HomeMy WebLinkAboutSWG2011-00195 - SWG As-Built - 6/5/2012 ' 3 OL2 • 5CQ • cCC.) 3
RECORD DRAWING (ASBUILT) Mason County Public Health
PARCEL IDENTIFICATION
Assessor's Parcel# �� —�
Permit Number SWG O'OI/ -- !VQ/9S- (Twelve-Digit Number)
OP Applicant's Name J c 7'7- Subdivision (Name/Division/Block/Lot)
Applicant Address PC'QoX 7b/ Installer's Name P Ji• S-4.4 ` c
��t Z 77Z4 �iJi 5f�� Desi er's Name S S
City,State,Zip _
INSTALLER CHECKLIST
N/A Yes Prior to Completion
I. SEPTIC TANK
>5 ft.From foundation? ❑ X 0
>50 ft from wells? ......................................................_........._ ❑ JEt 0
>50 ft surface water? ..................................................._.......... ❑ .12r 0
Building stubout to septic tank:cleanout if not 1-2%? 0 .0 0
Baffies intact and clean?................................................_......... ❑ JR 0
Dividing wall intact?................................................._.............. ❑ g1 ❑
Risers installed for acc ?................................................ ...... ❑ 0
Screen basket or fluent filter'nstalled?(circle one) .................... ❑ Aa ❑
Tank size:12L - _ ., • anufacture: M.;L¢S C414..Gttes"7h"
II. D-BOX
Leveled with water? 0 If 0
Speed leveler used? ❑ ..1Ei' ❑ ii:
III. DRAINFIELD
>10 ft from foundation? 0 ET 0
>5 ft from property lines and easement lines? 0 g 0
> 100 ft from wells? 0
> 100 ft from surface water? 0 trl 0
>10 ft from potable water lines? 0 Pd 0
Laterals level to±1 inch&end caps present if not looped? 0 Pr 0
Gravelless chambers utilized? P 0 0
Gravel clean,properly sized,and proper depth? ❑ C' 0
PRESSURE SYSTEMS
Sand quality ASTM C-33? xi 0 0
Head height uniform >24 inches? Actual head height
a` ❑ ❑
Clean-outs and ob ation ports g sent > ❑ .O ❑
Mound: Side Slope 3:1? ell." ❑ ❑
Owner informed electrical connections must be made by
owner or licensed electrician and inspected by L&I?............. ,Er 0 0
IV. PUMP/PUMP CHAMBER
Pump make ; Pump model Pi 0 ❑
Chamber size gal; Manufacture , g ❑ ❑
Height of pump off bottom of pump c j inches
Pump chamber draw-down i ,,g lons per inch per minute
Pump capacity gallons per minute
Pump controls:Timer,Elapsed Time Meter,Counter?(Circle all
❑ ❑
that apply). If timer:Pump On Pump ilf
Off
Riser installed for access?............................•......................... illi ❑ 0
Alarm installed? _......_ [� 0 0
..............
ki___' -_ _
. ,,
r Pin(T t37) C
wev,
RECORD DRAWING i r{,n LA i 5l't
CHt.CKLIST Pdl`f-K ff -l'"'"".
❑ Drainfield& l I
manifold orientation _ .i, - k'tI „
&layout �__�_ t�c� I"'
❑ Trench/bed �''
dimensions and
critical distances
within layout
❑ Septic/pump tank li).)(
placement
❑ Location of
buildings I
❑ Observation port& \--_________ --
clean-out location Ns-LA) t s Lo r Z_
❑ Location of wells&
roads '
O Undisturbed native
soil between
trenches — �'"'�— ,
❑ North arrow r r l LOT Z- a-�'r N3-t�-P D-&A y
1,0 X ID O �f A .�.
i351) ,T,A, '' • for l
le
Pr p Sn- t1:75'1 ,,°•ru"- . 4o Tr.°obc
bc'--' '''''M sit.:c.,7 -,_____i
CAUTION:Minor adjustments to septic tank location and drainfield orientation made in the field by the installer aregenerally acceptable
to both the department and the designer, but could in certain cases compromise the viability o/'the system. It is the insfaller's responsibility
to obtain prior written approval from either the health department or the designer before making any deviations from the design that affect
the system viability. Any deviations from the approved design must be shown above.
CERTIFICATION OF INSTALLATION
Installer: Check a box from Row"A"and"B",sign and d the certification
A. 0 I certify that I installed the system without any I certify that all deviations from the design stamped
deviation from the design stamped"APPROVED"by r "APPROVED"by MCPH are shown above.
MCPH
B. I certify that I contacted the designer and left the ❑ I did not contact the designer prior to final cover because the
system open for inspection up to 48 hrs prior to cover. designer waived the notification requirement.
I further certify that all information contained on this form is accurate. I understand that if the information contained herein is not
accurate,there will be just cause for immediate suspension of my installer certificati . kt i
5- 3f — lz--
Si of Installer Date
The undersigned approves this installation on behalf of Mason County Public Health. C
• C i 161/L
Environmen Health Specialist Date
tt Revised January 2008