HomeMy WebLinkAboutSWG2008-00122 REVISED AS-BUILT BY HEMLEY SEPTIC - SWG As-Built - 8/28/2023 Petted s f t by lei/e y sec aS of 8/4/0ci ,
ONSITE SEWAGE SYSTEM APPLICATION irAW
' MASON COUNTY PUBLIC HEALTH Official use only AUG ? 0iF
426 W.CEDAR STREET
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PO BOX 1666 PERMIT NUMBER: SWG '�C, —CD • : D a
SHELTON,WA 98584 DATE RECEIVED: —\ L4AMOUNT RECEIVED:$ Y [6
(360)427-9670, Ext.352 o O
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APPLICANT DATE CHECK APPLICABLE ITEMS Z f
❑ NEW SYSTEM 3 <
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MAILING ADDRESS `M I n ❑ REPAIR SYSTEM m
DAYTIME PHONE 0 TABLE 6 REPAIR �_
tit TANK REPLACEMENT m
CITY STATE ZIP 0 RV HOLDING TANK ONLY il
(requires waiver) pp
❑ INSTALLATION PERMIT ONLY A
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SITE ADDRESS 0 SINGLE FAMILY
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Q I N 6 Mar(ne, LA t,.w.j Or Pleasee describe: 3
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NAME OF DESIGNER PHONE NUMBER tT
Note: m
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Asbuilts required for all installations. Z.
NAME OF INSTALLER
DRINKING WATER SOURCE !
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CI\, 4CiPlIt < ❑ PRIVATE INDIVIDUAL WELL R
NUMBER OF BEDROOMS j LOTSIZE: ACRES FT X FT 0 PRIVATE TWO-PARTY WELL I
❑ COMMUNITY/PUBLIC WATER SYSTEM H
SYSTEM WFI#:
SYSTEM NAME: I i-
SPECIFIC DIRECTIONS FOR LOCATING SITE. W
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Site must be flagged from main road and test holes must be flagged with test hole numbers r- I
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Official use only below this line I" II 1
SOIL LOGS COMMENTS/CONDITIONS I tr.,
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SOIL TEXTURE CODES:
V =very G=gravelly S=sand L-loam Si=silt C=clay E=extremely
INSPECTOR SIGNATURE DATE DESIGN EXPIRATION DATE DESIGN APPROVED BY DATE
DATE INSTALLATION FEE PAID INSTALLATION EXPIRATION DATE £ % ,L
LATION APPROVED BY D TE
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Revised 4/9/2007/ eed FromM zii r County yP iy,.
Printed from Mason County OM 7
RECORD DRAWING (ASBUILT) Mason Counq2ublic Health
+� PARCEL IDENTIFICATION
'Permit'slumber SWG o`(r'( ` -- (*I Assessor's Parcel# )-)`�'��_ t), —L ).cj 04
(Twv.1ve-Digit Number)
Subdivision
Applicant's Name it 4- -.-
/� /J (Namr/Divisiott/E3 a IJLot)
Applicant Address 6 / Ai . %t,4,,,,,, 042. I(Z, Installer's Name ac„.„,„„lertscT..50071G , .
City,State,Zip z 2 .. Designer's Name --- -
INSTALLER CHECKLIST
�.4.✓k �ta� •d- N/A Yes Prier to Completion
I. SEPTIC TANK
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>5 ft. From foundation?............................................................. ❑ ❑
............................... . .
>50 ft surface water? ................................................................ ' i^ .
Building stubout to septic tank: cleanout if not 1-2%? 0 .er APR`
23
zBaffles intact and cle•
Dividing wall intact?......................................• ❑
ter
Risers installed for ace- . ............ ..........................
Screen basket o ld installed?(circle one) . p _ ❑
'Tank size: gal.; Manufacture: 1 RED
II. • D-BOY
Leveled with water? ❑ ❑ AUG 2 2023
Speed leveler used? �0- 0 ❑ RECENED
I11. DRAINF1ELD Tq,rK p/,trsw.wfd- a+f Y•
.>10 ft from foundation's 0 /E' 0
> 5 ft from property lines and casement lines? . 0 el' 0
> 100 ft from wells' 0 0
> 100 ft from surface water? ❑ ,e' ❑
>10 ft from potable water lines? ........... 0 ....Er 0
Laterals level to_t1 inch &end caps present if not looped? .............. ❑ 0 0
Gravelless chambers utilized'? ..-13-- 0 0
Gravel clean, properly sized, and proper depth's 0 0 0
PRESSURE SYSTEMS
Sand quality ASTM C-33'? D ❑ ❑
Head height uniform >24 inches? Actual head height ❑ 0 0
Clean-outs and observation ports present'? 0 0 0
Mound: Side Slope 3:1? 0 0 ❑
Owner informed electrical connections must be made by
owner or licensed electrician and inspected by L&1? ............... ❑ 0 0
1V. PUMP/PUMP CHAMBER
Pump make _; Pump model ❑ 0 0
Chamber size _ gal: Manufacture 0 0 0
Height of pump off bottom of pump chamber inches
Pump chamber draw-down gallons per inch per minute
Pump capacity - gallons per minute
Pump controls: Timer, Elapsed Time Meter,Counter? (Circle all that ❑ 0 0
apply). If timer: Pump On Pump Off
Riser installed for access?...............................................
Alarm installed?.......... 0 0 0
...........................
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` ' rrom Mason Cuunty DM S
Printed from Mason County OMS r;., ,. , 1 LUGS rq
RECORD DRAWING
CHECKLIST
iDrainfield& , ,
manifold orientation t' ,%, •
& layout AUG 2 �z// ►
❑ Trench/bed gc43
dimensions and • • REC /Ift
critical distances • . .
Sithin layout
eptic/pomp tank
placement
O Location of
buildings f
Njill
❑ Observation port& D•v-I,
clean-out location
❑ Location of wells& >
roads
❑ Undisturbed native
p.
soil between ./
trenches
Vi North arrow
git,,,r6s1)
eto
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CAUTION: Minor adjustments to septic tank location and draialield orientation made in the field by the installer are generally acceptable
to both the department and the designer, but could in certain cases compromise the viability of the system. It is tlrc installer's responsibility
to obtain prior written approval from either the health de'nartntent or thr dc'.ripnt•r before',inking any eleviationc•Irt n the devi;;tr Mot allect
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 date the certification
A. 0 1 certify that I installed the system without any 0 1 certify that all deviations from the design stamped
deviation from the design stamped"APPROVED"by "APPROVED"by MCPH are shown above.
MCPH
B. 0 I certify that I contacted the designer and left the 0 1 did not contact the designer prior to final cover becau+c the
system open for inspection up to 48 Its prior to cover. designer waived the notification requirement.
1 further certify that all information contained on this form is accurate. i understand tha ' information contai ed herein is not
accurate,there will he just cause for immediate suspension of my installer certilicatio .
Signal of nstaller Date
The undersigned approves this installation on behalf of Mason County Public health
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- c F^a� y� fir' :�°}2y'Ctg) COL!
c [�°�, ,{�C Environmental Flea tlth Specialist hate
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Printed from Masora County OMS