HomeMy WebLinkAboutAFTER THE FACT - SWG As-Built - 12/21/2021 6(=TEZ 1114t 'A<-I
RECORD DRAWING (ASBUILT) pg. 1 MASON COUNTY PUBLIC HEALTH
PARCEL IDENTIFICATION
Permit Number Assessor Parcel # 9‘12-21 -53 - I ),(0
Applicant Name 5‘‘,.nv1l %NJke5 Subdivision (Name/Div/Block/Lot)
Applicant Address 1 (1 St 04-(c..aio. C
City, State, Zip St.) be% Wo- ASS-VI Installer Name
Site Address 1- 51 E Ti-)an o11 cc4iscle Designer Name
INSTALLATION CHECKLIST
❑ Full System Installation ❑ Tank(s) Only ❑ Drainfield Only "t Repair ❑ Other
System Type Pretreatment Type
>5 ft. from foundation? - _ _ - N/A -1 YES ❑ NO
>50 ft. from wells? - l T_-1 - ❑ ❑
>50 ft. from surface water? - 1 1 ❑ ❑
Z
H Cleanout between building and tank? - - -7!- 4 E- -2.1 - .021- ❑ -FE ❑
U Tank baffles present? - sr - � ❑ n ❑
a24" access risers over each compartment?, ❑ 11 ❑
W Effluent filter installed?- - ❑ ❑ u
Cl)
Septic tank size 1 00 0 gal Manufacturer
0 D-box water level and speed levelers used? - - ElN/A ❑ YES El NO
oO Manifold/D-box accessible from surface?- - ❑ ❑ CI
co, Z Check valves installed? - - ❑ ❑ ❑
oa 30
E Transport Line Size 9 Schedule/Class
Bedrooms installed (check one) g 2 ❑ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A 'YES ❑ NO
>100 ft. from wells? ❑ ❑
CI
LijJ >100 ft. from surface water? - - V ❑ ❑
LL >10 ft. from potable water lines?- - ❑ Irr ❑
Z > 5 ft. from property lines and easements?- - ❑ [ ❑
12 > 30 ft. from downgradient curtain/foundation drains? - - ❑ ❑
o
Drainfield level and observation ports present - - ❑ ❑ ❑
❑ Graveless chambers or [Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ E:r ❑
Pump tank setbacks consistant with septic tank? - - ❑ N/A ❑ YES ❑ NO
• Pump tank size gal Manufacturer
Q24" access riser(s) and accessible from surface?- - ❑ ❑ ❑
F-
a Alarm or Control Panel Installed? - - ❑ ❑ ❑
2 Control Panel equipped with Timer/ ETM/Counter- - ❑ ❑ ❑
D
a Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
a'• Pump Make/Model ❑ Floats or ❑ Transducer
0.
a 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
orientation&layout
w/dimensions for
re-location.
❑ Trench/bed
dimensions and
critical distances DO��
within layout gkjv
cy�J
❑ Septic/pump tank k Hd tex�
placement kp)C `►o
ID Location of buildings 7 V•
�� •�I,
existing/proposed pl
❑ Observation ports,
clean-out locations,
&manifolds/d-boxes
❑ Location of wells, 44\ ('n
surface water,roads, VsD
&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
I certify that I 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
I 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.
("Li 174
Signature of Installer Date
4tv `.—r`e- r4G`P1'eS
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
1 vY Sc�n
Signature of Environmental Health Spe&alAt 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