HomeMy WebLinkAboutSWG2022-00198 - SWG As-Built - 1/22/2024 ,t
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RECORD DRAWING (ASBUILT) pg. 1 MASON COUNTY PUBUC HEALTH..
PARCEL IDENTIFICATION
Permit Number SWGC��r CO L �7 Assessor Parcel# ,Lola-3z- qn'3/7_
Applicant Name t/ � N1Q,lI- Subdivision(Name/Div/Block/Lot)
Applicant Address Itx�� q L . �� rr
City.State,Zip old p qq5!7 Installer Name 2 i, �Rf7!1(
Site Address �,r6lltJ.A. QAr, signer Name Ada,ot, Nuk) r-
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INSTALLATION CHECKLIST
, ®Full System Installation ❑Tank(s)Only 0 Drainfield Only 0 Repair ❑Other
Fvf i System Type PIV:SI I __— Pretreatment Type
>5 ft.from foundation? - - ❑N/A e'tres ❑ No
>50 ft from wails? - - ❑ ta i
Y >50 ft from sufface water? - - 0 g ❑
Z
a Cleanout between building and tank? - - ❑ El ❑
V Tank baffles present? - - ❑ 0 ❑
I- 24"access risers over each compartment?- - ❑ CS3 ❑
a.
Lu Effluent fitter installed?- - ❑ e ❑
CO
Septic tank size /Zop gal Manufacturer I- uu `3 r6'111.4.
9 D-box water level and speed levelers used? - - ❑ N/A ayes 0 NO i` `
(1O Manifoki/D-box accessible from surface?-
❑ la 0
oZ Check valves installed? -
2 Transport Line Size Z I y\ Schedule/Class '4d
Bedrooms installed(check one) ❑2 5r3 ❑4 ❑5 ❑6 0 Commercial/Other
>10 ft.from foundation?- - 0 NIA RYES ❑ NO
• G >100 ft.from wells?- - 0 ❑
W >100 ft-from surface water?- - ❑ [I ❑ c! '
LT. >10 ft.from potable water lines?- - 0 (A 0 71
a
ZZ >5 ft from property lines and easements?• - El (� 0 t
CI
y et a >3C ft.from dcwngradient curtain'fo' rdstion drains?- n Uil 0 '
Drainfield level and observation ports present - - 0 El CI "- I`
❑ Graveless chambers or Clean gravel used? (check one) c
Proper cover installed over dra nfield?- - ❑ (I 0 . l
Pump tank setbacks consistant with septic tank?- - 0 N/A ISI YES 0 Nd t . :;
X Pump tank size /7_43b gal Manufacturer f-fav yc. goo -tt
24"access riser(s)and accessible from surface?- - 0 ® ❑ >
a Alarm or Control Panel Installed? -
0 ® CI
j Control Panel equipped with Timer/ETM I Counter- - El23 ❑
a Pump Installed in ❑ Bucket or Qs On Block or 0 Other
'a' Pump Make/Model Z 4(ICJ' N 1 S?, ® Floats or 0 Transducer
2
a
Tank draw down pZ Inlmin Pump capacity & gpm Squirt Height / ft
, Pump on time_ "_ Pump off time 4 h,/`3 Daily flow set at 3G0 gpd
uia..e 12a7 C,0
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` 3v MCPH RECORD DRAWING (ASBUILT) pg. 2 Assessor Parcel# -
RECORD DRAWING
1
..-' 0 D49tr:Sa i a manifold
orientation&layout
w/crnIna one(or
rs4ocauon.
0 Trench/bad
dimensions and
��Lst critical distances
egl` within layout
❑ $*ptic/{xunp tank
placement
❑ Location of bulkli gs
axisergrproposab
❑ observation ports.
clean-out locatkms,
&manifoldsta-boxes
❑ Location of welts.
seism Mahar,roads,
• &watarllnes.
❑ Reserve area(s)
❑ North Arnow
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
I 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
hem 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
1 further certify that 3i1 information contained or,this I further certify that all information contained on this
form and attached R D cu form and attached Record wi is a .
I .
ilf/2
Slgrta re n Iler date `
Printed Name of Slgnee �� to
MASON COUNTY PUBLIC HEALTH /•4,- I., s)�4
The undersigned approves this Installation Report and A?' sifkir3 'rIi. 4,
r O pmEs It.ifuN ER '' +
Record Drawing on behalf of Mason County Public • t
r l.ICrFicrf)^FSIGN�R 1
Health: �•..�� -• :.•- csi. •s,
E{mot S: •O 1122/Z
`mot (---7_242:--1
Signature of Environment I Health Specialist Date and date)
stamp, signature
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE U Sd 121m°1
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