HomeMy WebLinkAboutAFTER THE FACT - SWG As-Built - 4/14/2023 AFTER THE FACT RECORD DRAWING, pg 1 MASON COUNTY PUBLIC HEALTH
PARCEL IDENTIFICATION
Owner Name A- �C� S 5 Assessor Parcel # �a c) O\-0� CX 113
Mailing Address L Ot A) b , O/M Specialist Name GO E,S C, I- S
City, State, Zip , " Installer Name %J/A
Site Address ILA Al 3ec,\?.- e, Designer Name lu/i-
Please complete this checklist to the best of your knowledge. If items are unknown leave blank.
\ INSTALLATION CHECKLIST
System Type C-i`x i t y Pretreatment Type
Drainfield Ln. Ft. q S Drainfield Sq. Ft. Drainfield depth >
>5 ft.from foundation? - - ❑ N/A NI YES ❑ NO
>50 ft.from wells? - .- 0 ® 0
Z >50 ft.from surface water? - - El Dil ❑
< Cleanout between building and tank? - - t83 ❑ 0
V Tank baffles present? - - ❑ 0 0
a24"access risers over each compartment?- - El 1K
LU Effluent filter installed?- •- 0 El
Septic tank size ' j gal Manufacturer
I 13 D-box water level and speed levelers used? - - N/A ❑YES ❑ NO
DO Manifold/D-box accessible from surface?- - LA ❑ ❑
OQCheck valves installed? - - 0 0
Transport Line Size yu Schedule/Class Schedl.,\e_ y?
Bedrooms installed (if known) ❑ 2 ❑3 ❑4 ❑5 ❑6 0 Commercial/Other
>10 ft.from foundation?- - 0 N/A NI YES ❑ NO
GI >100 ft.from wells?- - ❑ IA 0
W >100 ft.from surface water? - - ❑ ❑
u. >10 ft. from potable water lines?- - ❑ El ❑
Z4 r— > 5 ft. from property lines and easements? 0 El ❑
> 30 ft.from downgradient curtain/foundation drains? - - 0 ® ❑
cl
Observation ports present? - - ❑ 0 El
❑ Graveless chambers or 14 Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ VI ❑
Pump tank setbacks consistant with septic tank?- - ❑ NIA ❑ YES ❑ NO
Pump tank size gal Man facturer
Z - El El El
access riser(s) and c ssible fro surface?-
a Alarm or Control Panel sta ed? - - - 0 0 ❑
2 Control Panel equippe with 'mer/ TM/Cou er- - - - - ❑ 0 ❑
M
a Pump installed in Bucket r On B ck or Other
d 2 Pump Make/Mode 0 Floats or 0 Transducer
aTank draw dow in/min ump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 2/29/2016
3
AFTER THE FACT RECORD DRAWING, pg 2 Assessor Parcel#
RECORD DRAWING
❑ Drainfield&manifold
orientation&layout
w/dimensions for
re-location.
❑ Trench/bed
dimensions and
critical distances
within layout
❑ Septic/pump tank
Location w/dimen-
sions for re-location
❑ 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 needed drawing may be attached on a separate page No. Pages Attached
C RTIFICATION OF INSTALLATION
DESIGNER/APPROVED O/M CIALIST
I certify that the information .ntained in t, do - . is accurate to my knowledge. The drawing and information
has been/.ine• . =•; ommon I. -,n • • . es.
a Ere o .-si.•- .'l"pproved O/M Spe cst Date
MAS• ' C' • TY PUBLIC HE. T
This is an after the fact recor, dr, ing, which may or may not include a county inspection. This information is to only
document an existing OSS i ation and components.
S6g rS1
Signature of Environment Health Specialist Date
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 2n9rz016
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