HomeMy WebLinkAboutSWG2021-00151 - SWG As-Built - 6/22/2022 J�1`�
ttttAVttU UIiAWINU 1--, , (AbbUILI) pg. 1 MA5UN COUI� CIBIC H TH
PARCEL IDENTIFICATIONe( ee�
Permit Number SWG ;0/4 -p4/S'/ Assessor Parcel# 2Z.02 56o =.t ��i, �`
Applicant Name \ 5TE.0 V.5skt" Subdivision (Name/Div/Block/Lot) W�
Applicant Address `(tc 1 1 Lo wc'ovZ)3%.AJ
City, State, Zip ..„175Sft cz k A tt f L>i 9 86 21- Installer Name S ,
_liorrn
Site Address 5(,t c .'a i c, Siconie--uwn Designer Name IA,ti J e4.v_o v I c.vt-
INSTALLATION CHECKLIST
® Full System Installation ❑Tank(s)Only ❑ Drainfleld Only 0 Repair 0 Other
System Type OSC.rt 9- Pretreatment Type'?,4v.4)f°r- - .N p-600
>5 ft.from foundation? - - ❑ NIA (YES 0 NO '
>50 ft.from wells? - - 0 a' 0
Z >50 ft from surface water? - - 0 Er 0
< Cleanout between building and tank? - - 0 0
U Tank baffles present? - - ❑ ®' ❑
a24"access risers over each compartment?- - 0 a ❑
W Effluent filter installed?- - ❑ ❑
Septic tank size 120 o gal Manufacturer . v G >,J .cS"
0 D-box water level and speed levelers used? - - FA WA 0 YES ElNO
O.el� Manifold/D-box accessible from surface?- - In 0 0
m2 Check valves installed? - - (e 0 ❑
2 Transport Line Size t Schedule/Class SC it-Vb ¢ W
Bedrooms installed (check one) ❑ 2 Rj 3 ❑4 ❑ 5 ❑6 0 Commercial/Other
>10 ft.from foundation?- - ❑ N/A [SI YES 0 NO
0 >100 ft.from wells?- - 0 t] 0
W >100 ft.from surface water? - - 0 ® 0
te. >10 ft.from potable water lines?- - 0 El
z > 5 ft.from property lines and easements?- - El Er 0
0 > 30 ft.from downgradient curtain/foundation drains?- - 0 (a El
Drainfield level and observation ports present - OSC AP- - El ❑ El
Graveless chambers or ElClean gravel used? (check one) Ir
Proper Dover installed over drainfield?- L_/L'' S - 3 3 - 0 u ❑
Pump tank setbacks consIstant with septic tank?- - ❑ WA ❑ YES 0 No
zPump tank size 1'2-6 d gal Manufacturer j-w0.5 .o s - _Coate. t< 24° access riser(s)and accessible from surface?- - ❑ ,® ❑
00.. Alarm or Control Panel Installed? - - ❑ ER 0
—E Control Panel equipped with Timer/ETM/Counter jz�DG a1-3----4
Pump installed in ❑ Bucket or 0 On Block or Other
d Pump Make/Model 0 Floats or 0 Transducer
0.
a Tank draw down In/min Pump capacity- gprn Squirt Height ft
Pump on time Pump off time Daily flow set at D.16 qpd
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Updated t2r7Ro1s
MCPH RECORD DRAWING (ASBUILT) pg. 2 Assessor Parcel#-2.?-02-O- ao /8'O
• RECORD DRAWING
o Drainfield&manifold
orientation&layout Si s-rE wlk )tJST PtU-5D -TO T14E '"C tS l E A)
w/dimensions for -
re-location_
DI mery SO PJS Sitr
0 Trenchibed r
dimensions and
critical distances
within layout
0 Septic/pump tank
placement
C3 Location of buildings
existing/proposed
0 Observation ports.
dean-out locations.
&manifolds/d-boxes
[] Location of wells.
surface water,roads,
&waterlines.
` 0 Reserve area(s)
0 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 1
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 Meson County Public Health and that any deviations
here have been cleared/approved by both the designer shown here have been cleated/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 atta d Record Drawing is accurate. form and attached Record Drawing is accurate.
(,r-7/O-2Z r ih-
Date = phi -
Signature of I Ner I !�, "
� G1/t L iyi ,,,�!
Printed Name of Signee ,' 2 ,
MASON COUNTY PUBLIC HEALTH .' 5100385 % A ,
MICHAEL D.JERKOVICH l
The undersigned approves this Installation Report end A LICENSED DESIGNER I
Record Drawing on behalf of Mason County Public EXPIRES 01-19-2023
Health: . mi lzejerieatt oli &//2//OR
, ciwl[,
Si nature of En ironme al 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 12AI2G15
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