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HomeMy WebLinkAboutUPDATED AS-BUILT - SWG As-Built - 7/26/2007 ASBUILT FORM 'R Mason County Aldwe&007 PARCEL IDENTIFICATION. TAL HEALT Permit Number SWG __ Assessor's Parcel# a-at 3 to M 0 00 Z O (Twelve-Digit Number) Applicant's Name Subdivision ` (Name/Division/Block/Lot) Applicant Address 1 V 5 "'�a►gtU►tl�'y `�` Installer's Name City,State,Zip "AIL S1 E NE ISt-4N) 1�t W besigner's Name ti i INSTALLER CHECKLIST N/A Yes Prior to Completion I. SEPTIC TANK >5 ft-From foundation?............................................................. ❑ ❑ ❑ >50 ft from wells? .................................................................. ❑ ❑ ❑ >50 ft surface water? .......... .................................................. ❑ ❑ ❑ Building stubout to septic tank:•;cleanout if not 1-2%? ................... ❑ ❑ ❑ Baffles intact and clean? Dividing wall intact?.......................... Q:. ...................;. ❑ ❑ ❑ Risers installed for access?. .#.... ;f... ........................ ❑ ❑ ❑ Screen basket or effluent filter installed?(ctrclo one) ..........._......._ '❑ ❑ ❑ Tank size: gal.; Manufacture: ® ,. H. D-BOX Leveled with water? ....................................,.....................:. ❑ ❑ l3 Speed leveler used? ❑ ❑ ❑ III. Drainfield >10 ft from foundation? ❑ ❑ ❑ >5 ft from property lines and etsement lines? ............................. ❑ ❑ ❑ > 100 ft from wells? ❑ ❑ ❑......... .:............................................... . >100 ft from surface water. ❑ ❑ >10 ft from potable water lines? ....... ❑ •0 ❑ Laterals level tb±1'ihci h&end caps present if not looped?.............. 0 ❑ Q Gravelless chambers utilized?,............................................... ❑ ❑ ❑ Gravel clean,properly sized,and proper depth?........................... ❑ ❑ ❑ PRESSURE SYSTEMS Sand quality ASTM C-33? ......................_....................... ❑ ❑ ❑ Head height uniform >24 inches? Actual head height ❑ ❑ ❑ Clean-outs and observation ports present?......................... ❑ ❑ ❑ Mound: Side Slope 3:1?............................................. ❑ ❑ ❑ Owner informed electrical connections must be made by owner or licensed electrician and inspected by L&I?.............. ❑ ❑ ❑ IV. PUMP/PUMP CHAMBER Pump make Pump model ❑ ❑ ❑ Chamber size gal; Manufacture ❑ ❑ ❑ Height of pump off bottom of pump chamber inches Pump chamber draw-down gallons per inch per minute Pump capacity gallons per minute Pump controls: Timer,Elapsed Time Meter,Counter?(Circle all that ❑ ❑ ❑ apply). If timer:Pump On Pump Off Riser installed for access?......................................................... ❑ ❑ ❑ Alarm installed?.....................................................................-. 0 0 11 ASBUWT RAMC CHECKLIST p,, I_- - O✓n d�G/ ❑ Drainfield rt ,8i ("'" `.. �l C40-n�4 j " manifold orientation I-� &layout b 30 P" ,arc 9W4CM ov n1E wrskw anu+LL+ P.O k 1107 ❑ Trench bed �v4� '7�31 j.�-'7 we o`rt'r�-d'w�► � dimensions and ` � critical distances W Al E within layout ❑ Septic/pump tank placement ❑ Location of ,I buildings 3 U ( N ❑ Observation port& a r clean-out location ❑ Location of wells& © l r 2 roads .♦—..3 D.. ) ❑ Undisturbed native 060 soil between , O r101�$ trenches �4 ❑ North arrow 30, �►O 1 1 35 154 Z 3��' 43' 4 �V i i 4 S7. S1 30 137 "bRiyQW%*%Y CAUTION.•Minor adjustments to septic tank location and drainfield orientation made in the eld by the installer are generally acceptable to both the department and the designer,but could in certain cases compromise the viability pf the system. It is the installer's responsibility to obtain prior written approval from either the 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 II1ALLATION Ins er: 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 design stamped"APPROVED"by "APPROVED"by MCPH are shown above. MCPH B. ❑ 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 hrs prior to cover. designer waived the notification requirement. 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 County Public Health. O1 Signature of Sanitarian Date Revised January 2007