HomeMy WebLinkAboutAFTER THE FACT - SWG As-Built - 5/23/2023 AF/ER THE FACT RECORD DRAWING, pg 1 MASQN COUNTY PUBLIC HEALTH
PARCEL IDENTIFICATION
Owner Name RAY BREAZEALE Assessor Parcel# 47217- n-1 nn7
Mailing Address PO BOX 1243 O/M Specialist Name
City, State, Zip HOODSPORT, WA. 98548 Installer Name
Site Address 101 N OLYMPIC AVE, HOODSPQJ igner Name CINDY WAITE
Please complete this checklist to the best of your knowledge. If items are unknown leave blank.
INSTALLATION CHECKLIST
System Type GRAVITY Pretreatment Type
Drainfield Ln. Ft._ 8t9 Drainfield Sq. Ft. 1.(V Drainfield depth it- 2tf PI
>5 ft.from foundation? - - ❑ NIA /.YES ❑ NO
>50 ft.from wells? - 71ECt MI o ❑ ❑
Z . >50 ft.from surface water? - L• - ❑ la ❑
HCleanout between building and tank? --; - -- +11 1 -- - 0 0
V Tank baffles present? - Ml LULL - ❑ IS 0
a24"access risers over each compartment2y. ----- - 0 0 El
LU Effluent filter installed?- tSS - 0
0
121
Septic tank size 1000 gal Manufacturer EXISTIN
CID-box water level and speed levelers used? - $III A ❑YES ❑ NO
DO Manifold/D-box accessible from surface?- - El 0
u.
GQ Check valves installed? - - ,g, I 0 0
2 Transport Line Size Schedule/Class L
Bedrooms installed(if known) 2 ❑3 04 ❑5 06 ❑Commercial/Other
>10 ft.from foundation?- - 0 N/A l)YES 0 NO
O >100 ft.from wells?- - 0 0
W >100 ft. from surface water? - - CIZi 0
LT >10 ft.from potable water lines?- - 0 Xl 0
z > 5 ft.from property lines and easements?- - El ] 0
d >30 ft. from downgradient curtain/foundation drains?• - 54 0 ❑
Observation ports present? - - 0 0
❑ Graveless chambers or 0 Clean gravel used? (check one)
Proper cover installed over drainfield?- - 0 A 0
Pump tank setbacks consistant with septic tank?- ❑ N,A 0 YES gi NO
ZPump tank size gal Manufacturer
< 24"access riser(s)and accessible from surface?- - 0 0 0
a. Alarm or Control Panel Installed? - - 0 0 0
• Control Panel equipped with Timer/ETM/Counter- - 0 0 0
- Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
a Pump Make/Model ❑ Float$ or� 0 Transducer
a=. Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 2292018
AFTER THE FACT RECORD DRAWING, pg 2 Assessor Parcel#_ Y.7.2L-2 .- O7
RECORD DRAWING ,
XGrainfield&manifold
orientation&layout
w/dimensions for
re-location.
gTrench/bed
!!!!`"���� dimensions and
critical distances
within layout
Ggr Septic/pump tank
Location w/dimen-
sions for re-location
1gLocation of buildings
existing/proposed
dbservation ports,
dean-out locations,
���&manifolds/d-boxesm�
i,i cation of wells,
surface water,roads,
&waterlines.
Reserve area(s)
'0 North Arrow
If needed drawing may be attached on a separate page No. Page hed '
CERTIFICATION OF INSTALLATION ?' .p
DESIGNER/APPROVED OIM SPECIALIST ru-41. a ;'si
I certify that the information contained in this document is accurate to my kno ike:I" w inryfitiO
has bee ined thro h common locating practices. y� sfo s
�� l
+ 2-0ITE
ICEN EDEDESIGNERS
Signature of Des er or Approved O/M Specialist Date
l.d.~. .,6"o
MASON COUNTY PUBLIC HEALTH
•
This is an after the fact record drawing, which may or may not include a county inspection. This information is to only
document an existing OSS location and components.
kCCVLA 112-3/Z_
Signature of Environmental ealth Specialist Date
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE updated 2/292016
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