HomeMy WebLinkAboutSWG2021-00242 - SWG As-Built - 7/26/2022puimior
RECORD DRAWING (ASBUILT) pg. 1 MASON COUNTY PUBLIC HEALTH
- PARCEL IDENTIFICATION
Permit Number SWG 2Q ` —QQ Assessor Parcel # 9 23 3 Z5/ 0600
?-
Applicant Name Subdivision (Name/Div/Block/Lot)
Applicant Address se,
City, State, Zip L[tui W A _665O j Installer Name tj� c[VW U fr1 +.
Site Address SILO AS J O - L ch ' .raame J".\69 titAl Pr ACcip
INSTALLATION CHECKLIST
Full System Installation ❑Tank(s) O y ❑ Drainfield'Only
! Li Repair ❑ Other
System Type b�i kid. (h (�r�SSUf {� /�h Pretreatment Type 111
>5 ft. from foundation? - - ❑ N/A Os ❑ NO
>50 ft. from wells? - - ❑ ❑
>50 ft. from surface water? - ❑ 0/ ❑
- �-,
HCleanout between building and tank? - - - - - - ❑ L�i/ ❑
U Tank baffles present? - - ❑ Lid' ❑
d24" access risers over each compartment?- - -f tiri--1-3-f 2. - 0 L� ❑
WW Effluent filter installed?- .-:--1Li❑ ' ❑
Septic tank size I tj OO gal f3 manufacturer ._nrl(Witr
t3 D-box water level and speed levelers used? - - ❑ N/A I34ES ❑ NO
QO Manifold/D-box accessible from surface?- - ❑ [p" CI
CD Check valves installed? - - ❑ [[ ❑
E Transport Line Size 2-f( Schedule/Class go()
Bedrooms installed (check one) ❑ 2 ❑ 3 Eil ❑ 5 ❑6 ❑Commercial/Oth r
>10 ft. from foundation?- - ❑ N/A "YES ❑ NO
O >100 ft. from wells?- - ❑ CEr. ❑
W El/>100 ft. from surface water? - - ❑ ❑
Li >10 ft. from potable water lines?- - ❑ Dr ❑
Z > 5 ft. from property lines and easements?- - El [K ❑
ii > 30 . from downgradient curtain/foundation drains? - - ❑ [ ❑
ro
Dr infield level and observation ports present - - ❑ [It' ❑
Graveless chambers or ❑ Clean gravel used? (check one) /
Proper cover installed over drainfield?- - ❑ L—�'/ ❑
Pump tank setbacks consistant with septic tank? - - ❑ N/A YES ❑ NO
• Pump tank size (.50 0 gal Manufacturer f ('r"' 4Qr
< 24" access riser(s) and accessible from surface?- - ❑ ❑
a Alarm or Control Panel Installed? - - ❑ ❑
• Control Panel equipped with Timer/ETM /C unter- - ❑ [ ❑
- Pump installed in ❑ Bucket or On Block or ❑ Other
CA Pump Make/Model j't I Ex .�1_ /L /;i1� oats or CI Transducer
a Tank draw down —,)( r in/min Pump capacity �0•'., gpm Squirt Height .S.?? i h 4'
Pump on time [ S-QC. Pump off time ../ ti rs Daily flow set at *To gpd
Updated 12/72015
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.
LI 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.
\n(
Signs ure of Installer Date
bralA6OV\ 1\MN WO
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and INVO-
Record Drawing on behalf of Mason County Public
Health:
-7(2 r
Signature of Environmental ealth Specialist Date (designer's stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updates 12l72015
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