HomeMy WebLinkAboutSWG2019-00280 - SWG As-Built - 5/10/2024 (2) 260 - -7 o s-- i36o
RECORD DRAWING (ASBUILT) pg, 1 MASON COUNTY PUBLIC HEALTH
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Permit Number SWG q�0 Assessor Parcel# -f�-/,'1.�-j/-- "�[�„Zc>
Applicant Name '$��s p 11 c>Kf Subdivision (Name/Div/Block/Lot)
Applicant Address
City, State, Zip -Sur^ Jve/�. D/'. q 7704nstaller Name.. a,2ke ,Exem L L N,
Site Address 57.E f L ISrycc,K'+ Q Designer Name IV✓� V
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Full System Instl!a��llation ❑ Septic Tank/OJnly ❑ Drainfeld Only ❑ Repair
System Type Y "Z 6 L es e,-.cs( Pretreatment Type
"31>5ft.from foundation? -------- ---- ---- -- - ------- ❑ MIA ' YES NO
3 -_>60 ft.from wells? ---- - - - - ----- - - ❑ ❑
~ >50 ft.from Surface water? -_ ___ -_ - - - - - -_- Q ❑
.,at.Cleanout between building andtank? ------- -- - ❑ ❑
Tank baffles present? --- - -- -- -- - --- - - - - ❑ f. ❑
eh= '.24"access risers over each compartment?- -- -- -- -- - - ❑ ❑
❑ SEl ❑
u
4W ? Effluent filter installed?------------ ---- --- --- - -- --
° Septic tank size al Manufacturer J[rlti++e(' ���Cc. ile'111
D-box water level and speed levelers used? - -- ---- ®„wA El YES El NO
4 Manifold/D-box accessible from surface? - ---- ---- - .® ❑ ❑
Check valves installed? -- - - -- -- - -- - --- - -- - - ---l— ❑ El�
d
Transport Line Size It Schedule/Class LA , yo ,
ii i ' y Bedrooms installed (check one,) ❑ 2 D ❑4 ❑ 5 ❑6
>10ft.from foundation?-- - -- - - - --- - - -- -- - - --- -- -- El MIA AYES El No
p >100 ft. from wells?- ---- ----- --------- --- -- ----- ❑ 2 ❑
100 ft,from surface water? ------- -- - ❑ 9j ❑
W..
su,l>10 ft from potable water lines?--- -- -- -------- --- - --- El -KI El'2 ->5ft.from property lines and easements?- ---- - - - ------ - - ❑ 19 ❑
''..> 30 ft, from downgradient curtain/foundation drains? --- - - -- --- ❑ ® ❑
"Drainfield level and observation ports present - ---- - -- ------ ❑ -®. ❑
❑ Graveless chambers or a.Clean gravel used? (check one)
'.Proper cover Installed over drainfleid?--- ----- ----------- ❑ ] ❑
* k'Pump tank setbacks consistent with septic tank?---- -- ------ El MIA ,,�] ves a} El No
;'Pump tank size /,AQ6 gal Manufacturer � Ior ��FP-I -cam
r 24" access risers)and accessible from surface?---- - - - - ❑ 2 ❑
�^-`t SAlarm or Control Panel Installed? -- - - - - ----- - - - -- - ❑ ❑
Control Panel equipped with Timer I ETM/Counter-- - - - - - ❑ ®„ ❑
Pump Installed in ❑ Bucket or Z On Block or ❑ Other
v, } Pump MakelModei L Floats or El Transducer
'l.Tank draw down_. -?inl Pump capacity_��gpm Squirt Height � 6 ft
Vj: �.Pump on time - Pump off time Daily flow set at U!lv apm
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RECORD DRAWING (ASBUILT) pg. 2 MASON COUNTY PUBLIC HEALTH
RECORD DRAWING
❑ nralnfield&
manifold orientation
&layout
❑ franchised
dimensions and
critical distances
within layout
septidpump tank
Placement
Location of
buildings
Observation ports
clean-out locations
❑ Location ofwells,
surface water,&
roads
Undisturbed native
sail between
trenches
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 separate page attached. No. Pages Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER
I certify that I installed the system in accordance with 1 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 Masan County Codes
I further certify that all information contained on this i further certify that all information contained on this
form and attached Record Drawing is accurate. form and attached Record Drawing is accurate.
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I our flnstaller Date fJ
Printed Name otSignee ra zT r r
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public rr>'o �I lfflsrr^ fir<I r ft
Health:
Signature ofEriviemmental Health Specialist Date (designer's stamp, signature and date)
THIN FORM MAYBE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE
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