HomeMy WebLinkAboutSWG98-00514 - SWG As-Built - 7/11/2003 AS-BUILT FORM Revisc January 4,1999
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Applicant ci ElfAy AA OwnYnl/-. 16UP aeo NAssessor's
Parcel V 3 2. 1. 3`( 44-- o O Q to
Permit Number SWG !o - 051 `t (Twelve-Digit Number)'
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Subdivision ."se' L"T ( -5 --C 34 72�ri h a
Installer k►2R U� /'1 a t-�- o • (Name/olvlslon/Blook/Lob
Designer i o7cl-:, v rtN50 •
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4 N/A Yes Prior to Completion
I. SEPTIC TANK
A) >5 ft.From foundation? - D Q. Di
B) >50 ft from wells and surface water? 0 Li 0
C) Bldg stub-out to septic tank:clean-out if not 1-2%? 0 0 0 i
D) Baffles intact and clean? 0 0 0
E) Dividing wall intact? 0 0 0,.
F) Risers installed for access? 0 0
G) Tank Size: `lc'v gal.;Manufacture
II. D-BoX
A) Leveled with water? D 0
B) Speed leveler used? lam' ' 0 El
Ill. DRAINFIELD
A) >10 ft from foundation and>5 ft from property lines? 0 Er 0
B) >100 ft from wells and surface water? 0 Cg-• 0
C) >10 ft from potable water lines? 0 [
D) Laterals level to+ 1 inch&end caps present if not looped? 0 0 0.
E) Gravelless chambers utilized? 0 CO"' 0
F) System dimensions the same as shown on the design? 0 0 - 0 1
G) Gravel clean,properly sized,and proper depth? lB" 0 01
H) PRESSURE SYSTEMS
1) Sand quality ASTM C-33? 0 0 01
2) Head height uniform and z24 inches? Actual head height 0 0 0,
3) Clean-outs and observation ports present? 0 l O'
4) Mound: Side Slope 3:1? 0 0
5) Owner informed electrical connections must be made 0
by owner or licensed electrician and inspected by L&I? 0 Er
IV. PUMP ' id ' CHAMBER
A) Green basket it effluent filter(circle one)installed? 0 0
B) Riser ins : e• for access? 0 d' 0
C) Alarm installed? 0 CO 0'
D) Pump make 6)5 ( ; Pump model I
1 % l1l;
E) Chamber ssizze�((3�?) /7 gal; j-L.,� gal/inch; Chamber Manufacture P 3 v l 5 hit-it-7 c. C(f'(`,( A -70 li
F) PUt ch .ftibbr�drav-down inches per minute; Height of pump off bottom of pump chamber _inches
tiA.G) Pump controls:Timer(or)Elapsed Time Meter (circle if installed); If timer is used:Pump On/ 14` Pump Off
O 4-34— 41 11 — ) CY v
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>. , > S{;.,,>CHECKLIST
❑ Drainfield&manifold
orientation &layout
❑ Trench/bed dimensions val.VL R 6
and critical distances ram, , 3 F'
within layout J
❑ Septic/pump tank o 1
placement.
❑ Location of buildings. faf •
6
❑ Observation port&clean-
out location.
1 °
❑ Location of wells& o
roads.
I v
❑ Undisturbed native soil
between trenches.
❑ North arrow
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CAUTION:Minor adjustments to septic tank location and drain field orientation made in the field by the installer arc generally acceptable to bo the department
and the designer,but could in certain casts compromise the viability of the system. It is the installer's responsibility to obtain prior written approval either the
health department or the designer before making any deviations from the design that affect the system viability. Any deviations from the approved;design must be
shown above.
":'.`: t'• CERTIFICATION OF INSTALLATION
Installer Check a box from Row"A"and"B",sign and date the certificar
A. I certify that I installed the system without any certify that all deviations from the design stamped
deviation from the design stamped"APPROVED"by "APPROVED"by MCDHS are shown above.
MCDHS
B. ❑ I certify that I contacted the designer and left the UY I did not contact the designer prior to final cover faecause the
system open for inspection up to 48 hrs prior to designer waived the notification requirement.
cover.
I further certify that all information contained on this form is accurate. I understand that if the information contained herein is not
ac urate� will be just cause for immediate suspension of my installer certification.
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ter,
4.re nsta Ier Liezate
The undersigned approves this installation on behalf of Mason County Dep mcnt of HsaIth rvices. -
Ct`ete.a-k_ ��:.,i 1-- 7 /(/c)
Sanitarian
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