HomeMy WebLinkAboutSWG2016-00089 - SWG As-Built - 1/18/2023 RECORD DRAWING (ASBUILT) pg. 1 MASON COUNTY PUBLIC HEALTH
PARCEL IDENTIFICATION
Permit Number SWG Z.V i t --000g67 Assessor Parcel # _2,1 ci tj 5 5 p ce:c) cr,
Applicant Name a;cc,,ccAo P.,dr;,3,.G- Subdivision (Name/Div/Block/Lot)
Applicant Address GI31 0 D p1Vi V.) O t,y Vft I A7 h/' 4jg slZ
City, State, Zip 5v-c.,` ..... ,.-"\- 'ram -I Installer Name
Site Address 100 5 t~ 14,91/4. tei. ( .Dc - Designer Name , ,, ,. ----
INSTALLATION CHECKLIST
Full System Installation ❑Tank(s)Only 0 Drainfield Only ❑ Repair ❑Other
System Type '1`e S -h Pretreatment Type
>5 ft. from foundation? - - ❑ N/A EZI YES ❑ NO
>50 ft. from wells? - - ❑ Q' ❑
>50 ft. from surface water? - ❑ Er 0
Z
Cleanout between building and tank? - - ❑ 0
V Tank baffles present? - - 0 12 0
a24"access risers over each compartment?- - ❑ Q' ❑
cW Effluent filter installed?- 0 2°' r"-p - ❑ ❑
Septic tank size 12-0 0 gal Manufacturer p\tSfi Z
CID-box water level and speed levelers used? - - JIA ❑ YES ❑ NO
oO Manifold/D-box accessible from surface?- - ❑ Er ❑
m—Z Check valves installed? - alll 0 ❑
�
oQ
2 Transport Line Size Z 'r Schedule/Class SGA^—(
Bedrooms installed (check one) ❑ 2 [l3 ❑4 El ❑6 ❑Commercial/Other
\r,„i
- ❑ N/A 'YES Et ft. from foundation? - NO
CZ >100 ft. from wells?- r1 c d ❑
W >100 ft. from surface water? - 3U ' 11% ❑ if o
Z >10 ft. from potable water lines?- ❑ d ❑
Q > 5 ft.from property lines and easements?- TV(:_. - ❑ ❑
rt > 30 ft. from downgradient curtain/foundation drains? - - 0 d 0
Dra-nfield level and observation ports present - - ❑ ❑ ❑
Graveless chambers or 0 Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ CJ 0
Pump tank setbacks consistant with septic tank? - - ❑ N/A dYES ❑ NO
ZPump tank size t2-.u:) gal Manufacturer -Sv-, \ «A-^-,-'-
< 24" access riser(s) and accessible from surface?- - ❑ EI ❑
aAlarm or Control Panel Installed? - - 0 0
E Control Panel equipped with Timer/ TM/ oun '- - 091 0
n
n- Pump installed in 0 Bucket or [✓'On Block or ❑ Other
2 Pump Make/Model N -d'c -4-,c S.P `-�c.P F�loats or El Transducer
d Tank draw down "2 -S in/min Pump capacity L.o C, gpm Squirt Height 3.12 ft
Pump on time Pump off time Daily flow set at 3 LC qpd
Updated 12'712015
MCPH RECORD DRAWING (ASBUILT) pg. 2 Assessor Parcel # '31oio5- Si- 0UUO 6
RECORD DRAWING
❑ Drainfield&manifold
orientation&layout
w/dimensions for
re-location.
❑ Trench/bed
dimensions and
critical distances
within layout / r- A. r-A C P l' 0
❑ Septic/pump tank
placement
❑ Location of buildings
existing/proposed
0 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
l further certify that all information contained on this I further certify that all information contained on this
form and attac ed Record Drawing is accurate. form and attached Recor rawing is accurate.
S//Z/� �
St ure of Installer Date
rAU , rs..;\
Printed Name of Signee ��",oF,'17�
MASON COUNTY PUBLIC HEALTH h`� s
51au73 ,,,
The undersigned approves this Installation Report and 0' LAMES HUNTER
Record Drawing on behalf of Mason County Public LICENSED nES!GNER
Health: Fx n''22lt>9
J
1 '7) I2 3
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 Updated 127/2015
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