HomeMy WebLinkAboutSWG2020-00361 - SWG As-Built - 3/16/2022 • ............... _ .
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RECORD DRAWING (ASBUILI)pg. 1 "� -••
yy ____JIIASON COUNTY PUBLIC HEALTH
PARC IDLNTIflCATION
Permit Number 3w0
26� -C)O�ie� Assessor Parcel#22-t 1 b-3 2—q U°a`'�
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Applicant Name �'lJL Q 2 Ui ) Asses Subdivision(Name/Div/Block/Lot)
Applicant Address x� Jvin��,,�{ ,,� r�n
CitY�State. ` Installer Name
Site Address `1,rj . ln/\t),S v\C \A' Designer Name sow.
INSTALLATION CHECKLIST J
t [EFui System Installation j]Tenk(s)Only 0 Drainfleld Only 0 Repair 0 Other
PP) System Type ('2 (C A 4 Pretrsatrnent Type
Li'
>5 It.fromfoundation? - - 0 NIA NO
>50 ft from wags? - - ❑ 0 0
Y >50 ft.from surface water? - - 0 a 0
Cleanout between building and tank? - - ❑ a 0
V Tank baffles present? - - 0
0 0
E 24'access risers over each compartment?- 0 in 0
�W
Effluent fixer Installed?- - 0
Er
Septic tank size IZSb gal Manufacturer l4,F3 . 4
9 D box water level and speed levelers used? - - 0 WA E3 Yea ❑ No t 1
O0 Mu. anifold/D-box accessible from surface?-
.. 2a Check valves installed? - El ® ❑
gTransport Line Size `1"•` - ❑ 0
Schedule/Gass r Zcer)
Bedrooms Installed(check one) ❑2 ❑3 in 4 CI5 ❑6 ❑Commercial/Otheri
>10 R from foundation?- - ❑WA taws 0
NO
>100 It from wells?- - ❑ 0 0
>100 R from surface water?- ❑ 0 1
Z
>10 R from potable water lines?- - 0 ❑
`
>5 It.from property lines and easements?. - 0
❑ !
CI >30 fL from downgradient curtain/foundation drains?- - ❑ ❑
Drainfield level and observation .•,- present- 0 ❑Er ❑
ElGraveless chambers or is Clean gravel used? (check one) ❑
Proper cover installed over drainfleld?- 17,`' - ❑ a- ❑
Pump tank setbacks consistent with septic tank?- - ❑ NA ❑ rat
❑ NO
zPump tank size pal Ma to .
24"access rlser(e)and aaoeeeible from surface?-
dAlarmor Control Panel Installed?- 0 O CI
E Control Panel equipped with Timer Cou - 0 0
❑
IL Pump InstaNed in 0 Bucket or El Block or 0 Other ❑
1 Pump Make/Model __ 0 Floats or ❑Transducer
iTank drew In/min Pump capacf y aprn Squirt Height
Pump offtime
Pum thrre Dairy flow set at-- ----____Spd
•
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tlrov MCPH RECORD DRAWING(ASBUILT)pg.2 Assessor Parcel it
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RECORD DRAWING ,
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❑ Tw,db
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01° altos drtanas
ese Wrn leyaa
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ApplIQM ED
0 Location et bulking@
reacisenotpeopossid APR i 2 2022
❑ 0e o locations.ds„ �q,pN COUNTY EN�I�ONMENTAL HEALTH
a nwerolaa ad000es J B
❑ Location at wok
.ueso.,nh►,toads,
❑ Reserve sres(i)
El NaT Mora
It!he 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 scoot-
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 deared/approved by both the designer shown here have been cleared/approved by both
and Meson County Public Health end meet all State myself and Mason County Public Health and meet all
and Mason County Code& State and Mason County Codes
I further certify that all information contained on this I further certify that all information contained on this
formar7d)attached R rd Drawing Is accurate.4 form and attached Record ` is accurate.
of Installer '1 Ike je Pill
/4`v :4r f a10 ll1/c-z-
Printed Name of Signee r/.:n' :t"
MASON COUNTY PUBLIC HEALTH M , z':`.i+t
The undersigned approves this Installation Report and 5100.112 ��<'
/-l; ADAM J.HUNTER ,f
Record Drawing on behalf of Mason County Public /`� L itE'r. F''i lil 'i; ll'A'_"
Health: N...�.. �r� % Nelk l_10.
. , ,,.;Health Specialist Date
signior. ( signer's stamp,signature and date)
THIS FORM MAV BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE vie hxmors
\`J O O O O O ® 16463'
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