HomeMy WebLinkAboutSWG2019-00487 - SWG As-Built - 5/1/2023 r ��
RECORD DRAWING (ASBUILT) pg. 1 Q MASON COUNTY PUBLIC HEALTH
PARCEL IDEf7TIFICATION
Permit Number SWG 201/I -- NH j3- Assessor Parcel# O ( ?5 00 0) / 9
Applicant Name Dc‘ncU 'L LcuActo Kl Subdivision (Name/Div/Block/Lot) •
Applicant Address 2 Z (7 (n)cL10r Par - I2c.
City, State, Zip S. +t5►\ i WA q 3 5 C-1 Installer Name ?Li S 1,/)61q- C0 ' C hO
Site Address 7�� E Loxes-We. (x(J) Designer Name '6m..--1 um-er A- .Sly('(C(�S
uk.0 t-}ovxi tilt eti% I. L
INSTALLATION CHECKLIST
)a :
Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair 0 Other 1L
System Type Al V k){,�tc.(rl r f S SU re_} Pretreatment Type Alt/INCLTLr
>5 ft.from foundation? - - ❑ N/A !1lYES ❑ NO
NJ >50 ft.from wells? - -- — -- ❑ 'VA' ❑
>50 ft.from surface water? - 1-�-r-C1- }A ❑ w ❑
HCleanout between building and tank? - ❑ 0.- ❑
4present? - I _9P_R 2 2Q23 _ i
U Tank baffles I ❑ ❑
n� a 24"access risers over each compartmen . - ` El 0
'�l W Effluent filter installed?- ktY.
❑
. coSeptic tank size /00C qal Manufacturer.! C /AU r*ADO
in D-box water level and speed levelers used? - - ►! N/A ❑YES ❑ No
J ❑ CI
Manifold/D-box accessible from surface?- -
m- Check valves installed? - (� :! ❑ ❑
oQ ( Schedule/Class 90
Transport Line Size
Bedrooms installed(check one) A 2 ❑3 ❑4 Q 5 ❑6 ❑Commercial/Other
>10 ft.from foundation?- - ❑ N/A Ffj YES ❑ NO
>100 ft.from wells?- - ❑ > 1 ❑
wo
>100 ft. from surface water? - - ❑ r ❑
>10 ft.from potable water lines?- - -- - ❑ ro El
>5 ft.from property lines and easements?- - El al ❑
d > 30 ft.from downgradient curtain/foundation drains?- - ❑ al 0
a
Drainfield level and observation ports present Awl_ 0 14 ❑
XGraveless chambers or ❑ Clean gravel used 1k G c( Lt )1t)n) Ctika, 19-e v S
Proper cover installed over drainfield?- - I El P ❑
Pump tank setbacks consistantis with septic tank?- - ❑f _N/_A_,� �f- ES ❑ No
Y Pump tank size I0 CQ t,� gal Manufacturer V-(4,6 1 1 ( ek- ) r
z
I - CI 24 CI
24"access riser(s)and accessible from surface?-
a -
or Control Panel Installed? - - CIgel ❑
2 Control Panel equipped with Timer/ETM/Counter- - ❑ W ❑
D
a. Pump installed in ❑ Bucket or ,yil On Block or ❑ Other
a' Pump Make/Model zo{Ile.r l" I L ( Floats or CI Transducer
2 r�,
D
a Tank draw down in/min Pump capacity (Q pm Squirt Height 3-1 ft
FF 'l� p
Pump on time -J 0 -� VOS Pump off time 1--- S Daily flow set at ?A 0 gpd
Updated 1217/2015
' MCPH RECORD DRAWING (ASBUILT) pg. 2 Assessor Parcel#
RECORD DRAWING
El Drainfield&manifold
orientation&layout
w/dimensions for
re-location.
❑ Trench/bed
dimensions and
critical distances
within layout
❑ Septic/pump tank
placement
El Location of buildings
existing/proposed
❑ Observation ports,
i dean-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
CERTIFICATION OF INSTALLATION
INSTALLER 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"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.
6(37ZOZD
Signature fInstaller Date � // _ 2.U - 23
g1 `t
% ctvdo çov �� ��,w,:h Viz,
Printed Name of Signee F 1
to
if
MASON COUNTY PUBLIC HEALTH stu,..'13 �s,.4
The undersigned approves this installation Report and O' IAM1 R.MIN1ER ' 'S
Record Drawing on behalf of Mason County Public itrxrist:t)DEStG!v:R 11
Health:
EXPi!'[S: 03/22/2_
Cg.----1\Q-Pr\' CA471
11 Iz5
Signature of Environmental) ealth 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 1217/2015
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