HomeMy WebLinkAboutSWG2023-00215 - SWG As-Built - 10/10/2023 RECORD DRAWING (ASBUILT) pg. 1 MASON COUNTY PUBLIC HEALTH
PARCEL IDENTIFICATION Permit Number SWG 2G2 ?- C. 2 I') Assessor Parcel# 4 2 �7 C L C (LI`/L'('
Applicant Name C. nrinra \LhCS'Qb ivision (Name/Div/Block'Lot) •
Applicant Address .7 ' C' AILt' Sff ,1—l-1U I /``
City, State, Zip (. Ll)1 1) Iel, IA, IA Cq?`6C )-Installe�r�Name Otte (\Iic(jib ,
Site Address 3371 wl aPjtn \ Au (.b si4Name Aci ni .41u1 Y
INSTALLATION CHECKLIST
Full System Installation ❑Tank(s)Only p Orainfield Onii Repair ❑Other ,
System Type <1GyA� 1.1IM L \i2SS\:( fpatment Type ,ti'1 (N.'.
>5 ft. from foundation? ❑ NA Ds ❑ NO
>50 ft from wells? - ❑ V ❑
Z >50 ft.from surface water? - ❑ Et/ El
1--
• Cleanout between building and tank? - 0 EV ❑
O Tank baffles present? - ❑ EY ❑
I— 24"access risers over each compartment? 0 LW' ❑
0.▪ Effluent filter installed?- 0 By ❑
tO
Septic tank size- l( 7t ) 0 qal Manufacturer \I\"-\—t 1,44,
S D-box water level and speed levelers used? IA 0 YES ❑ NO
Ou.
0 Manifold/D-box accessible from surface? —/ ❑ 0
r?= Check valves installed? - L7 ❑ ❑
f Transport Line Size •T chedule(C lass LAC,'
Bedrooms installed (check one) ❑ 2 3 0 4 0 5 ❑6 ❑CommercialOt er
>10 ft.from foundation?- ❑ WA [�ES I] NO
O >100 ft. from wells? ❑ ❑
W >100 ft.from surface water? - ❑ 00
II >10 ft. from potable water lines?- ❑ Ei ❑
3 > 5 ft om property lines and easements?- ❑ gi ❑
2 > 3 ft from downgradient curtainHoundation drains?- ❑ /' ❑
0 �DIr6ainfield level and observation ports present ❑ [� ❑
ly Graveless chambers or ❑ Clean gravel used? (check one) J
Proper cover installed over drainfield? - ❑ LJ/ ❑
Pump tank setbacks consistent with septic tank? N/ YES ❑ No
Y Pump tank size 1�J(.JL.' qal Manufacturer 1M° [A,, /
FZQ- 24"access riser(s)and accessible from surface? ❑ J[J ❑
O. Alarm or Control Panel Installed? - ❑ ❑
2 Control Panel equipped with Timer/ETM,/Counter ❑ Et ❑
D
O. Pump installed in 0 Bucket or dOn Blockk or ❑ Other
O. Pump Make/Model t\�a\ 1\I \ ) h I IY\ ( Floats or 0 (Transducer
a Tank draw down in/min Pump capacity /I ''U11/ qpm Squirt Height
Pump on time 1() S i C , Pump off time L-1 1"\\ S Daily flow set at q(t'C qpd
updated lb7/I013
MCPH RECORD DRAWING (ASBUILT) pg. 2 Assessor Parcel#
RECORD DRAWING
Drmnfield&manifold
orientation&layout
w/dimensions for
re-location
El Trench/bed
dimensions and
critical distances
within layout
El Septic/pump tank
placement
El Location of buildings
existing/proposed
El Observation ports,
dean-out locations.
8 manifolds/d-boxes
❑ Location of wells.
surface water,roads.
&waterlines
❑ 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 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 hem 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 t t ell information contained on this I further certify that all information contained on this
form a�/{�-nfj\a a eco Drawing is accurate, form and attached Record Drawing is accurate.
h C. (.I / 7/C /- I... , R
Signature of Installer Date r �'I1Y h)
�,( (kiIA611 1� 1( 1110S( )'�• �
Printed Name of Signee h "11
MASON COUNTY PUBLIC HEALTH 1r
The undersigned approves this Installation Report and
�,
Record Drawing on behalf of Mason County Public C� ,.,.
Health_ Gtrct 1 ,>,-�x x>LX.:,'
Cit-TNQAMVC6141 I 0 f h 123 ,.,
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 utweua vnrzou
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