HomeMy WebLinkAboutSWG2023-00081 - SWG As-Built - 9/27/2023 i
#11
RECORD DRAWING (ASBUILT) pg. 1 MASON COUNTY PUBLIC HEALTH
PARCEL IDENTIFICATION
Permit Number SWG k4 Qa 3 -- 000 \ Assessor Parcel # ?.02 C A0 -10 -g00--7('
Applicant Name k%r-'t t•-t OR 2\c--, Subdivision (Name/Div/Block/Lot)
Applicant Address 1 ,9,9. ,(, iv. Oc.
City, State, Zip i t Cza ,j]pi. , C1(?)001 Installer Name Ij $, -1v Um- -raa (C n
Site Address LttO e- 't. l(,CLC L__ Designer Name 1\-k +..cM skiff---R
INSTALLATION CHECKLIST
3ull System Installation ❑ Tank(s)Only ❑ Drainfield Only ❑ Repair ❑ Other
System Type -\ E SSv f-r Pretreatment Type
>5 ft. from foundation? El El YES ❑ NO
>50 ft. from wells? - tl 1 - El El El
Z >50 ft. from surface water? - s€ --�r r S-- - - ❑ ❑ ❑
H Cleanout between building and tank? - - El CI ID0 Tank baffles present? - t\rr 1 - El El Elfey
d24" access risers over each compartmenf?------ --- ==----_--- El ❑
W Effluent filter installed?- - ❑ ❑ ❑
U)
Septic tank size OW n gal Manufacturer T-1-11t; k 1...t_rrY2.PrTD V,
0 D-box water level and speed levelers used? - - ❑ N/A ❑ YES ❑ NO
DO Manifold/D-box accessible from surface?- - ElEl❑
OOZ Check valves installed? - - ❑ ❑ ❑
OQ
2 Transport Line Size 2-. Schedule/Class SC-H C>k- 1---E7 90
Bedrooms installed (check one) [ 2 ❑ 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation? - - ❑ N/A YES ❑ NO
O >100 ft. from wells?- - ❑ � ❑
W >100 ft. from surface water? - - El Ell El
>10 ft. from potable water lines?- - ❑ [Y' ❑
Z > 5 ft. from property lines and easements?- - ❑ E ❑
a
O ❑ B"> 30 ft. from downgradient curtain/foundation drains? - - ��,/ ID
Drainfield level and observation ports present ❑ L� ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one) ^�
Proper cover installed over drainfield?- - ElL ❑
Pump tank setbacks consistant with septic tank? - - ❑ N/A DYES ❑ NO
• Pump tank size ►Q ID 0 gal Manufacturer l --1 c-t�a"9-R`-LA
Q24" access riser(s) and accessible from surface?-
I—
d Alarm or Control Panel Installed? - - El DM_
El
2 Control Panel equipped with Timer/ ETM /Counter- -
❑ ❑
D
n- Pump installed in ❑ Bucket or D7On Block or ❑ Other /
1- Pump Make/Model U'(ZI�C.O S r I 0 uD l k L( Floats or ❑ Transducer
Tank draw down a in/min Pump capacity 1 •, ( gpm Squirt Height i�1L1��C'-�t T-1-1
a a
Pump on time 2 5 C C., • Pump off time of �-'S Daily flow set at ‘ V 0 gpd
Updated 12/7/2015
MCPH RECORD DRAWING (ASBUILT) pg. 2 Assessor Parcel #
RECORD DRAWING
❑ Drainfield&manifold
orientation&layout
w/dimensions for
re-location.
❑ Trench/bed
dimensions and
critical distances
within layout
❑ Septic/pump tank
placement
❑ Location of buildings
existing/proposed
❑ Observation ports,
clean-out locations,
&manifolds/d-boxes
❑ Location of wells
surface water roads.
&waterlines.
❑ Reserve areals)
❑ 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 certif t t all inform on contained on this I further certify that all information contained on this
form al d a ohe ecor rawing is accurpte. form and attached Record Drawing is accurate.
1Z/.2-3
Sign ure'oflnst Iler Date #;•- �tk o/
On , (.),,, ( it ioNcifx:c n 'i: -T17.* 1
la
Printed Name of Signee ,,.,>: ''\#
/4-:.:0 w.t,, .•i.,f,
MASON COUNTY PUBLIC HEALTH �•t a. a ��++
g
The undersigned approves this Installation Report and ' •
} `r>
Record Drawing on behalf of Mason County Public /`�• ADAM J.HUNTER 1�
Health: , wok, % 14.1. • igokm. iiimi
kP3 --1'Ny.A, 6f'( I-I t_>:t Ls ti�
Signature of Environmental Health Specialist Date (designer's stamp, signature and date)
9 ( 9 P
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 1?172075
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