HomeMy WebLinkAboutSWG2021-00655 - SWG As-Built - 4/25/2023 4214.
RECORD DRAWING (ASBUILT) pg. 1 MASON COUNTY PUBLIC HEALTH CC
PARCEL IDENTIFICATION _.. — - ----Y---�---m�
I Pe
rmit mrt Number
mbar SWG ,,z2,Q a ( —Q QG S1115 Assessor Parcel# 3 ZQ—Z_ �,—5'1-0 (C_K)S1
Applicant Name Let.-s„ 0 V cca Subdivision (Name/Div/Block/Lot)
1
1 Applicant Address 6 1 zy k Sz,..0,,...._ L+-c.-. g R
City, State, Zip Y�.e_.l cc w� i 6,2,c, Installer Name rltrc�G. c 0 �Z7 t=x c..,C_r�
Site Address I -in E. SoyA ui Designer Name
i
INSTALLATION CHECKLIST . - f
0 Full System Installation 0 Septic Tank Only ❑ Drainfield Only ❑ Repair
System Type Orli> Pretreatment Type
>5 ft. from foundation? - -- ❑ N/A [Q YES ❑ NO 1
>50 ft. from wells? - ❑ ❑ ❑
Z >50 ft. from surface water? - ❑ El
• N Cleanout between building and tank? - -� N-�-� - ❑ ❑ ❑
Tank baffles present? El
d 24" access risers over each compartme __APR 1 9 ZO/.3 0 0
W Effluent filter installed?- -( - 0 ❑ ❑
tn
Septic tank size 13N GCS00 gal BY—Ahanufactur&/- -fit.9.-' -
•
�0 D-box water level and speed levelers used? - 0NIA 0YES 0 NO 1
• a0 ManifoldlD-box accessible from surface?- - ❑ 0 0
mZ Check valves installed? - - ❑ El ❑ a
6Q r
: 2 Transport Line Size l ' ` Schedule/Class t-`o I
Bedrooms installed (check one) ❑ 2 Z 3 ❑4 0 5 ❑6 1
>10 ft. from foundation?- - ❑ NIA B YES ❑ NO 5
0 >100 ft. from wells?- - ,0 El El
t >100 ft from surface water? - - - -- - ❑ El El
Zs. >10 ft. from potable water lines?- - 0 El ❑
9 dd
> 5 ft. from property lines and easements?- - 0 0' 0
Idie > 30 ft.from dovmgradient curtain/foundation drains? - - El 0 El
1L) Drainfield level and observation ports present - -• ❑ ❑ ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ 0 El
a
P
Pump tank setbacks consistent with septic tank? - - ❑ NJA a.YES ❑ No
It Pump tank size 12_00 _,gal Manufacturer ! „is se-H-%-.*-
< 24" access riser(s)and accessible from surface?- - El 2 0
F0. Alarm or Control Panel Installed? - - ❑ E] Cl
2 Control Panel equipped with Timer I ETM/Counter- - ❑ 3
• •
LI- Pump installed in ❑ Bucket or ❑ On Block or ❑ Other^ r c._ _r
Pump Make/Model Oc- e c PF /d d ,5--- ❑ Floats or El Transducer •
Q Tanis draw down I�e_ in/min Pump capacity ZS- gpm Squirt Height ft
ll
iPump on time JO .,,1 Pump off time C l4es Daily flow set at gpm
x �
4
RECORD DRAWING (ASBUILT) pg. 2 MASON COUNTY PUBLIC HEALTH
RECORD DRAWING
Dra;rfi &
manifoldeld orientation
&layout
t Trench/bed
dimensions and
critical disbances
within layout
p Septic/pump tank
placement
Location of
buildings
El Observation ports&
clean-out locations •
�j�'J
u
Location of wells. 1
surface water. &
roads
0 Undisturbed native
soil between
trenches
Q 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 separate page attached. No.Pages Attached
!
_ CERTIFICATION OF INSTALLATION
INSTALLER 1 DESIGNER
I certify that I 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 °APPROtVED"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.
Signature of Installer Dale
Printed Name of Signee
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
Ipj-r-u(N- yvvi
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
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