HomeMy WebLinkAboutSWG2022-00514 - SWG As-Built - 10/23/2023 DaceSign Envelope ID:BF381CC1-66FF-4704-B781-C9094C6B8E82
Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2022-00514 Parcel # 22021-50-00905
Applicant Name LYNCH ANDRFW C & SUSAN K Subdivision (Name/Div/Block/Lot)
Applicant Address 919 N RUSTIC RIDGE PL
City, State, Zip SAHUARITA AZ 85629 Installer Name Scott Johnson
Site Address 831 E BENSON LOOP Designer Name Micah Halverson
INSTAL 1ST
❑ Full System Installation ❑Tank(s)Only I] Orainfield Only Repair ['Other
System Type Pressure Trench Pretreatment Type Future NuWater
>5 ft. from foundation? - - X❑ NIA ❑YES ❑ NO
>50 ft. from wells? - - 0 0 ❑
Z >50 ft. from surface water? - - I] ❑ 0
F Cleanout between building and tank? - - 0 ❑ ❑
0 Tank baffles present? . - 0 ❑ ❑
a24" access risers over each compartment?- - 0 ❑ ❑
W Effluent filter installed?- - 0 0 ❑
CO
Septic tank capacity(working) gal Manufacturer
O D-box water level and speed levelers used? - - 0 N/A ❑ YES ❑ NO
DJ
O ManifoldlD-box accessible from surface?- - ID 0 ❑
(92 Check valves installed? - - 0 0 ❑
OQ
5 Transport Line Size 2" Schedule/Class 40
Bedrooms installed (check one) 0 2 0 3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A 0 YES ❑ NO
O >100 ft.from wells?- ❑ ® ❑
W >100 ft.from surface water? - ❑ 0 0
it >10 ft. from potable water lines? ❑ 0 ❑
Z > 5 ft.from property lines and easements?- - El 0 ❑
a
W > 30 ft, from downgradient curtain/foundation drains? - - ❑ 0 ❑
0 Drainfield level and observation ports present - - ❑ 0 ❑
0 Graveless chambers or 0 Clean gravel used? (check one)
Proper cover installed over drainfeld?- - 0 0 0
Pump tank setbacks consistent with septic tank? - 0 N/A ❑ YES ❑ NO
• Pump tank capacity(flood) gal Manufacturer
< 24"access riser(s) and accessible from surface? ❑ ❑ 0
~ Alarm or Control Panel Installed? - - ❑ 0 ❑ a-
a
2 Control Panel equipped with Timer/ETM/Counter- - ❑ ❑ ❑ -
ri
a_ Pump installed in 0 Bucket or 0 On Block or ❑ Other
O.f Pump Make/Model ❑ Floats or ❑ 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 8/912018
DocuSign Envelope ID:BF381 CC1-66FF-0104-8781-C9094C6B8E82
Mason County OSS Installation Report pg. 2 Parcel# 22021-50-00905
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - YES Q NO
If yes, please describe:
Were all components pumped out and properly abandoned per WAC246-272A-0300? - - ❑ YES ❑ NO
RECORD DRAWING
This la a permanent record and must be accurate and descriptive enough to re-locate In the need of maintenance activities and future development Typical Record
Drawings ronlain. Drainfield 8 manifold onentalion&layout,Septic/pump tank location,North arrow,reserve drainfield.existing and proposed buildings,location of wells,waterlines,
wells,observation pods cleanouls,and other maintenance access points. Incomplete Record Drawings may create additional delays in final installation approval and related permits.
Drainfield Installed only.
see Approved Design
Q Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
1 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 certify that all information contained on this I further certify that all information contained on this
fn(g,agagached Record Drawing is accurate, form and attached Record Drawing is accurate.
10/11/71
utteauttettleatetat
Signature of Installer Date
i • III
Rend [Musson t i� f1t
Printed Name of Signed 0 if t
e.MASON COUNTY PUBLIC HEALTH / tit
The undersigned approves this Installation Report and V : R y�sl1
Record Drawing on behalf of Mason County Public 5100409 �r
SCANTAN&W14VE118 I t
Health: i uceiseo Dea3NEe 11
(���M (0 �3 R3 E oenwfl t
Signature of Environmental H Ith Specialist Date (stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated PQ112018
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