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REC 1RD DRAWING (ASBUILT).pg. 1 MASON COUNTY PUBLIC HEALTH
PARCEL IDENTIFICATION
Permit Number SWG O/g-QOl 6 Assessor Parcel # JZJ /O')O7
Applicant Name The, (;7e-r Subdivision (Name/Div/Block/Lot)
Applicant Address 7gi i. . i2 0 -rpiklee
City, State, Zip ,5kfiloyt tA/t '83-R y Installer Name ,Rj id AA "ktrn A.I h s, .
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SiteAd�iress S�,1.,� JI Designer Name wt titn i^ .
INSTALLATION CHECKLIST : • . ^ .
•
g Full System Installation ❑T1ank(s)Only ❑ Drainfield Only Repair ❑Other
System Type �.ti4J—O-O..Sc=- ' (Ware, /V k retreatmentType
>5 ft.from foundation? - - ❑ N/A Q YES 0 NO
>50 ft.from wells? .. .. I -. t144- - - ❑ 17.4 0
Z- >50 ft.from surface water? - - El0 El
.�: Cleanout between building and tank? -- 1 -M�0.-� ❑ .-- - I- I ❑
0:. Tank baffles present? - - 0 K ❑
24"access risers over each compartment'By - ❑ El ❑
.IiJ' Effluent filter installed?- •- ❑ ❑ ❑
Septic tank size iae-C gal Manufacturer .:-ncif 40/'
. , C1 D-box water level and speed levelers used? - - ❑ N/A OM. ANO
dWManifold/D-box accessible from surface? - 0 C1 0
F9E: Check valves installed? - - ❑ al ❑
'ad. >> /
;' 2. Transport Line Size 0( Sat 1/0 Schedule/Class SC,li t9
Bedrooms installed (check one) El2 El3 gm 4 0 5 El6 ElCommercial/Other
?10 ft. from foundation?- • - ❑ NIA j2g YES ❑ NO
>100 ft.from wells?- - ❑ 0 0
. :Q ElJI 0
>100 ft. from surface water? - -
: mc. >10 ft.from potable water lines?- - 0 El_ ❑
:Z > 5 ft.from property lines and easements?- - ❑ ❑
> 30 ft.from downgradient curtain/foundation drains? - - 0 [:[ ❑
- ,. Drainfield level and observation ports present - - ❑ 0 ❑
. ; ., 0 Graveless chambers or rgi Clean gravel used? (check one)
.- Proper cover installed over drainfield?- - 0 [S ❑
Pump tank setbacks consistant with septic tank?- ❑ N/A NI YES ❑ NO
W Pump tank size art) gal Manufacturer ,firs)y( eP- -4}=.
F: 24" access riser(s)and accessible from surface?- - 0 � Eli
..a.a Alarm or Control Panel Installed? 0 ❑
2: Control Panel equipped with Timer/ETM/Counter- - ❑ ❑
'd' Pump installed in ❑ Bucket or NI On Block or 0 Other
II Pump Make/Model Zoe-I lei- A/ -3 ® Floats or 0 Transducer
a. Tank draw down !J gJ' in/min Pump capacity Li 0 gpm Squirt Height 2- ft
•
Pump on time a r' y' Pump off time le ltn..f S Daily flow set at Lig 0 . gpd•
Updated 12/7/2015
_ _
M%rz1 RECORD DRAWING (ASBUILT) pg. 2 Assessor Parcel#
.. RECORD DRAWING. .' :..: .: •
❑ Drainfield&manifold
orientation&layout
wldimensions 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.
❑ 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
•
• _CERT)FIGATION OFINSTALLATibIII
INSTALLER DESIGNER
I certify that 1 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 Recor awing is accurate.
Signature af'tnstaller Date Y J
)Cv 1\r t�t A� 1 ',,
1,
Printed frame of Signee
MASON COUNTY PUBLIC HEALTH ^`
The undersigned approves this Installation Report and p41' luwFS A.titliTER '
Record Drawing on behalf of Mason County Public LI<77!` t?f.Slt,NC.R
cccCS� •'�.+ : :a .
Health: In:'t S:
Signature of Environmental Health 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 1277l2015
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