HomeMy WebLinkAboutSWG94-1112 - SWG Application / Design / As-Built - 8/29/1994 PERMIT NO. SWGLCI 1112m D
MASDN COUNTY DEPARTMENT OF HEALTH SERVICES Lj `oc
Date
426 W. CEDAR/ P.O. BOX 1666/SHELTON,WA 98584 Receipt No. >30
PHQNE (206)4WA7rj%oww Amount$
N nsl. Alm. CHECK APPLICABLE REMS ✓ m m
MAILING R S DAYT E PHONE: INSTALLING NEW SYSTEM m
ct PAIRING OLD SYSTEM
PANDING SYSTEM
CITY:_ STAT SINGLE FAMILY m
R SS: OTHER
PROP TYA c
,-� s SPECIFY: 3
S CIF DIR CT ON F R L CCAT SIITEE 7C / ? PRIVATE WELL n
ll(( PUBLIC SYSTEM
( SYSTEM ID NUMBER
SYSTEM NAME I�
\ PPL ANT
S
P.� E� — IL D ESS
Name o . Lot ft. x_eft.
Installe _
Size: acres TEL P
Name of d umber o X RE
Designer C. Bedrooms
PL ate')_ OU to
Dra nsional plan, I W
incl 1 �/
❑hlo noft� �� IS.1� ALR
h s,sho ((a/
r�jj red ista rie (41
7�JyCjdarie —
N r L^
❑(alrfisLe oad!gher ro�s, _ �(
NOTE DO NOT D IN 3S r—
�YSTEM D N 72,
OFFICIAL USE ONLY. DO NOT WRITE BELOW DOUBLE LINE.
OGScv>A ��e�s rrf�� ra*
o6�Ur
t'u it 0 abo ue
Depth from Original
►^ Grade to Restrictive
460,I e M 62; <70 Layer or Water Table: �In.
DESIGNER DESIGNATION SCORES Or l MINIMUM SYSTEM REQUIRES
Designer Level: ❑One 9TWo �0
Finding Score C✓.' j O,/� ��'Lo��'/t,�
Soil Type
Septic Tan Daily �O
Vertical Separation in. Capacity: Gal. Flow: GPD
Slope Appl, PUate
Parcel Size 61 Ac. Rate , GPD/FT' FT2
Distance to Shoreline<aM Total Insp ctor
( t?l9or2
COMMENSul° TN s R APPROVAL
C) �h�re -e'Wlf �n �� l5P -- l
)wt � In s1
e �- z
cats 2 �a) Ala Cd id Coot? renelr
Q S a� ¢ if c�u� a5 : Flo sor ?
(1 a16drms �o-`�ril l `' ��� fir' 1,�� _ �n tc��� a.
(pr r��,lna���c°,n�'�rP1t`�Irn
cha a from tie pec�fied use of the property or an site alteration affecting the system design may invalidate this permit.
(This Permr expires 3 years from date of site inspection.Genial o this permit may be appealed to the Health OfficKwithin 10 days of denial date.
SITE; Approved ❑ n Required ❑No[ DESI roved ❑Not ov IN A T Approved ❑Not 1 d
BY: DATE BY: ATE: B DATE:
TOP: Health Dept. CopyRIDDLE: Designer's Copy BOTTOM:Ap nt's Copy
i DESIGN FORM - PAGE ONE R-_:-.a �•.��.�•
A design will be reviewed when 3 copies of each of the following items are submitted:
completed aesign norm that has beer, signed and dated
Cumple%ed Resource Lands aad. Cri.tical Areas Checklist attached
scaled plot plan, including all applicable items on checklist
Scaled -layout sketch, including all applicable items on checklist
• Cross-section sketch, including all applicable items on checklist
II PARCEL IDENTXBICATION
Permit Number ci � Designer's Name 61k U_l ...... �)
II Applicant'., Name �4t(_•i ILtnc. ,-6L Prop. Owner's Name
II Mailing Address t o 8 „� 11 Mailing Address 7 tpIJ[ Ne uiv oN Ai tl ab II
7.41
•L"wa'.0 Q. I)
II Li-'fy SYa�"e Lxp SCa e � II
Assessor's Parcel No- o01C Subdivisi ° II
II TIiJS2'v �17'i 4E`l� er ° II
it DESIGN PARAMETERS11 AU
Initials IJ
I{ U U -� , Designed vertical II
Separation
�I Mound Subsurface Pressure Gravity Bed Trench / Z in p
II Septic Tank/Drainfield Specifications I 1"_1 rk 71
11 No. Bedrooms Z I Pressure Distribution? J Yes W+2 No I
II Daily Flow ?-j!o qRd 18ii6iiiEfii::i::ra;8:ei (if yes, proceed. . .) ,........ .,.99EI:E3..
..............
p Septic TaT Capacity gal I II
Receiving; Soil Type (1-6) F ;1 Ts II
H Receiving,'Soi� Appl. Rate to
t= I Laterals 11
II Trench/Bed Boitom Area ft° ( Schedule/Class
II Trench/Bed Width 3ho ft I Length i8' ft II
II Trench/Bed Lexgth t1:1,fti III
IIII
Diameter in
Hls aticn Measurements Number Ll
Orig. .Draiaigld Area slope I
t I separation 9' ft �I
II Final Drainfiold Area Slope I Orifices II
I� Depth.of Bottom of Trench/Red Total Number of Orifices 3Lm II
from .original .Grade 10' in Diameter 3.V -in .11
Spacing 21r" II
in I Manifold 1 II
Schedule/Class $44
i I I Length r6 ft
Infiltrator. Used? Yes L-.1 No I Diameter 09 in II
r'TI
i Transport Pipe II
u Pump Required? Yea u No I Schedule/Class0 II
IISBSESei;:989t6EE9EEE43 (If yea, proceed. . .) ccEEE4:ci."IiEiEciEiS:9EEI Length b ft II
u I Diameter
II Pump/giphon Specifications I Posing and P=p Chamber II
1` Difference in ;Elevation Between Pump Shutoff i # Doses/Day �!
II and uppermost Q=i€-M tv-Qox 1 ft Dose Quantity al II I II ILY al
p2j IJj' Chamber Capacity _(!.
II Uppermost Orifice is higher, "lower I II
)j than Pump Shutoff I Check the following components if they drain 11
Capacity W Tot. Pres. Head � •�N m I between doses: —7,.as;'f,-.'. C 4-11� ��y1W�11
I� Calculated Tot- Pres. Head 7 e.RA ft
11 (Attach Pump Curve) I U Laterals 1--1 Manifold Transport 11
)tSIGN FORM _ PP,GE ONE
- of the £oll +Q .!
A design ,will be reviewed when 3 cr••,_••ooies of each signed a d
. Complar�.o dc•.icn form that. has been sr4
Compleracl R,ssourCe Lands and. 11 tppli abler items once attached¢
Scaled plot plan, including all applicable
items vcYtz ,"lis lT
S ? t sketch, including all apP
„ca],ed . ay including all applicable items oi'� checYclist
sketch, -.�
. Cron.,-sectio^
PARCEL IDENTZPICATioN I -
Designer's Name
Number 1 �gtN �OFLuS N III
Permit NutAk+. pwrner'i s Name 7 yp III
'Prop. 1� 7oN
l Applicant's Name v
1 Mailing Address Al
II Mailing Address .�4Si.( uN\ .: A.. 480s3'. ll.
II iLYei:a alt' 4,P�t g S y I i Y
Y 11M lnG (a� t�j3. �G ;
II Ez�.r�U Subdivision
Z s n o
I Assesaor'g :Parcel No. v i
u
II'
DESIGN. PAPAM>3TZRS
1�
�P: � Date n sign ertieal .1II
II � rL, rLl Separation 1;?- a in
H IJ Trench .
U Pressure Gravity Bed
�l Mound Subsurface ...., ... I{{
ecifioatiGns I Y.Di U N6 if
Septic Tank/Drainfleld Sp L I Pressure Distribution?
U
o Yes
trod I : es, )
(if y P
NO. $edrooms o {I'
pDaily
Septic Tank Capacity --- I. Lae®rate I'
Receiving Soil 'Type (1-6) — `�--fta E�+� u'o
Receivin3 Soil APP1• 'Pats : Schedule(Clasa
z , C
Troaeh/ggc} 'Bottom Area ft Length
NTrench/Bed Width ( { Diameter
Trench/Bed Length X. II
a I Number `, w ,o t ill
8leva tion Meaeurexents t separation
II i ld Area orifices t'Y b
b Orig 'Drainf a 11 � —k I Total Number orifices/
Final.'Drainfield Area Slope - '�� b in a
th of Bottom of Trench/Sad ci in l Diameter
priginal Grade Spacing x i€old _
Pe Schedule/Glass
Length II
e8'
Yee U No "i Diameter Transport Pipg -_: '.
•..\ Cla" C _�-mo
No � Schedule/ s t
g I. S� I Yes " C Tensth y.� in
. IIII
Diameter
I Dq�ia9 and Pomp'
iaatianq Shutoff # .Roses/Day ' (me,G �5r
` eert Pumps . ft Done (duantxty: ie dal 'II
Chamber capspity
,
I.--J lower components if they drain ill
Check the following II
between doses.: t"�QNL II
Manifold�� U Tranelort 'ill
U . Laterals
i
i
I
A '
DESIGN FORM - PAGE TWO Re"iead 08'24/9"
II DESIGN CHECKLISTS
I� Scaled Plot Plan Scaled Layout Sketch Cross-Section Sketch
II I Reference depth from orig-
Test hole locations Drainfield orientation inal grade:
and layout i II
� �{ Uy Septic tank lid and
Property lines
LJ Trench/bed dimensions and drainfield cover depth
II L'j critical distances within
Existing and proposed
/ layout i Reference
wells within 100 ft depth from orig-
of property lines , I,—J,1( inal grade and restrictive
II 2/Critical LJ D-Box/"T"/"L" locations strata:
distance
measurements to cuts, LJ Septic tank/pump chamber ,u Laterals, trench/bed II
II top and bottom
banks, surface water location
Location and orientation '=' Observation port location CuY�tain drain collector II
of curtain drain and all �( Sand augmentation
absorption area Cleanout location II
components rjY H
tJ Manifold placement No external reference needed:il
u Location and dimension Observation ports and
of primary system and u Orifice placement
cleanouts
reserve area L_J
Lkeral placement, with
Ea Buildings distances to edge of bed Additio a mound information-11
ll
� ible visual alarm u upslope and downslope 11
Direction of slope ref /
indicator referenced fillidth II
�
1—,y/
II Waterlines I Scale of drawing shown i U Settled cap depth at 11
on scale bar center andedge of bed
uRoads/easements/ n Oki II
driveways/parking Additional Mound Information: U Sidew{aII�p 1 slope II
Up/do bed elevat.
LJ Critical resource lands L.J En slope width
(if applicable) i u N ted Resource Lands and
OV2all fill dimensions i Comple
North arrow and scale of Critical Areas Checklist 'I
drawing shown on bar
1 ,
I� '7]DDEESIGN APPROVAL
r �I
u does, '-a do es not, waive the reqirement to be notified by the
The undersigned designer
installer of the installation and given 48 hours to perform a final inspection prior to
cover. A
- II
;eanspec
a e
The undersigned has revi i n on behalf f son County of Healthservices. 9�
I' CAUTION: THIS DESIGN IS F STAMPED "APPROVED" BY MASON CO. DEPT. OF HEALTH 'I
MrSSURC: UISTAMUTION WOIUtStl=l;,"
A. DESIGN 01.7 -1119 bIS'i1t1UUi'ION SYSTEM VV
1. Select the orifice spacing .2` ft.
Z. Select the orifice diameiteF
3. Lateral lenXofl*d .5 ft.
1KNp fv\Am, Fa Co.
G. # oforifices/lateral _ Let th ;
pac pg be 'ween orumes
1 $ fL.
Y a fLa
g
5, lAteral diauieLec
G. Lateral spacing; # of laterals a ft.
Uistame -between laterals d .2 1L.
pi tatice [rots outer- laterals .. a it.
)dill edge of bed
71 Transport pipe dlamel;er A" ill. Masan
8. Trvw rL l Let th D ft, An�j.16 �eOHeato
9. Manifold dleuuaLer, 2 `� ill. Inittais�� 4
'10: Matifold length !i, Lk. Date
a. UFS'IGH 11tE YUMRING SYSTEM
1. Welug freyuemy/voluute
a, base volme based on type of fill tuaterial
b+ 10 times Lite itiLelidr volUme of- Lite par( of Lhe distrlbutlou system
Lhat dralus after each cyol,el
Vultrne - lU ($ of latekdle x )..eltgth of iaLeral x Vuitmie/ft of pipe) '
- io x ) a fL x �058 kal/rt)
i
�. 1U11
Chouse lakger,Q Vditynes ill it or b aLmes pit No gai ,,,..:a.
• URP chamber sized Laos gal
310 P,Ump eeleuLlou
at Required pump capacity m Orifice discharge rate x # of 1aLerals x of
orifices/lateral
a •i.S'`1 gal/min x � ' x �
U. h4lip head Eleyativp difference +, Z rt residual stead 4 fkicLiou losses
fL of elevation differaw,6
►o 10 ft tesid0ai head deeiied
38, friction loss. id L•rattsport: (pipe its ft (see below)
0.6 ft of friction loss In distribution system
i
'91
0.9g ft of total head against wUlcli tlte:puup. must PlApp
Fur friction luess
slow through friction lose/ friction
0iaWer/Platerial Le_ mth _SePiKent _ 100 ft Loss/SiAmeut
�..ekS
ram. Select a pump Lhat pumps the requited.flow, at Lhe. calculaLed!heads
( 4ntiP - VvWS i +N P A, vV N ry yw. aF ;L, ;A.G461414 „ QI It
Mason Count
ntMvw� \ or, �418 ; �DeOHersh
' yR � „ev:ces
Initials Eb
Date
imssum, uIS w3uTION Woku SUEEt%'
A. DESIGN 01. 111E DIRRIBUl"10N SYSTEM
1. Sel,eut like orifice spacing '= j fL.
2. Select the orifice diametep
3. Lateral length of bed lengL11 0 ft.
n r
• �� .1 ft� ..GNA .�•.ANiF�� • ,
�( X
ft:
4. # of. ',vt'ifices/iaCerai �, lateral feu Ch�� '
pac ng mtween or'i- des
(n{ _fL•
ft.
• � 2;2
5, I*teral diameter e i� in.
G. lateral, epaclugI f of laterals q �• ..
Distance •beWeeu laterals Co ft. C-"-, s
U ��$$tatyze- fran outer. laterals S ft-.
>f�1tl edge of fed
7, : 'TranspoU pipe diameter a Z" in.
$. Transport pipe leugtlt ZS ft, Mason cO,nty'D
Pt.,� ' ntd u
9. Maulfvld diameter Z" in. v;RO
" Initials
' 10, Menlfukt' length � {� • ft.
' Date
U. DESIGN WE PUMPING SY51'Fl4
1. . Dvsiug frequency/volume
ao buse vulwns based on :type of fill limLeriai Lou gal. .
Ar vn.;iut N v w. of: t 2 14 w.
A.L aSif.Q9 �oa;K� w�uy5" trOI cis, oi. •.61 Do�r;,�, Fox--Q pk
NOV 18 '94 14:22 BENIK 206 692-5606 P 7i7
j
r
b, lO Limes Lite itlLeki(je volume or- Lite. part; of Lite dlatrOuLlvn syatetn
that draitts after each cycle!
" Yolwtre . 10 i . .
(# of laLetals x LQttgtit of IsLeral x Volupie/ft of pipe)
" lU ( l x�.�fL x 058 real/f,k)
�. 10x - --i �
a1
c, LItOUse larger of VUILMaea ill.A orb above:
S �a1
2" "Pump dtamber size e
311 Y,�rup aelecliun `---�
ea , ILequlred pwup capaciLy p Orifice discharge ra.Le x $ (if A%Letala x J, of
orifices/bL•eral
b- L'wnp iseacl •.irle'vaNiou diEferetxe b Z fL tealdUei React f. fricliun lveaea
b ' Lt Gf elevativu diffarettca
!fasppCOU + f t teaiddal bead deulted
� h I.
'�["PDe�i heal( t .
<CV tS �7j -j tq fraction ioss iii Lrat>s�Ort �IpeIill flt (gee below)
Aniria/s\ 0.6 fL of frictivn loss in dlslrilwlivu s stem
Date �` l3 .7 ft yf Lnlal, as agstiust wlticli Ll�e p' n
}a p utttat ptautp
Fqt Ir1cliuti ltias:
Diameter Platerial Let Ut Fldw through �ricLion lvea/ k' ictlon
t _5ekn�ent 1W fl
Loss Se uettt
i
4• $elect.a pump tltaL.putttps Lite r'eyi:lted f 1.ow at the cal elated heads
��"u twp tvw SS �uN •
0SI
EFFLUENT PUMPS
35 L } 4 -t- } -$ 1/4Hp.to 1J2 Hp. P3
--_.
_ -
;.
_ SINGLE PHASE,60 HZ Nov.
1151230 VOLT 1991
-
30 _
W e
W
u_ 25 _t ;
ZL
4 201
..:.
` � I
I IN
L `
- - - T.
- - -:�. E03
I
_. 1 !_ t. :..»_ } ;— '.---•—{ ..L. ' OSS300+••.
10 Y
i »..t..T
-EPO 414.
. _�._ _ ...i._...�•Y ...ice `-�-- - - - -.;_.:_ _ .. ...;...�._ '..i ._ice.. _
: 1
0 10 2 n 30 • 40 50 60
NET DISCHARGE, GPM
2826 Colonial Road Roseburg,OR 97470 50387"165
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th
_ s IN
C � A
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1 / I �C�+ a_
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F. NO'd 17 '94 16:04 BENIK 206 .692-5600 _ ti, -r`S`o Sc.�i - I P.9i10
'" ��rC.ePlCs, N�„a5 � , �'1 �.•` Cw ri�..l.�C�•e���
31t `Ln�F-Lr2.4le7 ic-.^ it G�2.hl)f,�
Y�J^ 55� ;a '
Sao'J f{S r� it
'se:t� AOA-4l:. .!voTEL Fob
flTr
7c �1�,ry$T�f TANK:+ VY.Ac( �40-r w'.. USES.. . -Z)vF— `Ta �'ess'� E STry��;K,"i'u
AL Vt „
Fd .
IJO i _ Zra g4llt.0
0
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S'j�I cI L!L p2,P;C;.� •^ .\,
10 G V- tti w O C(oc �rtt/dts Oj�e �O�P`
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tIA�E`'
D
niF
i ,p scot° ')Pzz usz. CkTRErnL Au�;00 Doalwl s;TE cLE^^ARi..x5
SPRE PPQ--Tle r.1 So AS NOT To '4f_rV10 JE•- _ r'Nx1
Sotly , �ES'�t,"Uz zeq'ins AN CxcAVA'-0Z Fog
STum9 Vc; Ww VAL.
i t1
VATi.0 •007,5 ..
8 I1
I�I.II ' F- �RPI iJF 'tL.D �AT E.P A.C. i.oc A-,of 1S UASED ON
�% � '.'� c. ' a ANTI C;PP-- F.b CoN'rou R2- AFT F.,2- C(,,E-A eL0
V�
.� .— SITE ?Pz PwQ.ATio�l .
U �TT.
_ 17ESrc�r.�E.R �E.QJI RES •,--L NF;LT ZAT O R S„
o I F02 �H7E PPLS =S.NPi�EAD Of Co NV ENTioNAI� C,&vrL
i S -�cNu(v� lt•�S�( 11 �Q,`j5
° Lek lea *
__—._ U1ISERJ PT'OrJ pb27.y
4
S, y d
1 SO-7
CO3
� nty pePt.
pAO Health SeNi�
tn�laie v��
C A 7-00 -rRAJSPoP-, �t♦
NO Pl1R�C{ U LINE �\
ON SNiO FaTER
--. idx Zo'
o �, Sin_ r;uEa
_ '[07 or_ E��Eflrt�a r... .N No E
xQANTi o.J of CA 611)
FOOT PEoNr AII°wEi. ` TvwAk.pS
�OAil
use oRE.Nco toxzo SPc—s FoR
30 r'ti SA r-i,9 1=;lT ER
TANS
� M5p 1000 E\Al YNIN,
s zcsEeywJ„ ,° * Pump Is required
SO cLEgN_ ,B. Z070 TA,4V.. F`2 * Pump alarm Is required
our
�� �tlnat cover
E 5' vakicular traffic
10
ID / over drainfiaW area
* Drain Uric mmt follow 6oR1w
o c! wale .*� ihtor required
9 t' 5° D CL IiAtit
This map does not reprosem a
survey nor does it purport to
° show all oessinents or
/ encroachment if ar+'•,
oER epnr �To sE wen S{- e. ' �
-- i/IDS CL,L To lAvc AS/
To so. G/ Pos 1 S Le NO WELLS IN'W
IILe Nvatnx . '�«� 'L;.,� ALL COVERSTOB � 5MIN/INCH
\QCp7 aN• —C, 1 (A-T 1w,P. DIVERTALLSURFA EWATERAWAY
FROM DRAINS 0AREA.
q(,r ' PREPARE SITE&INgALL DRAINFIELD
DURING DRY CONDMONS.
S' ,
ON-SITE SEWAGE INSTALLATION
PRE-INSPECTION
mn
nnm
............................................ DATE CALLED IN:
TIME: ) .J,S►"�1
INSTALLER:
APPLICANT/OWNER: �r?Oi31.J VCIt'hJ�:A, �
CALLER:
PHONE # OF CALLER: ` ! SQ - O /41
SWG #: 9 q- (..J `� ',.
PARCEL NUMBER: ),), ��'l�
SUBDIVISION:
DIVISION: LOT:
SYSTEM TYPE (CHECK ONE) : J
PRE SURE GRAVITY of
�/ O" � y^'
INSPECTION SCHEDULE (CHECK ONE) : n n Q / I"
APPOI7T PLUG IN ^
AS-BUILT ON-SITE? (CHECK ONE) : ^ I( YY
YES NO
••••• STAFF INITIALS:
h:enllin.w
Revised 04/09/96
rR
ON-SITE SEWAGE INSTALLATION
STAFF INSPECTION REPORT
......................................................
I STA" CEXCA.IBT
1 I
I CORPIRBED BY IBSPBCTOB7 I
I. SEPTIC TMM Yea No Ca®anb
A) >5 ft from foundation?
B) Bldg stubout to septic tank: cleanout if not 1-2%? - 1
C) Baffles intact and clean?
1 D) Dividing wall intact?
II. a-Box Leveled with water or speed leveler (circle one)?
1 III. DRAIRPIELD
A) >10 ft from foundation and >5 it from property lines?
B) Laterals level to tt inch & and caps present if not looped?
c) System dimensions the same as shown on the design? _
I n) Gravel clean, properly sized, and proper depth?
I E) PRESSURE SYSTEE —
1 1) Sand quality ASTM C-33?
z) Head height uniform and t24 inches?
3) Cleanouts and observation ports present?
1 e) Tad: Side slope 3:17
1 5) Owner informed electricaL connections must be made
1 by owner or licensed electrician and inspected by DLI?
I Iv. POTABLE VOTER LIBES
A) >10ft from drainfield, transport Line, and septic tank? _
B) Wells >100ft from drainfieLd?
I I
I V. Pena raeoc I
1 A) Screen basket or effluent filter (circle one) installed? _ 1
E) Riser installed for access?
a) Alarm installed?
I I
I vI. as BCILr RagDIRSD?
I
viz.
I
The undersigned has reviewed this instalLati a verifi th a finding on behalf of Mason County of Health Services.
� 19t
I ea rs a e I
h:callin.w
Revised 04/09/96
ON-SITE SEWAGE INSTALLATION
FINAL INSPECTION
......................................................................... ..............................:ei:"
DATE CALLED IN:
TIME: CJ=-1�Jfll I
INSTALLER: U"AL,c.e• _
APPLICANT/OWNER: y2OC /� r)F-♦�
_. .. CALLER: 1�.� ._ :13PF Ct& S. ----
PHONE # OF t nr.r.rm; L+ #LTA I l
SWG
PARCEL NUMBER: rJ-�d�3\\�i�_J S 0 a 15
SUBDIVISION: 1 1 •'I vVN �7't�(
DMSION• LOT:
:::.......»......»«.......».........«...........---.........«....».«.-«..................«................ ««.........«...«....«»...............«.»..«...........
SISTEM TYPE (CHECK ONE) :
Q
GRAVITY .'.. _. .
3[SPECTION SCHEDULE (CHECK ONE) : ^
u
APPOINTMENT PLUG IN
IS-BUILT ON-SITE? (CHECK ONE) : ^ U U
vs LNO.
•3e................»................................«...........»........................................».»
............................»»..........«....»«......».........«..
STAFF INITIALS: . 1
h:callin.0
ON-SITE SEWAGE INSTALLATION
STAFF INSPECTION REPORT
STA" CSS=XGT I
I I
I COBPIRIO+D BY IRSPRCrOR? I
I I
I I. SEPTIC TANK Yes No comments I
u >5 ft from foundation? _ I
a) Bldg stnbout to septic tank: cleanout if not 1-2%? _
c) Baffles intact and clean? _
D) Dividing wall intact?
rz. D-aoz Leveled with water or speed leveter (circle one)?
I
III. DRAnun .D I
a.) >10 ft from foundation and >5 It from property lines? _ I
a) Laterals level to ti inch a end caps present if not looped? _
c) System dimensions the same as shown on the design? _ I
D) Gravel clean, properly sized, and proper depth? _
a) PRaSSORa sYSTEK
3) sand quality ASTM C-33? _ I
z) Head height uniform and L24 inches?
3) Cleanouts and observation ports present?
4) Mound: side slope 3:1? _
s) owner informed electrical connections aust be made
I by owner or licensed electrician and inspected by DLI? _
zV. POT3atd t01TnR anazs '
10 >10ft from drainfield, transport line, and septic tank? _
I a) wells >100ft from drainfield?
! V. P@@ Tam¢ .. I
. Screen basket or effluent lter ircle one) installed?
a)
I a) Riser installed for.access
I c) Alarm installed? I
1
I vz. as sear RS94IAZD7 I
vsx. o==mega
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The undersigned has reviewed this installation ve if t findi an behalf of Mason County of Health services.
I I
I ea ns or V Date
I
h:callin.w
Revised 02/01/95
WALKER SEPTICtSYSTEMS 8335782 P. 03
ks-BUILT FORM - PAGE ONE Revi.aa I9/14/94
L- . .. . .-. ------- PARCEL IDENTIVXCATION J iV1 AJ I
( Applicant's Name cB 1 N GNNSo� � 2�1srY(D� t� wAII
11 ( ( 'L Subdivision
T'pf) tAj tnxz- "�
II Permit Number SwO9 4 - )o ame 1vI8).OI] oc o II
(I Installer's Name WAlVIM- J 71 Tfn`5 Assessor's Parcel No.JL. 2� 33ug1 -OO�SI
Designer's Name
II INSTALLER CNECKLIBT
N/A Yea Prior to
I. SEPTIC TANK Completion II
A) >5 ft from foundation?
B) Bldg stubout to septic tank: cleanout if not 1-2&? — _ II
C) Baffles intact and clean? 'f
D) Dividing wall intact? i
D-DOX Leveled with water and/or speed leveler (circle) ? II
III. DRAINFIELD
A) >10 ft from foundation and >5 ft from property lines? _ Y — II
II B) Laterals level to 31 inch & end caps present if not looped? — I
C) System dimensions the same as shown on the design? _ II
D) Gravel clean, properly sized, and proper depth? _ - II
E) PRESSURE SYSTEM jl
II 1) Sand quality ASTM C-33?
2) Head height uniform and z24 inches? — II
�I 3) cleanouts and observation Aorta present? II
4) Mound: side elope 3 :1? li
II 5) Owner informed electrical connections must be made by —
owner or licensed electrician and inspected by DLI? — II
IV. POTABLE WATER LINES
A) >loft from drainfield? !�
B) Wells >100ft from drainfield? II
V. PUMP/PUMP CHAMBER
A) Designed pump used, or s ecs attached for equivalent pump?
B) Screen basket o uent (circle one) installed?
II C) Riser installed ccess?
( D) Alarm installed? �1
II CERTIFICATION OF INSTALLATION �I
(( Installers check box from Row "A," check box from Row "8, " sign and date the certification. I
II
Il r i
(( A. 1 I I certify that I installed the system I certify that all deviation" from II
II the design stamped "APPROVED" by M are
without any deviation from the design for i
p shown on the reverse side of this form-
Stamped "APPROVED" by MCAHS. li
II B, �y I certify that I contacted the U I did not contact the designer prior
I!
it
designer and left the system open for to final cover bon requirement.
inspection up to 48 bra prior to cover. waived the notificacattiio the designer
I
u 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 c rtification. iI
II l✓��{( J7/W�$7£^j4i F er y II
u o " a e U
artment of Health
The undersigned approves is 'nstal a 'on of behalf of Ma90 Co ty Dep ll
? /
(( Services. ',.- / l
w,r�nnrr Strl.l�: ,.iS.YS.l tMS 8335782 P. 04
µ
AS-BUILT FoRm - PAGE TWO
_ aevraed i!/34/!{
PARCEL IDRRTI:PICATION
Applicant's Name A&V
Permit Number SW29`t - I I 4. isubdivision ✓E.tJ �9Kc- l,.T/53 N
(� flfl ivisi ni''alock7roi7'--
Installer's Name WA�ICL/GS 7rCCJ41 [iy$ Assessor's parcel No.
Designer's Name 9 ve- lg u�i�i-gfh-
r�
AS-EIIILT DRANZNG II
Q
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s v oZ� S i aR,U4, WMy
y y t c a 33, i /17 1�/ 1 ' 1 P�
�6- L L c° I
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lX Pgx1 C -� <z T_ of 'r ja
GVJTZCH, Minor adjustments to septic took location a-;d drairfield orientation made in thAffleld by the installer are generally ao-
osptable to both the department and the deergrer, but could iz certain cues the viability of the system, rt is the
Installer's responsibility to obtain prior written approve: from °ither the health department or the designer tofore making any
devratitms from the desigr that affect system viability. Any deviations fret the approved design wee be shown above.
AS-BUILT CNECKL18T
q i
❑ Drainfield orientation Observation port location El Undisturbed native soil
and layout between trenches
II Cleanout location
El Trench/bed dimensions and r„I 0 North arrow
critical distances within 1 I Manifold placement
layout ^ 0 Scale of drawing shown
u LJ D-Box/"T"/"L" location orifice placement on Scale bar
U �
10 Lateral placement, with Additional Mound Information
Septic tank/pump chamber distances to edge of bed r,
location U Endslope width
u Location of wells, roads
Location of buildings El Overall fill dimensions p
N a