HomeMy WebLinkAboutSWG2017-00198 - SWG As-Built - 9/22/2017 r
RECORD DRAWING (ASBUILT) pg. 1 MASON COUNTY PUBLIC HEALTH
PARCEL IDENTIFICATION
Permit Number SWG `Z01") ' 0019 9 Assessor Parcel#
Applicant Name Xr)54 ,' Kgjenq Subdivision (Name/Div/Block/Lot)
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Applicant Address X 2 1 1J
City, State, Zip \,Ve\WI Wg Installer Name "T-J U 003
Site Address so N Oytx;k Designer Name or1`gn Sti h
INSTALLATION CHECKLIST
[3 Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type fy-es,".Y-Q- Pretreatment Type NAr
>5 ft.from foundation? -- - - - ------ - - - - -- - - - - - ---- - ®.N/A ❑YES ❑ No
>50 ft. from wells? --- ---- - - - -- - - - - - - - - - - - - -- - - - ❑ ® ❑
Z >50 ft. from surface water? - - -- -- - - - - - - -- - - - - - _-❑ ® ❑
Cleanout between building and tank? --- - - -R - - - - -- - -- ❑ ® ❑
V Tank baffles present? -- - -- --- - - - - - To-
0—~. 24"access risers over each compartment?-- - - - - - - - - - - - - -- El ❑
LLJ Effluent filter installed?--- - - ---- - - --- - - -
Septic tank size )000 gal Manufacturer 1-60frma n
0 D-box water level and speed levelers used? - - - - - - - -- - --- - - _ ® NIA ❑YES ❑ No
0 Manifold/D-box accessible from surface?- - - - - - - - - - - - -- - -- ❑ ® ❑
OOZ Check valves installed? -- -- -- - - - - - - - - - - -- - - - - - - - - ❑ ❑
0 a i/
2 Transport Line Size 2 Schedule/Class e<_� q d
Bedrooms installed(check one) [9 2 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?---- - --- - - - - - - - - - - - - - - - - - - ® N/A ❑ YES ❑ No
0 >100 ft.from wells?--- -- - - - - - --- - - -- - - - - - - - - - -- - ❑ ® ❑
W >100 ft. from surface water? -- --- - -- - -- ---- - - - - --- - - El El El
U: >10 ft. from potable water lines?- - ---- - - - -- - - - - - - --- - - ❑ a Vb L ,� El
Z > 5 ft.from property lines and easements?-- - - - - - - - - - -- - - - ❑ � :5 ❑
> 30 ft.from downgradient curtain/foundation drains?- - - - - - - - - - ❑ 13 ❑
Drainfield level and observation ports present - -- - - - - - - -- - - - ❑ Q ❑
❑ Graveless chaffibers or ® Clean gravel used? (check one)
Proper cover installed over drainfield?--- ---- - -- -- - - - - - - - ❑ ® ❑
Pump tank setbacks consistant with septic tank?--- - - - -- ----- ❑ N/A Z YES ❑ No
Y Pump tank size 1000 gal Manufacturer 1 r
Q24"access riser(s)and accessible from surface?-- -- - - ----- - - [Di Elf-
a. Alarm or Control Panel Installed? -- -- - --- -- - ---- - - - - - - ❑
Control Panel equipped with Timer/ETM/Counter- - - - -- - - - - - ❑ ® ❑
�- Pump installed in ❑ Bucket or ® On Block or ❑ Other
a. Pump Make/Model Ll o&V6 145 ❑ Floats or 5?Transducer
a Tank draw down in/min Pump capacity 12 gpm Squirt Height
Pump on time 1 40 Pump off time Daily flow set at 2N!? gpd
Updated iV7I2015
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MCPH RECORD DRAWING (ASBUILT) pg. 2 Assessor Parcel#
RECORD DRAWING
Drainfield&manifold
orientation&layout
w/dimensions for
re-location.
Trench/bed
dimensions and
critical distances
within layout
Septic/pump tank
placement
Location of buildings
existing/proposed
Observation ports,
clean-out locations,
&manifolds/d-boxes
® Location of wells,
surface water,roads,
&waterlines.
® Reserve area(s)
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 seperate page attached. No. Pages Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER
l certify that l installed the system in accordance with 1 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 /further certify that all information contained on this
form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
Signature of Ins ller Date
73 Ca oo.5
Printed Name of Signee
r
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and z ' ,oSI
Record Drawing on behalf of Mason County Public
Health:
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Signature f nvironmenta/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 iznnots
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