HomeMy WebLinkAboutAFTER THE FACT - SWG As-Built - 10/20/2022 AFTER THE FACT RECORD DRAWING, pg 1 MASON COUNTY PUBLIC HEALTH
-PARCEL IDENTIFICATION
Owner Name t(Srnij Assessor Parcel!#
Mailing Address O ax q2,5 OIM Specialist Name ! T f
City,State,Zip Shc,(Jptl A 115PG Installer Name
Site Address (/`121 - SKolrWn,r sV ner Name
Please complete this checklist to the best ofyourknowiedge. if items are unknown leave blank.
INSTALLATION CHECKLIST
rt� Pretreatment Type N ~
System Type rA/nQ �d (017 Drainfield depth gf_
Drainfield Ln.FL 20� DraIMNd Sq.Ft.
>5ft.from foundation? --------------------------- ❑NIA YES El No
>50ft.from wells? -__ _ _ __ _____ _____________ _ ___ ❑ �( ❑
X, >50ft.from surface water? ----- ------- --------- --- ❑ ❑
f
Cleanout between building and tank? ------------------- ❑ ❑
tl Tank bathes present? - ---- - -- - ------ --- --------- ❑ t..i ❑
24'access deers over each compartment?---------------- ❑ IN ❑
Effluent filter installed?-- --- ----- ❑ ❑
SePllctank size 12�00 oat Manufacturer ur+tF1ei"-�
0 D-box water level and speed levelers used? ------------- - - ❑IeA NO {
O0 ManifoldlD-box accessible from surface?-- - ------------- -ih ❑ ❑ �rL�j-fJs(
C?Z Check valves installed? -- ------ - - ------------- - - ❑ El
pQ n
g Transport Line Size Z SchedulelClaes
Bedrooms installed(if known) 02 D93 ❑4 05 06 ❑CommerdavOther
>10ft.from foundation?--------- - ------------- ---- L] WA YES NO
>100 R from wells?-__ __ __ __________________ ___ - ❑ ❑
>100fl.from surface water? -- -------- ------- --____. ❑ M El
W
li >10fL from potable water lines?--------------------- ❑ ❑
>5ft.from property lines and easements?---------------- ❑ ❑
>30 ft.from downgratllent curtaiNfoundatlon drains?----- -- -- - [� ❑
Observation ports present? --- ---- --- - --- ❑ ❑
19 Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?--------------- ---- ❑ ❑
Pump tank setbacks consistent with Sepik:tank?----------- -- ❑Q WA YES ❑ No
Y Pump tank size_;j sal Manufacturer s.ID¢wtxe
Z
24°access riser(s)and accessible from surfare7 -- ------ -- -• ❑ O
sL Alarm or Control Panel Installed? ----------- ❑ st
'E Control Panel equipped with Timer/ETM I Counter-- - -- -- - - - - ❑ ❑ L:1
IL Pump Installed ir. ❑ Bucket or ,X On Black or ❑ Other
a- Pump Make/Model 04 KNOW loafs or ❑Transducer
y Tank draw dowr irimin Pump capacity apm Squirt Height ft
Pump on time Q 04 QW4"" a Pump oft time Daily flow set at apd
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AFTER THE FACT RECORD DRAWING, pg 2 Assessor Parcel# r7"ll ?S ` 6po yp
RECORD DRAWING
❑ oralmleld&.1fold
orientation&layout
wlBm.nsiae fix
MAOcatkn.
❑ TrenWeed
dimensions and
vitkal dlat.noss
wilhinlniuit
❑ S.Prilpump lank
wosfionwNimen-
sions In'ro-Icodxn
❑ LiNNIOGn of Wildings
a Xistiiglproposed
❑ Observation cons,
da..t OLatpnS.
amanifoldsldrbmtes
❑ Loose.r Ofwells,
sort..water,roads.
&waterlines.
❑ Reserve area(-)
❑ Nor Arrow
If needed drawing maybe attached on a separate page No.Pages Attached G.
CERTIFICATION OF INSTALLATION
DESIGNERi APPROVED DIM SPECIALIST
i certify that themlIgniqation contained in this document is accurate to my knowledge. The drawing and information
a een obtain tl t ugh common locating practices.
L0 ( 19 �2z
Signature of Designer oi-Appmved DIM Specialist Date
MASON COUNTY PUBLIC HEALTH
This is an after the fact record cifawing, which may or may not include a county inspection. This information is to only
document an existing OSS location and components.
�� 1! %Nn to(14 I
Signature of Environmental Heallil Sjoa alis! Data
THIS FORM MAY BE SCANNED AND AVAAABLE FOR PUBLIC VIEWON THE MASCN COUNTY WEB SITE upe.w mmo�e
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