HomeMy WebLinkAboutSWG2016-00326 - SWG Application / As-Built - 11/2/2016 OFFICIAL USE ONLY
MASON COUNTY PUBLIC HEALTH DATE RECEIVED:
ONSITE SEWAGE SYSTEM APPLICATION AMOU ECEI RECENEDBY: W y
PO Box 1666,415 N 6th Street,(Bldg 8) Shelton WA,98584 I <
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Shelton:360-427-9670ext400 Belfair:360-275-4467ext400 S V V G &O
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APPLICANT PHONE >
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MAILING ADDRESS-STREET,CITY,ST E,ZIP CODE r
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21 lot sf iacbr Uo. c'8Ny6
SITE ADDRESS-STREET,CITY ZIP CODE W
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NAME OF DESIGNER PHONE I
NAME OF INSTALLER PHONE I-
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CHECKALLAPPLICABLE ITEMS DRINKING WATER SOURCE
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❑ NEW CONSTRUCTION ❑ RV HOLDING TANK ONLY ❑ PRIVATE INDIVIDUAL WELL 4/ lo
❑ REPLACEMENT SYSTEM ❑ INSTALLATION PERMITONLY ❑ PRIVATE TWO-PARTY WELL O❑ TABLE 9 REPAIR ❑ SINGLE FAMILY ❑ COMMUNITY/PUBLIC WATER SYSTEM
It TANK(S)ONLY ❑ COMMERCIAL SYSTEM NAME:
❑ UPGRADE TO EXISTING ❑ OTHER: BEDROOMS LOT SIZE to
❑ EXISTING FAILURE "Record Drawing required
for ell lnsbllegorrs" r 3
DIRECTIONS TO SITE-BE SPECIFIC AND ADVISE OF ANY NEEDED INFORMATION FOR ACCESS(ex.locked gate) OI
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SITE MUST BE FLAGGED FROM MAIN ROAD AND TEST HOLES MUST BE FLAGGED WITH TEST HOLE NUMBERS
OFFICIAL USE ONLY BELOW THIS LINE
UPGRADE I FAILURE SOURCE(for reporting purposes)
❑VOLUNTARY ❑MAINTENANCE/PUMPING ❑BUILDING PERMIT ❑HOME SALE ❑COMPLAINT El OTHER:
INSPECTOR SOIL LOGS COMMENTS I CONDITIONS
SOIL CODES:
V=VERY G=GRAVELLY S=SAND L=LOAM Si=SILT C=CLAY E=EXTREMELY R=ROOTS
INSPECTOR SIGNATURE DATE APPLICATION EXPIRATION DATE APPLICATION APPROVED BY DATE
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEBSITE REVISED aI2/2ot5
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RECORD DRAWING (ASBUILT) pg. 1 MASON COUNTY PUBLIC HEALTH
PARCEL IDENTIFICATION
Permit Number SWG 1016- p,-)32 C Assessor Parcel# 2;901 00 21'30100t`10013
Applicant Name ,Doi (,Uc )/!J Subdivision (Name/Div/Block/Lot)
Applicant Address 1-1) 21 COI 57. E
City, State, Zip Tt "Coyrtq cjc& 91821% Installer Name
Site Address '7OI D"^ Dr 5'A -l. Designer Name aY-
INSTALLATION CHECKLIST
❑ Full System Installation Tank(s)Only ❑ Drainfield Only ❑ Repair ❑Other
System Type cemm'Ar Drags t Pretreatment Type
>5ft. from foundation? --- - - - - - - - - - - - - - - - - - - - - - - - ❑ N/A ®YES ❑ NO
>50ft. fromwells? - -- - - - - - - - - - - - - - - -- -- - - -- - - - - ❑ 19 ❑
>50ft. fromsurfacewater? - - - - - - - - - - - - - - - - - - - - - - - - ❑ 91 ❑
F4- Cleanout between building and tank? - - -- ---- -- - ----- - - - ❑ ❑
U Tankbafflespresent? - - - - - - - - - - - - - -- - - - - - -- - - - - - ❑ ® ❑
24" access risers over each compartment?- - - - -- - - - ❑ ❑
W'' Effluentfilterinstalled?-- -- - --- - -- - - -- - - - - - - - - -- - - ❑. I. ❑
Septic tank size _2S6 gal Manufacturer ✓e'___
D-box water level and speed levelers used? - - - - -- - - - - - - - - N/A ❑YES ❑ NO
XOO ' Manifold/D-box accessible from surface?- - - - - - -- - - ❑ ❑
c Zi Check valves installed? - - - - - - - -- - - - 0 ❑
2 Transport Line Size Schedule/Class
Bedrooms installed (check one) ❑ 2 ❑ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>loft.fromfoundption?- - - ---- - - - - - - - - - - -- -- - - - - - - N/A DYES ❑ NO
>100ft. fromwells?-- -- - -- - - - - - - - - - - - - - - - ---- - - - ❑ ❑
J >100ft. fromsurfacewater? - -- -- - - - - - -- - - - - - - -- - - - - ❑ ❑
W-
Z >10 ft. from potable water lines?-- - ❑ ❑
> 5ft. from property lines and easements?- -- - - - - - - - - - - - - - ❑ 0
IX > 30 ft. from downgradient curtain/foundation drains?- - -- - - - - ❑ ❑
Drainfield level and observation ports present - - - - - - ----- - - - 0 ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - -- - ❑ ❑
Pump tank setbacks consistant with septic tank? - N/A ❑ YES ❑ NO
Pump tank size gal Manufacturer
Q 24" access riser(s) and accessible from surface?-- -- - -- -- - - - - ❑ ❑
aAlarm or Control Panel Installed? -- - - -- --- - - -- --- - - - - - ❑ ❑
D
Control Panel equipped with Timer/ETM /Counter - - - - -,- - - - ❑ ❑
Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
a Pump Make/Model ❑ Floats or ❑Transducer
D Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 12/7/2015
MCPH RECORD DRAWING (ASBUILT) pg. 2 Assessor Parcel,#
RECORD DRAWING:
❑ Drainfield&manifold
fl�}orientation&layout I p
w/dimensions for
re-location.
❑ Trench/bed
f\fPfdimensions andLR
Av Dr `L`/-1
critical distances
within layout91
• ❑�S tir/pump tank
placement -
Location of buildingsr N1
existing/proposed
Observation N
cleanni oldsld do xe
&manifolds/d-boxesLocation of wells, I 177
surface water,roads,
�p w&waterlines.
LI Reserve area(s) Auakvvvs wQ;-
North Arrow
If the designer or installer feel the need for additional information/comments, it may be attached.Record drawing may also be on a separate page attached. No.Pages Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER
I certify that I installed the system in accordance with I certify that the system has been installed in accor-
the septic design stamped"APPROVED"by Mason dance with the septic design stamped"APPROVED"by
County Public Health and that any deviations shown Mason County Public Health and that any deviations
here have been cleared/approved by both the designer shown here have been cleared/approved by both
and Mason County Public Health and meet all State myself and Mason County Public Health and meet all
and Mason County Codes. State and Mason County Codes
l further certify that all information contained on this I further certify that all information contained on this
form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.4
Ld cr a�wr e
Signature d f/n taller Date
73 �coS
Printed Name of Signee t f' 7 j(6
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:."
Signature ofE nmental Health Specialist Date (designer's stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 1217/2015