HomeMy WebLinkAboutSWG2023-00099 - SWG As-Built - 7/6/2023iimir
`RECORD DRAWING (ASBUILT) pg. 1 MASON COUNTY PUBLIC HEALTH
PARCEL IDENTIFICATION
Permit Number SWG 2_02.3 -COC 1 q Assessor Parcel # 32c; 3( ( i (% I G C,
Applicant Name lY L Lt OtJ.ik€ n Subdivision (Name/Div/Block/Lot)
Applicant Address 3 3 I 5 (� S*L� e_ ►�( � -
City, State, Zip 5 f j; lit 0 /(4 A q 24/-Installer Name L311i ct in re (crash att'o11
Site Address 5 UJY\( . el S al-WVk.- Designer Name J 1 M+kU1' -r 4SSeiC.i Gt14S
INSTALLATION CHECKLIST
❑ Full System Installati Tank(s)Only 0 Drainfield Only ❑Repair ❑Other
System Type 1' " ' Pretreatment Type /I l6--,
>5 ft. from foundation? - - ❑ N/A ,[,,/YES ❑ NO
>50 ft. from wells? - }f f H - r -- 0 L��,/ 0
Z >50 ft. from surface water? - t -- ❑ [3" ❑
Cleanout between building and tank? -JUN —7- r.t.+23 I J - ❑ 2:i ❑
U Tank baffles present? - - ❑ L'�' ❑
d 24" access risers over each compartm - R __- - ❑ (_ / ❑
W Effluent filter installed?- - 0 El 0
U' 1 , 1Y1ft (+-1 ,
Septic tank size ,) �? � gal Manufacturer <<LfZ. r
D-box water level and speed levelers used? - - ❑ N/A El YES ID NO
><O Manifold/D-box accessible from surface?- - ❑ ❑ 0
u.
OOZ Check valves installed? - - 0 0 0
OQ E Transport Line Size - 4-,I S ` 11Cj Schedu lass (JY ( c '1 p1(T—
0 Bedrooms installed (check one) ❑ 2 ❑3 1 ❑ 5 0 6 ❑Commercial/Other
>10 ft. from foundation?- t S .6- )- - - - - - ❑ NIA 121<:ES ❑ NO
0 >100 ft. from wells?- - ❑ ( ElW >100 ft. from surface water? - - 0 [3--"' 0
Z >10 ft. from potable water lines?- - ❑ [1,-' 0
> 5 ft. from property lines and easements?- - ❑ L� ❑
d � /> 30 ft. from downgradient curtain/foundation drains?- - ❑ LA ❑
't ca
Drainfield level and observation ports present - - - - AvZ - 0 Y ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one) —- C 7 t S-h (�,}/
Proper cover installed over drainfield?- - ❑ E ❑
Pump tank setbacks consistant with septic tank? - / I /C - IA ❑ YES ❑ NO
Y Pump tank size ri /C4,, gal Manufacturer il / Gam'
< 24" access riser(s) and accessible from surface?- ❑ [�/ ❑
~ Alarm or Control Panel Installed? - - L7 ❑
a ❑
2 Control Panel equipped with Timer/ETM / •unter- - ❑ ❑
D
d Pump installed in ❑ Bucket or ai.1.411 Block or ❑ Other 0 C-----
a Pump Make/Model Y1 / t ❑ Floats or 0 Transducer
d Tank draw down vi (o'o,/ in/min Pump capacity t, /6'. gpm Squirt Height 1,1 /c ft
Pump on time A(Gv Pump off time I 1 1Ct. Daily flow set at it 76-- qpd
Updated 12/72015
imommirmir
'MCPH RECORD DRAWING (ASBUILT) pg. 2 Assessor Parcel #
RECORD DRAWING
❑ Grainfield&manifold
orientation&layout
w/dimensions for
re-location
❑ Trench/bed
dimensions and
critical distances
within layout
❑ Septic/pump tank
placement
❑ Location of buildings C/�`+
existing/proposed
5� 11
❑ Observation ports,
dean-out locations.
&manifolds/d-boxes
❑ Location of wells,
surface water.roads.
&waterlines
El 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 1 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 ce ify t at all information contained on this I further certify that all information contained on this
form and at ach d Re rd Drawing is accurate. form and attached Record Drawing is accurate.
Signotr of lnsta r Date =
�c ;
e'0yt 1 �:.�•
1 .
Printed Name of Signee a •
MASON COUNTY PUBLIC HEALTH ` r•
f
The undersigned approves this Installation Report and 41 '�fO
Record Drawing on behalf of Mason County Public SiOUJiz
Health: Off. ADAM J.HUNTER •'
/ 11c`I'nSl'ti15F�i;xll-'t7"•
s"-1 A,/1/� \^O V J !23
I xRNES 07.12, IA
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 Lpaatec 12'rzc15
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