HomeMy WebLinkAboutSWG2016-00089 - SWG As-Built - 1/18/2023 (2) RECORD DRAWING (ASBUILT) pg. 1 MASON COUNTY PUBLIC HEALTH
PARCEL IDENTIFICATION
Permit Number SWG iU I i„ 000 Assessor Parcel # _?,l c-i t S 5 t o Q:o to
Applicant Name a�cc,,rc*, , C--(,d y;-1,.c- Subdivision (Name/Div/Block/Lot)
Applicant Address GIS I 0 D,{i{41 Svc 0 Ly I?'1r l hill- Cfi3 s 7_
City, State, Zip 5 .-e.A `,.-4,- y0 t,'f Installer Name ,-.y S\-«.--z `�,...),,-,-...--,--4,4:,-..
Site Address I vo 5 14,c,v•te,..e.( De • Designer Name , ., .. ,--
INSTALLATION CHECKLIST
Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair ❑Other
System Type Fr-e5 s we- -- i-e Pretreatment Type
>5 ft. from foundation? - - ❑ N/A 'YES ❑ NO
>50 ft. from wells? - - 0 Q' ❑
>50 ft. from surface water? - - ❑ d ❑
<- Cleanout between building and tank? - - ❑ �/ ❑
V Tank baffles present? - - CII� ❑
d24"access risers over each compartment?- - ID Q' ❑
�W Effluent filter installed?- ,stpte�� rp ❑ I CI
Septic tank size 1-2.-0 0 gal Manufacturer p‘(A51,
--.0 D-box water level and speed levelers used? - - dNIA ❑ YES ❑ NO
XO Manifold/D-box accessible from surface?- - ❑ ❑
m- Check valves installed? - ❑ ❑
oQ
2 Transport Line Size Z ' Schedule/Class Stet.---(. �
Bedrooms installed (check one) ❑ 2 12'3 ❑4 El 5 ❑6 El Commercial/Other
>10 ft. from foundation? - - ❑ N/A 'YES ❑ NO
CI >100 ft. from wells?- O i ' ❑ d ❑
W >100 ft. from surface water? - ()UIi d 7.9�Fi ❑ ��,( ❑
E. >10 ft. from potable water lines?- - ❑ ad ❑
Z > 5 ft. from property lines and easements?- Ni - ❑ 1 El
0 a ❑ d ❑
> 30 ft. from downgradient curtain/foundation drains? - -
Dra•nfield level and observation ports present - - 0 ❑ ❑
(Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ d ❑
Pump tank setbacks consistent with septic tank? - - ❑ N/A ''YES ❑ NO
ZPump tank size 12 0 gal Manufacturer Tv,. \ -- - '-
24" access riser(s) and accessible from surface?- - ❑ ❑
aAlarm or Control Panel Installed? - - ❑ ❑
TM
2 Control Panel equipped with Timer/ / oun '- - ❑ ❑
n- Pump installed in ❑ Bucket or [✓✓'On Block or ❑ Other
CL
2 Pump Make/Model y a.4 ,....,,-k c sP.P'--c Floats or ❑ Transducer
a Tank draw down -'2 -5- in/min Pump capacity L C, gpm Squirt Height 3 11 ft
Pump on time Pump off time Daily flow set at 3 4-c gpd
Updated 12/7i2015
M^PH RECORD DRAWING (ASBUILT) pg. 2 Assessor Parcel # 31eie> S I- 00uo
RECORD DRAWING
❑ Drainfield&manifold
orientation&layout
w/dimensions for
re-location.
❑ Trench/bed
dimensions and
critical distances
within layout / A 0
❑ Septic/pump tank
placement
❑ Location of buildings
existing/proposed
❑ Observation ports,
clean-out locations,
&manifolds/d-boxes
❑ Location of wells.
surface water,roads,
&waterlines.
❑ 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 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
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.
"Jc/Z (
S� ure of Installer / Date
•
Printed Name of Signee Ask., w,"+>,1F
MASON COUNTY PUBLIC HEALTH51
The undersigned approves this Installation Report and ct lAMEs Ht NTER
Record Drawing on behalf of Mason County Public LICFN<!=r!r)ipc;NfR
Health: 119
mil• ' 1(7) 123
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 17/7/2015
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