HomeMy WebLinkAboutSWG2019-00426 - SWG As-Built - 4/19/2023T.
RECORD DRAWING (ASBUILT) pg. 1 C •
PARCEL IDENTIFICATIONMASON COUNTY PUBLIC HEALTH
Permit Number SWG 20n OO--zto Assessor Parcel# 3Z2Z 3Z3062,__CO5
Applicant Name AM, fi-Ol)u-`\ Subdivision (Name/Div/Block/Lot)
Applicant Address 27 3'5 ScATicrY ►- p. MO
City, State, Zip �`l�wt,')j(,(t IJUA q g5-OZ Installer Name T �� Y )0 S-h&iCii onSite Address )6( F . i&/A (C O Designer Name (IYIVAA.2;‘,u1AiP( SSO(1C lR S
INSTALLATION CHECKLIST
0 Full System Installation 0 Tank(s)Only ❑ Drainfield Only ❑Repair 0 Other
System Type 9 re,Ss-ore, Pretreatment Type ft)
>5 ft.from foundation? - - ❑ N/A YES ❑ NO
>50 ft. from wells? - - ❑ ❑
Z >50 ft. from surface water? - - CI ❑
HCleanout between building and tank? - - ❑ ❑
o Tank baffles present? - - ❑ 60 ❑
F.a 24"access risers over each compartment?- - ❑ 2 ❑
W Effluent filter installed?- - ❑ P ❑
1_
Septic tank size S100 gal Manufacturer 1,/1 A (- y 1 nY
o D-box water level and speed levelers used? - - O+NIA ❑ YES 0No
oO Manifold/D-box accessible from surface?- - ❑ '® GI
mZ Check valves installed? - - Cl 6 ❑
°Q 2d0
• Transport Line Size I l Schedule/Class
Bedrooms installed(check one) 0 2 0 3 ❑4 15 ❑6 0 Commercial/Other
>10 ft. from foundation?- - ❑ N/A YES ❑ NO
>100 ft. from wells?- z - - ;_,-I-1 ❑ El
W10> 0 ft. from surface water? - - CI 'S El
IL >10 ft. from potable water lines T. ❑ `®, ❑
> 5 ft. from property lines and a s'ements?- :`. . - El ❑
12 > 30 ft.from downgradient curt i foUn ationf drains?--. -1 Cl ❑
0Drainfield level and observation- orfs'preseirSt. 'L edl `I } - ❑ tfr El
KGraveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ PI> ❑
Pump tank setbacks consistent with septic tank? - - 1❑ N/A ES ❑ NO
• Pump tank size AD O gal Manufacturer ��'" 1 0-' t '
Q 24"access riser(s) and accessible from surface?- - ❑ 15 ❑
N-
a Alarm or Control Panel Installed? - - ❑ 8. ❑
• Control Panel equipped with Timer/ETM/Counter- - ❑ ` L, ❑
n
n- Pump installed in ❑ Bucket or fOn Block orr/�❑ Other
a. Pump Make/Model (As 0.Q,1/-�'1n 115v LES I/" t.r„2 �:eloats or ❑ Transducer1/
a Tank draw down t in/min Pump capacity TOO gpm Squirt Height
Pump on time q 5 S zko r Pump off time (-4 k r,c _ Daily flow set at 6J( ( J�1
gpd
Updated 12M2015
•
• MCPH RECORD DRAWING (ASBUILT) pg. 2 Assessor Parcel#
RECORD DRAWING
0 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,
&manifoldsld-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
CERTIFICATION OF INSTALLATION .
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 Record Drawing is accurate.
ffr 1 I9(ZO20 ry 11; �� .
Signature of Installer Date • _ '%'
Grt
('GO V� 0 �a n
•
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
•
r a
The undersigned approves this installation Report and 44, •tr
Record Drawing on behalf of Mason County Public 5,o0 t r2
fD/MJ.HUNTERHealth:
.�t•si;l-''n'SL'ti
\k,-.,(\Qtyvq
Xi.1i4ES LW.
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 Updatad 121712015
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