II
banks, surface water I location Plotr .d+ I top and bottom II .
I W II
Location and orientation � "� Observation port location I 4 Curtain drain collector II
of. curtain drain and all .I �p I , II
II absorption area I LLf Cleanout location IlSand augmentation II
II rnmponents
1� YT Mani.foid I>l acement No externalreference needed: ll
' Location and dimension rr''��•• I I�
II of primary system and - � y'i Orifice placement I- Observation ports and II .
reserve area I I cleanouts II
Lateral placement, with I
II
Buildings - - I distances to edge of bed I Additional mound information: Il
I I r-, II
Direction.of slope I Audible/visual alarm., U Upslope and downslope II
indicator I referenced P��/ ,„y fill width II
Waterlines I � Scale of drawing shown I u Settled cap depth at II
on scale bar I center and edge of bed II -
�I Roads/easements/ I
II driveways/parking I Additional Mound Information: I U Sidewall slope II
II U n I n II
II Critical resource lands I U Endslope width - I U Up/downslope bed elevat. II
(if applicable) i u �U'Jri'y tee. tt
Overall fill dimensions et'�sdf rce Lands and
I' North arrow and scale of I ii Y%jjclist
drawing shown on bar I I lnitidKul) II
Date
iDESIGN APPROVAL I�
IIThe undersigned designer 'does, does not, waive the reqirement to be notified by the II
installer of the installati nd g'ven 48 hours to perform a final inspection prior to
II cover.
igna u o esigner a e
II The undersigned has reviewed an oved this design on behalf of Mason County of Health II
U Services. 4 1 �/� '9v,
II ea . , or a e
_ II
II LTH
CAUTION: THIS DESIGN IS ONLY VALID IF STAMPED "APPROVED" BY MASON CO. DEPT. OF HEA II
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�niti�ls_
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opt, llQ�llll
Q/Gr/,[ e SPvv y ROV
Initials �D
Da to
34" 3L" 3fe Ld IL'
I?OX , cJ XW q = 36 X,1'9 6Pn7 =:2lj2.q 4pm
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• GENERAL NOTES
ANY VARIATIONS TO THIS DESIGN SHALL FIRST BE APPROVED BY CINDY E.
BINGHAM, DESIGNER AND THE COUNTY SANITARIAN.
OWNER/INSTALLER SHALL NOT REMOVE ANY TOP SOIL WHILE CLEARING TREES
AND STUMPS IN DRAINFIELD AREA. REMOVAL OF TOP SOIL COULD RENDER THE
SITE UNUSABLE.
ALL CONSTRUCTION MATERIALS AND THE INSTALLATION OF THESE DESIGNED
SEPTIC SYSTEMS SHALL CONFORM TO ALL APPLICABLE STATE AND COUNTY
HEALTH DEPARTMENT REQUIREMENTS.
USE OF SOME RESERVE DRAINFIELDS MAY NECESSITATE PUMP INSTALLATIONS.
ALL REQUIRED TESTS SHALL BE SUCCESSFULLY RUN PRIOR TO CALLING CINDY
E. BINGHAM FOR FINAL INSPECTION. ALL COMPONENTS, INCLUDING ALL TANK
ACCESS LIDS MUST BE ACCESSIBLE FOR INSPECTION. CONTRACTOR SHALL BE
RESPONSIBLE FOR COST OF RETURN INSPECTIONS DUE TO FAILED TEST OR
INACCESSIBLE COMPONENTS.
THIS IS A SPECIAL DESIGN DUE TO ADVERSE SOIL CONDITIONS,
GROUNDWATER TABLE AND/OR TOPOGRAPHY. CINDY E. BINGHAM HAS DESIGNED
THIS SYSTEM IN ACCORDANCE WITH ALL CURRENT STATE AND COUNTY HEALTH
DEPARTMENT REQUIREMENTS AND 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 CINDY E. BINGHAM.
INSTALLER/OWNER IS RESPONSIBLE TO LOCATE ALL UNDERGROUND UTILITIES
BEFORE INSTALLATION STARTS.
��Dot,O Hes• y ,, ., .
tes
ials vi�L
�a to
JIM RAGSDALE
Parcel #32136-21-90190
DESIGNER COMMENTS AND CONDITIONS
SYSTEM TO BE HELD IN TOP 26" OF ORIGINAL SOIL.
AUGMENT TRENCHES WITH TWO FEET OF APPROVED SAND.
FILTER FABRIC OTHER APPROVED MATERIAL WILL BE USED FOR BARRIER
MATERIAL.
USE 2" 200PSI PIPE FOR PUMP LINE.
USE 2" 200PSI PIPE FOR MANIFOLD LINE.
USE 1" SCHEDULE 40 PIPE FOR LATERALS.
USE 3/16" ORIFICE SIZE SPACED AT 36" .
AFTER PRESSURE TEST ROLL ORIGICES TO SIX O'CLOCK.
USE TEE TO TEE CONSTRUCTION WITH MANIFOLD BELOW.
INSTALL 1" BALL VALVES AT THE START OF EACH LATERAL TO ADJUST
EFFLUENT FLOW.
INSTALL OSP33 HYDRAMATIC PUMP OR EQUIVihAN0b ,jITH AN AUDIO/VISUAL
ALARM IN A 300 GALLON FIBERGLAS PUMP TAN Y Dept,
.1�4,/^�- fle�r,hs
INSTALL SCREEN TO ENCLOSE PUMP IN THE PUMPT• rlJvY.� ices
INSTALL 1" SCREW CAPS WITH 45 DEGREE AT'PSFi END OF EACH
LATERALS FOR FUTURE CLEANOUTS. \
INSTALL OBSERVATION PORTS AT EACH END OF THE TRENCES.
PUMP CURVE IS ATTACHED.
VERIFY PUMP SIZE WHEN THE GRADE OF THE RESIDENCE IS DETERMINED.
MARK THE ENDS OF TRENCHES WITH REBAR OR SOMETHING SIMILAR FOR
ACTUAL LOCATION OF THE SYSTEM.
SYSTEM WILL BE INSTALLED IN DRY WEATHER. HEAVY EQUIPMENT IS
PROHIBITED FROM DRIVING OVER DRAINFIELD AREA.
WATER LINE TO BE TEN FEET FROM DRAINFIELD, IF NOT IT WILL HAVE TO
BE DOUBLE CASED.
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initials E
pate
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ENGINEERING DETAILS
+ OSP33
Performance Data
32
I'I Pump Characteristics
! Pomp/Mete1 U1d1 Submersible
Mnm1d Meddt s 0SP33RI1 CISP33M2 d 24 v31+P
AatonWk Madels: OSP33A1 0SP33A2
I
Horsepower 1/3 � 10
Fall Lied Atap4 T.8 4.6
77
Motor lype .., t Phasa
1750
R.P.M. ° u
Phase 0 1
VoUaBa 115 1 230
id 0 0 10 20 30 _40 '60 60
1 NMI 60 caPncm-U.S.0.6.M.
Op/rai16M „. Intermittent
TialpeFdlYni .i,. " 1401 Ambient Total Head (feet) 4 8 12 16 20�k 2$ 25
�P NFAUDes18B B GPM 1/3 HP 60 SS 48 39 28 > 0
li InstdaNBa 0ass F 77
I Sl}d 1-1/2"NPT CY 0 Hg ��
g wedgy 5/e• Dimensional Data "at
Solde 19and16Gj '
Walybl 501bs. ''re 6-3/4 s.
powft Citd 1B/3,SITW, 16//3,S11W Bt
�. (20'opt.) 20'std. 1 adosMdMeMYu
tb 3d hM
1- _ Fr t.copink&MAWN
p 4.1/4 niey vattl/IMdi
t A aM%r wnmv m
Materials of Construction p„arMudraw"
1:Wevdmadwdphe
Handle fE , Steel eai , 5 5.WiMKO16r
" ln6rkaltng08 gw to
Dielectric 4 S.Witmmmtow
p� moke reoeare b our
motor Neusbs8. Castlroa "di4s Md d,*
eskW
Panels CosNtB Cast Irem> _ .. nuft
i. 5balt Steel
Medmokal Sod Faces:Carbon/Ceromk
Shalt Seal Seal Body:Brass
Springa3:Stainless Steel 12-1/8
j, Bellows:Buna-N s-vb
Impeller PUMP
Bronze
11-3 4 ON
Upper 8eatdYB Single Raw Ball Beariall
j Lower ad" ; :r Single Row Bag Bearing — f
lotCost Iron
Fastendrs . ,,- ; Stainless Steel PUMP OFF
AURORA/HYDROMATIC PUMPS, Inc.
1840 Soney Road,Ashland, Ohio 44805
(419) 289-3042
:aZlJt! WAkih_lNSl
ON LATION
FINAL INSPECTION
...................« t,V(s S3Az.t ::_::
DATE CALLED IN: � Z—Zv
TIME: q %5_5 I -
INSTALLER: ,gyp
APPLICANT/OR'NER- _
f
PHONE # OFCALLER- y3LIo ' tll�� � y.2�o•b/ 5J
SWG
PARCEL NUMBER: C
SUBDMSION:
DIVISION: LUST:
. .........................«..«..«.....«.«......««.....«................«...............«.....«.....«.«....«.. ::„ ««..«..................«
SYSTEM TYPE (CHECK ONE) :
._--PRESSURE- - GRAVITY
INSPECTION SCHEDULE (CHECK ONE) ; r,I
u
APPOINTMENT PLUG IN
AS-BUILT ON-SITE? (CHECK ONE) : T-{.� �I
j U
YES NO
.........................................««.....«...«...............«................ .............««......«..«..................«.....................................««
STAFF INITIALS:
hccaUin_u
Revised 02/01/95
ON-SITE SEWAGE INSTALLATION
STAFF INSPECTION REPORT
STAPP CFI IST
I
I
I CONPIRt1ED EY INSPEC R?
I I
IYee No C®nau I
I. SEPTit: fr I
I A) >5 ft t from foundation? I
s) Bldg stubout to septic tank. clearnrut if not 1-2%? — t
I c) Baffles intact and clean? - t
D) Dividing wall intact? -- I
xx. D-9ox leveled with water or speed Leveler (circle one)?
I I
xxx. DRAZKFI=
1 A) >10 ft from foundation and >5 ft from property lines? I
s) laterals level to :1 inch & end caps present if not looped?
1 C) System dimensions the same as shown on the design? I
D) Gravel clean, properly sized, and proper depth? I
E) PRESS9 SYSIEY
1) Sand quality ASTM C-33? X —
2) Head height uniform and 14 inches? I
3) Cleanouts and observation ports present? -
I 4) Hound: Side slope 3:1? I
5) Owner informed electrical connections must be made I
by owner or licensed electrician and inspected by DL17
xv. P ARLE VA= LINES I
AM from drainfield, transport Line, and septic tank? 6 -
I a) Hells >100ft from drainfield? - I
j V. /t I
I Ser
9) R sem or effluent filter (circle one) installed?
er installed for access? I
I C) Atana instat led? - 1
I
I vx. AS 3i1II.T REQUIRED?
I
1 vzx. onum cOHIffiiT5
1
I
I
I
1 The undersigned has reviewed this installation and veri ies a findings on behalf of Masan County of Health Services•
1 L f_,
I ns cor ae
I
h:caltin_w
R"iscd 02/01/95
; l
rnl.rr.l. rortrrTFlcArforl
. - I Heel Irvtl. 'r tlnnte MAN
l:I•et mi Number— ..c.4lG9S OI/?J -. subdivision
_ TTS:un�Jlliv i::.ton7Pl.,%li/I:%lU
I )w/ �, , 32 /3c- al- 9v190
I n•;lnller'. m� Assessor' s Parcel t}n.
Um ._ _ - Cl wclvo-iJiyiCNumb�il
THSTAKLER CHECKLIST
,T
n C'rnnpletid'r
N/A 1� Prior In I
I . TIRPTIC TANK
A) >5 fl. frnm fonndal-.ton?
R) tlldg ntnbrml. In septrr tnnL : rleanout if not. 1-•.1 : --
C) nnFflrn inlnct tnvl clenn?
It) Dividing nil inl:icl-? ----
II . D-ROK Leveled with water and/nr neeed leveler: (circl o) 7
DRAlturtrLI) ropot t)' linen?
r — � ._.-.
A) >to ft. frnm frnmdnlrnn nnl > , It-. from pi
II) Lnlernln level to 11 inch t end caps present if not looped? jef
C) System dlm .nninnn the bnvr . nn nb"W" on the denign? _1� - .
D) Clt-avel Aran, erroem ly sized, nild ),roper depth?PRIMSSURIT SYSTEM
{I 1) .^.a11d (tool tl:y A S fti (7- 13? Y�•
2) Hand beight unifrum and >24 inrlte.^.?
V101-
3) C.lennrnitn and nh •mrvntinn part- : present?
I 4) owner Side e1nee c: 1 �yy
51 owner informed electrical rnnner.tions moot be node X�o
owner (ir linen .ed r l crt r i vi nn and i unpo _d by DLT?
IV. PDTARLE WATER LINES -�-
A) >t.Oft frn- field or rbndile nlnev'd" -----
rt) Wn,lln -tnnft it mi chninf l••1.1'; ---
V, PUHP/PUriP CHAMItER J
A) t ign•-rI pvmi nn d, or alas-n ntI "hrd for rqui.val ant pump9 -
h) pAN n . .:et m: efflrient filter (Ci.rcJe one) iD.^•t-allyd? -
c) War in tnlled for acre n?
CEP.TTFICATIOR OF INSTALLATION
IIIBtbilbit Chock box from Pow A, " chn box from
now 'D, ' sign and date the certification
A- �.... � I cetti.fy that 1 inntnlled the rnntrm V?* T certify that. all deviations front
without nny devint inn from the design the design stamped "APPROVED" by P7eDIi. nr
nLnmped "Arrl:nvRD" by tCPHS . shown on the reverse aide of this form.
0. I certify Lhnt I c'rnd.art.ed the I--1 I dial not contact the ed btolgncr pribi�
designer and left the nyntem npen for to final cover because thtt designrr
iDnpectinit tq, to 4n his prim- 1-n r„vrr , waived the notification, requirement.
_ I further rill: i.fy tital: 411 information cnutnined on this .form is Accurate- I undernl:and
Ihnl 1f the Infr.r lent irnr coal nlned h••rr• in in not ncrurate, theme will be jI at cause far
immedlnl e nunpnnninu of my ntntnl I,r rert irtcnivion.
';iynSR� co r 1i
II ,fhe unrletnign�d ne1t ova••: thtr: inr.l all a I of hehnJf of hn nn/CounLy nopartment- of ilnn"'
. IL-' tltn lii�l��•71 �
II, AS-IIU[LT DORM - PAGE TWO Revised 08/24/94
II PARCEL IDENTIFICATION , -
II Applicant's Name r./ I- /2iYf o,/....1G II
II permit Number SWG96 -f�404l A ? Subdivision Name/ ivision oc ou II
II Installer's Name / r66e,r✓ Assessor's Parcel No•.
II Designer's Name C/MJ4— r�V*A,1 w -('I w'--c�Tv€-Di iE-hTunl6i�r II
I
II--� -- AS-BUILT DRAWING II
II
jj v
O II
II
I
? II
II p Z 3 Vq �771 It II
II 3 6 y'
71 ' S8 f 9 it II
/is 3y ii1 ll
6 1l3 /oy
II -
rArs"JON: Minor adjustments to septic tank location and drainfield orientation made in the field by the installer are generally ae-
ceptahle to both the department and the designer, but could in certain cases compromise the viability of the system. It is the in-
shaljer•a responsibility to obtain prlor written approval from either the health department or the designer before making any devi-
atlnna from the design that affect system viability. Any deviations from the approved design must be shown above.
II AS-BUILT CHECKLIST II
1
�i--�-
r
Drainfield orientation tJ Observation port location u Undistua,Xbed native soil
and layout n between trenches II
II u Cleanout location',
t_1 n
_ Trench/bed dimensions and n U North arrow ry
.. II critical distances within U Manifold placement n u
II layout n t--i Scale of drawing shown II
uu orifice placement on scale bar
D-Box/"T"/"L" location II
n
u Lateral placement, with Additional Mound Information
II septic tank/pump chamber distances to edge of bed.
II location n u Endslope width I :
I� L-J Location of wells, roads ensions
n
II Location of buildings U overall fill dim
L1— _11