HomeMy WebLinkAboutSWG2021-00476 - SWG As-Built - 4/29/2022 RECORD DRAWING (ASBUILT) pg. 1 MASON COUNTY PUBLIC HEALTH
PARCEL IDENTIFICATION
Permit Number SWG 2.0fI ' 04 { ((47 Assessor Parcel # G c-- 1-2-07.:C-0 5 60 .
Applicant Name Lk.)14i.1 ¶i 1 r tS Subdivision (Name/Div/Block/Lot)
Applicant Address SM r- v)"1, 1A ON-c&
City, State, Zip POf-vaizck., (9/ZCi 72I7nstaller Name -pat, o i c 6i rti, 1Ctic'1
Site Address 3V i 3 £ A1c2}' f t Vc�Cu DCesigner Name TI►�A '1 tuck 4s 4:;i -f,
J
INSTALLATION CHECKLIST
[ /Full System Installation ❑ Tank(s) Only ❑ Drainfield Only ❑ Repair ❑Other
System Type O.5C-f t " t / I Pretreatment Type A 't`LlL k r
>5 ft. from foundation? - - ❑ N/A 'YES ❑ NO
>50 ft. from wells? - - ❑ I2 ❑
�
Z >50 ft. from surface water? - -
❑
Cleanout between building and tank? - gip'-.aZ-9- 22 -i ±- - ❑ " ❑
❑
U Tank baffles present? - ElElr- - -24" access risers over each compartme tgy- - __. - 1::] Elina.
Effluent filter installed?- El
tank size `� &gal Manufacturer . -/"! 1 C ck, %7/
0 D-box water level and speed levelers used? - - El N/A [ YES ❑ NO
OO Manifold/D-box accessible from surface?- - El [g El
QQ Check valves installed? - - El ❑
lea
2 Transport Line Size '1 0
p �� Schedule/Class
Bedrooms installed (check one) 2 E 3 ❑4 ❑ 5 ❑6 ❑Commercial/Ot r
>10 ft. from foundation?- - ❑ N/A [f ES ❑ NO
O >100 ft. from wells?- - ❑ [> ❑
W >100 ft. from surface water? - - Cll2 El
ti >10 ft. from potable water lines?- - ❑ ❑
QZ > 5 ft. from property lines and easements?- - ❑ i:/ ❑
li > 30 ft. from downgradient curtain/foundation drains? - - ❑ [ ❑
Drainfield level and observation ports present - - ❑ ❑
❑ Graveless chambers or [Clean grave use ? (chec one cc&
Proper cover installed over drainfield?- - ❑ ❑
Pump tank setbacks consistant with septic tank?- - El N/A �ES ❑ NO
ZPump tank size 100 gal Manufacturer I OhI I-
24" access riser(s) and accessible from surface?- - ❑ IDI~ Alarm or Control Panel Installed? - - El
VElControl Panel equipped with Timer/ ETM i Counter ❑ ❑
n
a. Pump installed in ❑ Bucket or �n Block or 0 Other
a. Pump Make/Model •Al, N (, Sle -t 0 ❑ Floats or ❑ Transducer
2
d Tank draw down /G✓ in/min Pump capacity (ay Daily
gpm Squirt Height fl fGt ,. ...raft
Pump on time A./� ( (A Pump off time n , Daily flow set at I l v"qpd
Updated 12/7/2015
MCPH RECORD DRAWING (ASBUILT) pg. 2 Assessor Parcel #
RECORD DRAWING
❑ Drainfield&manifold
orientation&layout
w/dimensions for
re-location.
El 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.
0 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
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
I 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.
Signature of Installer Date
ycuid Y - .o °IA
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
( f7i/ zl—
Signature of Environmenta 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 12/7/2015
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