HomeMy WebLinkAboutSWG2001-00035 - SWG Application / Design / As-Built - 1/26/2001 PERMIT NO. SWG m 7
MASON COUNTY DEPARTMENT OF HEALTH SERVICES a v
Date y F `"FA O
426 W. CEESAR/P.O. BOX 1666/SHELTON, WA 98584 Receipt No. y
PHONE (360)427-9670 Amount$ m
PROP TY OW ER: DATE: CHECK APPLICABLE ITEMS f♦/
EW SYSTEM
MA I ADDR S: DAYTIME HONE:
N
noJ _ _ REPAIR SYSTEM
ZIP: TABLE E 6 REPAIR
v
CI r MAINTENANCE REVIEW m
PROPERTY A DRESS: SINGLE FAMILY c
OTHER: 3
SPECIFIC DIRE ONS FOR LOCATING SITE: PRIVATE WELL m
� L COMMUNITYWELUPUBLICSYSTEM f,
yZ m 1 r c t h{ o n SYSTEM NA N �•J
rt hi n lN1tKk e\sen I�GI. 5 SYSTEM NAME
APPLICANT W
NAME �—
Name t VIE4 yo��f ft.x ft MAILING ADDRESS I�r �
Installer Size: \ ' 55 acres TELEPHONE Iv,
Name of um er o SI o `Designer ja Bedrooms X J IRS
OFFICIAL USE ONLY BELOW THIS LINE I I�
DEPARTMENTAL SOIL LOGS DEPARTMENTAL COMMENTS/CONDITIONS
m ,
o
THE
G - 32-
Grp I I e
T L
U-3z Grp.
TId3 o -30„ 6-ft C
C;.
SOIL TEXTURE CODES:
V=Very G=gravelly S=sand L=loam Si=silt C=clay E=Extremely G
IN CTOR print na e) I PEC I N SI T RE DATE PERMIT EXPIRATION DATE
C�L
•All systems cMuire ongoing Operation and Maintenance(08M)as dpecified in Mason County On-Site Standards.
•All on-she 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 chan a from the spec'rfied use of the property or any site alteration affecting the system design may invalidate this permit.
•This expires 3 yee s from the date of she review.Denial of this permit may be appealed to the Health Officer within 10 days of denial date.
DESI REVIEW APP BY ) SATE: INSULATION PPRpd1ED BYE' - {c7ld
Cl f�
TOP: Health Dept. Copy MIDDLE: Designer's Copy BOTT M: Applicant's Copy
MASON COUNTY
DEPARTMENT OF HEALTH SERVICES
March 01, 2001 PO BOX 1666 SHELTON, WA 98584
SHELTON (360)427-9670
FAX (360)427-7798
ELMA (360)482-5269
BELFAIR (360) 275-4467
TO: Diana Field SEATTLE (206)464-6968
RE: Design for KNUDSEN TIMBER
Case No: SWG2001-00035
Parcel No: 321352390003
[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.
[] 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: Keep orifices at 12:00 o'clock, install as shallow as possible, use
orifice shields.
03/01/2001 1 of 1 SWG2001-00035
DESIGN FORM- PAGE ONE V � u.tags
A design will be reviewed twhhen 8 co lames of each of the following Items are udxwuec�.�AN2�(j( It `
% =p�tptat4 hetOit1on
Ik+blae�dMams�on tit Qrossse ion skald,.tine �' �sY1/iCENTER
x
Permit Number. Designer's Name
�� �' pesigner's Phone k:
Applicant's Name: �,�._ , OIP�"' Assessor's Parcel No.:
Mailing Address: Ca4
16hNv
, �%Pl. i !i>/I 9�s�� subdivision:
as sue ZIP
Treatment Device
O Glendon Blofilter O Sand Fitter O Mound O Sand Lined Dminfield
O Aerobic Unit-MakdModck — O Disinfection Unit - MakelModel:
Drainfield Type
pressure Cl Bed Dm1O1O
Gravity �Trench Giavelles Chambers
Septic Tank/Drainfield Specifications Laterals
`5 • � Schedule/Class ,
Number of Bedrooms Length
Daily Flow ' Diameter
Septic Tack Capacity / 1 Number
R�eeetv4 61 Ln&fe- Separation /
Requited Square Footage A/ W Orifices
Designed Square Footage Total Number of Orifices
Percent Reduction Taken Diameter iinn
ft
Y1Treach/Bod Width 7VAft Spacing
Rae7t/Bed Length .
Elevation Measurements Manifold
� Schedule/Class
Original Drainfield Area Slope T % Length
New Slope if Altered % Diameter
Depth of Excavation from Preferred Used? ®Yes No
Original Grade N �p pe) p
to �� in MC HEALT116'tC WTtPipe
(Downalope) Schedule/Cla 1 ,
Designed vertical Separation �� in Length IYIAR 2001 y.
Diameter
Gmvelless Chambers Required? [IYes ❑No ROptional
PumpRequired? JOEIn`g end Pump Chamber —
Yes 0 No Number of Doses/Day
Pump/Siphon Specifications Dose Quantity
Difference in Elevation Between Pump Shutoff and Uppermost
Chamber Capacity
Orifice: /O k Pump Controls: finer(or) Elapse Time Meter(elroto Krequlred)
if Timer. Pump On .Pump Off
Uppermost Orifice is M Higher, O Lower than Pum Shuto
Capacity Q Total Pressure Head: Cheek the following components if they drain between doses:
Calculated Total Pressure Head: ❑Laterals ❑ Manifold ❑Transport
(Attach Pump Curve)
DESIGN FORM- PAGE TWO
Rer11011 Apol24.
7100ftof
t Plan Scaled Layout Sketch Cross-Section Sketch
cations .0 Drainfield orientation and layout Referenced depth from o
es 61 Trench/bed dimensions and critical St Septic tank lid and dtainifield cover
d proposed wells within distances within layout depth
operty lines (7 D-Box/"T'P'L"locations
O Critical distance measurements to cuts, 0 Septic tank/pump chamber location Reference depth from original grade
banks,and surface water IV' Observation port location and restrictive strata:
O Location and orientation of curtain Ot Clean-out location JA Laterals,treach/bed top and bottom
drain and all absorption components Ili[ Manifold placement O Curtain drain collector
17 Location and dimension of primary Q Orifice placement O Sand augmentation
system and reserve area O Lateral placm eent,with distances to
> Buildings edge of bed Other cross-section detall:
IN Direction of slope indicator 01 Audiblehrisual alarm referenced
t`:I Observation ports and den¢outs
Ef Waterlines Q Scale of drawing shown on scale bar
13 Roads/easements/driveways/ w
pig //yy
O Critical resource lands(if applicable) �S,a�oo '� o ttp f+ 5temt
AT North arrow and scale of drawingl�dnn1S#Onss (t1
shown on scale bar .pryry� down;lope.alid� Fe k
Additional Information
® Design staked out
O Operation and Maintenance Notice
Attached
O Waiver(s)Attached
The undersigned designer R does, ❑does not,waive the requirement to be notified by the installer of the installation and given 48
hours to perform a final inspection prior torcov -
zs je/
Signature of Designer to
The undersigned has reviewed this design on behalf of Mason County Department of Health Services and determined it to be in j
compliance with state and local on-site regulatio
t)
Environme tal Health Specialist Date
Caution: DESIGN APPROVAL IS VALID ONLYUNDER THE FOLLOWING CONDITION:
./ The design is stamped•Approved"by Mason County Department of Health Services.
.11 The On-site Sewage Permit has not expired,the Permit Expiration Date is: d? 21/a V
.� The system is installed by a certified installer,unless prior authorisation is obtained from Mason County
Department of Health Services.
,/ Drainfield site conditions have not been altered to adversely affect conditions of design approval
ode I I e Ho1e_
Q - 3z� GSl� D- 34�� GSL � - 2U S �--
CI<ss
* / Z -f sd
���9er rbbOA,'l
0ed03/2000 15: 52 3604265995 KNUDSEN HUNGERFORD PAGE E1
Ica' R \1
, � , ••.r.ro ,`q`' Nos s,t�e..:
WELL SHE
�r
100' o'
ew
MASON COUNTY TREASURE AGE sEc
D 0R%NE RAE
P.O. OX 429
SHELTON,WA 98584-042<, 32135 23 90004 „
REAL PROPERTY DESCRIPTION 611-10'44' W
1/2 E1 /2 SW NW EX 233.99,
�4 OF SP #289 #647262 �►''
b
SW 1 /4, NW 1 /4, SECTION 35, e j'
TWP. 21 N., �R, . 3 .WEST, W.M. F .r a�
LQT
137.15'
`•G [�, loQ tS RES N 68•]613 /
A Q w LmT 3 1
Pial® :f / 1.34 ACRES
VON
100' R
27C
1 PO ou 7
IAO
? � Ilk . L\TY EAR
MERIOIAN:
BASED ON SHORT PLAT 02245 C-1
IN MASON COUNTY, WASHINCTON. '•i `"�_~ ��
L-1
J -2 - �---
#w � � �,• �W' PRIVATE_A-R
ROAD l�
UTILITY EASEMENT
R fy
Passau . • \ � 1® tl o i.
I WELL sI i r o b
1 / CNN
CORNER i
FOUND IRON PIPE PER 100, R
VOLUME 16 PACE 77 / 2 20 ACRES
OF SURVEYS
S�a1PC� ��Ot � �an�
I35 -a3 - 900C3
S_p� Lot��3
i
j
i
I
t
PSSIwr We
P' I
1 Y'osstb�e �Ur�vewa„ � J
t
i
jl
P$AOL
11
L
Mc HE DEEP
I ' MAR 1 2001
CE
0 ac) 40
�' = 40�
\L.D
j Go
C9
_4i0bx'_nUai1D(ro lOrfS
orrF,ccs }D be placed � C+oL'
DYC-LP- tMorf,c°s robe W' from
ends of irmch. Fjnol or+en}a hM t be
j ° y
40 / /i�� cat Cn o'clock Pos�t�oru . /�cljus+ to
{'Y)I nIMU'(Y� a' head. Lo�erals -to �nllow
con{au.r of ground .
�ow�rlrol Wvcs
-E1op � ck Vgives lPd i oj. %ou SiSe�Ck
3a135 - 6?3 9000 3
a APPRTHTH oMC i�t#.3
MAR 1 2001 9/ .1
CEW U' 3
i
1
$00 fray, D S /o
I
SECURED LID WITH GAS TIGHT SEAL
24"DIAMETER
1 ACCESS RISER
FINISH GRADE
—7--�I — — — — — 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 SERVICE
FINISH GRADE VALVE'
FROM SEPTIC TO DRAINFIELD
TANK
EMERGENCY STORAGE ANTI SIPHON
VALVE'
HIGH WATER ALARM LEVEL
INDEPENDENT
WORKING VOLUME —� — FLOAT STEM
NORMAL TIMER OFF LEVEL FOR FLOAT
ENCLOSED PUMP �J(j,��py�y]TING
SEDIMENT SHROUD• �.PR1F.Fq'I{ALVE•
18 1'7 UOoCr �
SEDIMENTS 1 5oUBMERSIBLE
EW CENTRIFUGAL
PUMP
PUMP CHAMBER
(TYPICAL)
•AS NEEDED
RISER WITH LOCKING LID
tLATERA
PR
a LOW CONTROL VALVESLOTS AS
REQUIRED
77
ECKE /XLONG SWEEPO 90 DEGREE //\ /ELBOW ��//A
SECTION A-A
WASHED ROCK
DRAIN SUMP
TRANSPORT PIPE FROM
PUMP CHAMBER
APPROVED
MC HEALTH .DEPT
DRAINFIELD CONTROL BOX MAR 1 2001
(SLOPING GROUND: MANIFOLD BELOW LATERALS) CEW
VG
DETAILSENGINEERING ,
d'
Performance Data
32
Pump Characteristics
Pump/Motor Unit Submersible
Manuel Models SP40M1 SP40M2 12e
Automatic Models SP40A1 1 SP40A2 W 4I10 HP
x
Horsepower 4/10 1s
Full Load Amps 9.4 1 4.7
Motor Type Split-Phase
J
R.P.M. 1750 `o a
Phase 0 1
Voltage 115 230
Hertz 60 0 0 20 40 60 so 100 120
Operation Intermittent CAPAMY-U.S.G.P.M.
Temperature 140OF Ambient Total Head (feet) 4 8 12 16 20 24 28
NEMA Design A
Insulation Class A GPM 4/10 HP 120 108 90 68 42 20 0
Discharge Size 2"NPT
Whig Handling 1-1/4- Dimensional Data
Unit weight 60 lbs.
3-15/16 &13/i6 1.ANAreajan in Where
Power Cod I8/3,SJT(2 115V=10'std. 5-1/8 2 a dm Caniaaaeminear
23DV=20'opt std. m
(V .) DIS2NPr mry31/1imh
CHARGE 3.mafaWprylpunianaa
4-5/18 unkes called
4.D'mxrioa ad adlhe am
approximem
Materials of Construction
5.we reserve the right to
3-3/4 make revisrom to ar
theak
Handle Steel L 16 pradama�spe Adfialioa ailan Ia&e
Lubricating 09 Dielectric 09
Motor Housing Cast Iron R
Pump Casing Cast Iran M P EA OH I)E P�
Shaft Stainless Steel AR 2001
Mean" Seal Faces:Carbon/Ceramk 14 /16
Shaft sew Sod Body Brass /+EN
Sprle¢Stainless Steel 13-1116 V
Bellows Bumo-N UMP
DISCHP.RGE PUMP
HEIGHT ON
Impeller Tbamsplastk
Upper Boring Single Row Ball Bearing3- 4
a-516
Lower Boring Single Row Boll Bearing PUMP OFF
Fasteners Stainless Steel
a
r
r
r
AURORA/HYDROMATIC Pumps, Inc. <
1840 Berney Road, Ashland, Ohio 44805
(419) 289-3042
C OJS s
_ rudspr ifyv e
SPA fat#3
l�l - I l� I�on�:e �=ou�✓ � ObsPruni�ory r�
�0 1�ra�nroc�. p
y � � nn � � eooncee c �° a. Y
flnrrktltioJ
x
PPROVED
C HEALTH DEPT
MAR 1 2001
36 - -- ---- CEW
MASON COUNTY SEPTIC SYSTEMS
Diana Fieid
P.O. Box 1341
Shelton,WA 98884
(360) 426.8642
INSTALLATION I MAINTENANCE
-=- ----------------------------
Pressure Distribution Systems
1. Install laterals with contour of the ground.
2. InstaIl trench bottoms level.
3. Install locator tape on top of all drainfl.eld laterals.
4. Install observation ports as indicated on the plot plan. (Minimum
two per drainfield with the bottom extending to the drainrock 1
native soil interface. Observation ports should:
a.) Have threaded removable caps
b.) Be accessible from tha ground surface
c.) Be void of gravel to the infiltrative surface to allow visual
monitoring of standing water in trench or bed
d.) Be designed with a'T'to prevent easy removal
b. 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 I visual high water alarm. AP
6. DEP
7. Install effluent filter on outlet of septic tank andlor lf8th KBalinOW 1
noncorrosive pump screen. (Minimum 12 sq. ft. surface area-riot to
interfere with controls or floats. (CEtt
S. Tee to Tee constrvcti,on'uetween laterals and manifold with
orifices oriented at 6 o'clock. Install laterals to the manifold with
orifices at 12.00,(do not glue), after pressure test and Health Dept.
approval,turn orfices down to 6 o' clock and glue laterals to manifold.
I
(Unless design specifies orifices to be left at 12.00, in which case orifice
shields would be required.)
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 Keld.
17. All materials and workmanship must meet County and St g ulations�.
MC HEA1 TV
MAR 1 2001
CEW
19. Deviation from this design without prior approval from the
designer and Mason Comity 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 scam 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 from:
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 biomat in a
drained,causing a decreased flow through the biomat and possible
ponding or flooding of the drainfield. High strength waste in a
residence is usually related to the'HfestyW or habits of the home,
generally resulting from one or more of the lbBowinv
1. Excessive use of a garbage disposal
2. Consecutive loads of laundry done all on one day
S. Excessive bleach or detergents with added whiteners MAPPROVED[� H
4. Dishwashing, showering,and laundering all at the sem, EAL.TH DEFT
6. Medications . antibiotics can kill or impair the biological MAR 1 2001
process in the septic tank CEW
6. Leaky plumbing (bydraulic overloading)
ON-SITE SEWAGE INSTALLATION
FINAL INSPECTION
DATE CALUD IN:
TIME:
INSTALLER:
APPLICANT/OWNER:
CALLER:
PHONE#OF CALLER:
SWG#: LcUI- O )o -
PARCEL NUMBER: _
SUBDIMION:
Div: ut
SYSTEM TYPE(CHECK ONE):
PRESSURE GRAVITY
INSPECTION SCHEDULE(CHECK ONE):
APPOINTMENT PLUOIN
AS-BUH.T ON-sTTE(CHECK ONE):
YES NO
STAFF WMAIS:
. .. ' .J.O ':"3`:v7S" <>: •::tziv% �� 3 Y'�
rAppowENTDATE: Tna:
ON-SITE SEWAGE INSTALLATION
STAFF INSPECTION REPORT
L SEPTIC TANK Yes NO Comments
A) >5&from foundation? AA 11
B) >50 ft from wells and surface water? Ye.}-
D) BBema beatand to seleic tank clean out if not 1-2%7
E) Dividing wall intact?
F) Risers installed for access? —�
IL D-Box Leveled with water and/or -JC
M D speed leveler(circled
KAnvx>Frn
A) >10 ft from foundation and>5 ft from perceived property fines? v
B) >100 ft fmm wells and surface water?
C) >10 ft from potable water lines?
D) Laterals level to±1 inch&end caps present if not looped? —�
E) Graveness chambers utilized? —aG
F) System dimensions the same as shown on the design? —�
G) Gravel clean,Properly sized,and proper depth? —�
B) PRESSURE SvSTTaM —1C
1) Sand4ualitYASTMC-33?
2) Dead height uniform and z24 inches? ✓
3) Clean-outs and observation ports present?
4) Mona& Side Slope 3:1?
5) Owner informed electrical connections must be made ✓
by owner or licensed electrician and inspected by L&i?
IV. PEMIPMrMW CHAMBER
A) Sereen basket or effluent filter(circle one)installed? _f
B) Riser installed for access?
C) Alarminstafled? _JC
D) Pump an timer o emend iroled
V. AS-Btnr,TREQUMM?
VL OTRstCO
MMENTS/OBSERVATIONS
-------------
---------------
The undersigned has reviewed this installation and verifies these findings an behalf ofMason County Department of health Services.
Sanrtarran Date
t«,M, aa,d�edcv�pd
RevisadglMW
t�1-B FORM M tt`vh°° ro ts,1998
Applicant ���vn holy AssParcel
#
(� (FWeWe-UWtt KWWeC7
Permit Number SWG_-
_�P�/A Subdivision
Installer Se/ioWlslbn/�8ioo' q
Designer
. x
A&MU
AR
N!A Yes Prior to completion
1. SEPTIC TANK
A) >5 IL From foundation?........................... ............ '.—
B) >50 ft from wells and surface water't .... .. .. _ x_
DBldg sWbout to septic tank clean-out if not 1-20 —
Baffies Intact and clean? .................•...... . .... . . . ....
E) Dividing wall intact?.. ........................ ... . ..:• ........
F). Risers installed for access? ........ ..... �
G) Tank Size: D 6 gal,;Manufacture
ll. Box
A)
A) Leveled wiW water? . . ..... ... ... .. ..... . . ... . . . . . . . . . . . . . . .. . —
B) Speed leveler used? .. ... .. . . . . . . ..... .. . .. . . .. . .
M. DRAINFIELD lines? �—
A) >10 R from foundation and ft from property _
B) >100 It from wells and surface wateR .... ... _
C) >10 ft from potable water lines? -
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? .. ... .. .. .
G) Gravel clean,properly sized.and proper depth?
10 PREssutteSvstM x_
1) Sand quality AS•IMt}33? ............................
2) Head height uniform and 2:24 inches? Actual head height X
3) f Lem-outs and observation ports present? —_
4) Mound: Side Slope 3:17 .................................. �—
5) o mer informed electrical connections must be made by
owner or licensed electrician and inspected by L&1? . . . .. . ..... ..
IV. PUMPIPUMP C MBER�r : Pump model - 4L} — Y
A) Pump make n p _
B) (lumber size— 1�1&— 8di Manuflaewre A544e15 _
G7 Height of pump off bottom of pump chamber inches
gallons per inch
D) pamp chamber dmw-down minute
E) pump capacity �1/ 7/ gallons per
F) pump controls:Tuna(or)Elapsed•time Meter (circle if installed) X _if timer is used:Pump On Pump cfF
G) eieen ba ` (circle Otte)Installed? ...... . . ....... . - -
H) Rlaer installed for aooess
I) Alarm installed? ....... i.................. .... . .. .. ...
C � 2
- d
CMCKLIST
O Dndufleld&Manifold
orientation &layout
I, lhach/bed dimensions
and critical distances
within layout
❑ Septic/pump tank "
placement.
❑ Location of buildings.
❑ Observation port&clean-
Out location.
Cl Location of wells&
roads.
❑ Undisturbed native soil
between trenches.
❑ North arrow
CAUTION:Minor adjustments to teptic tank Ioertan and dninfieid orientation made In the field 6 ate
hWa departm�cat or the desii�n� viability oCthe system. It is We the fid'sy -instill«arc g .
shoes above. designer beCorc makhag any deviations from the design aut aged the tvaability. ' to obW�n Yprior p�I 5�gn�therr(he tYttetn viability. Any deviations fiom the approved design nut be
Installer Check a box from Row"A"and"B',sign and date the certification
A. ,b-- 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 "MCDHS APPROVED"by MCDHS are shown above.
S. ❑ I certify that I contacted the designer and left the O I did not contact the des' nor prior to final cover because the
ccover.yst open for inspection up to 48 his prior to designer waived the notification requitement.
I further certify that all information contained on this form is accuratea&rz
accurate,there will be just cause for immediate suspension of my inst heroin is not
ate
The undersigned approves this installation on behalf of Mason Count y D
epartment e �,
a
719�o i
ate
�S�a1Pas �/b
��nu.dsenSmbe�
135 -a3 - 90003
_ S aay5 lr�t 3
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