HomeMy WebLinkAboutSWG2021-00469 - SWG As-Built - 12/30/2024 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/PERMIT INFORMATION
Permit Number SWG 2021-00469 Parcel# 321275400075
Applicant Name John Donjon Subdivision (Name/DivBlock/Lot)
Applicant Address 4760 MELISSA JO UN LAKE LIMERICK 5,Lot 75
City, State, Zip SAINT LOUIS MO 63128 Installer Name Jim Zlmny
Site Address 231 EKILMARNOM RD.SHELTON 90504 Designer Name Mike Skinner
INSTALLATION CHECKLIST
■Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other
System Type Pressure Distribution Pretreatment Type BNR 500
>5 ft.from foundation? -- ------ �(pl� {}1y7� -- ❑ NIA Eves ❑ No
>50 ft. from wells? - ----- --- - l��rr �Ij tu'J - -- ❑ ■ ❑
Y >50 ft. from surface water? ----- -
HCleanout between building and tank? -- -- -- -- -- -- ❑ E ❑
Tank baffles present? ---- - - --- --- - - -- - - - - ❑ ■ ❑
24"access risers over each compa ----- - ❑ ■ ❑
1-- Effluent fifter installed?------------- ----------- --- ❑ ❑ ■
Septic tank capacity(working) 1000 gal Manufacturer H gennan BNR 500
0 D-box water level and speed levelers used? ---- ----------- ■ NIA ❑yes NO
DO Manifold/D-box accessible from surface?--------------- -• ❑ ■ ❑
O?Z Check valves installed? -- - - ----- - - --- ----- ---- - -- ❑ ❑ ■
oa
f Transport Line Size 2" Schedule/Class Sch 40
Bedrooms installed (check one) ®2 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10ft.from foundation?----- -- --------- - - -------- ❑ NIA Eyes NO
0 >100 ft.fromwells?---- ---------- ------------ -- -
❑ ■ ❑
W >100 ft.from surface water? ------------------------ ❑ ■ ❑
tL >10ft.from potable water lines?---------------------- ❑ ■ ❑
ZZ >Sft.from property lines and easements?--------- ------- ❑ ■ ❑
R' >30 ft. from downgradient curtain/foundation drains? ---------- ❑ ■ ❑
Drainfield level and observation ports present ------ - ------ - ❑ ❑
E Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?------ ------------- ❑ ■ ❑
Pump tank setbacks consistent wfth septic tank?------ ------- ❑ NIA ■ yes NO
Y Pump tank capacity(flood) 1000 gal Manufacturer
Z 24" access riser(s) and accessible from Surface?------------- ❑ ■ ❑
aAlarm or Control Panel Installed? ----- --------- ------- ❑ ■ ❑
2 Control Panel equipped with Timer/ETM I Counter-- --------- ❑ ■ ❑
a Pump installed in ❑ Bucket or E On Block or ❑ Other
IL Pump Make/Model Liberty 280 ■ Floats or ❑ Transducer
ILTank draw down 1.5" in/min Pump rapacity 30 gpm Squirt Height 10 ft
Pump on time 1 min on Pump off time 4 Firs Daily flow set at___LBO gpd
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Mason County OSS Installation Report pg. 2 Palma �Z Z 7 S'/Oo07S-
ABANDONMENTRECORD 1
Ware e.." "DID, over amnia abae riore as pan of Ihre Proffitt I? - - - - - - - - - - - - - YES 0 No
If yth,plpme aaarrlee
Were all eanppnenn pumood oul end pNMnY nwndunea pq WACzae-172A-0lOOp - '' - - ' ' ❑ YES NO
RECORD DRAWING
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Record Drawing Attache;I
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I cIn ily thnt I installed Ihn.system m accordance with I raddy that she system bav bean installed In 8CCOM1
the septic design stamped"APPROVED-by Mason dance with the septic desgn sla aped"APPROVED by
County Pobla:Health and trial any tMnnlwns SIWwn Muson County Pvbhc Heallh and that any deviations
here have been ch amolapmoved by both It.desngnar shown here have bean Clemed/appmved by bath
and Mason Colmly Public Health and most all State myself and Mason County Public Health and meet all
and Mason County Godes State and Meson County Codes
I further,Cemty thaf:NI information cmrlmrrod on this I bother teddy That all inlormafoon contained on this
form and almrherl Rueoul Omwmg is accurate form and almrhod Renm1 Drawing is accurate
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Fretted Neroled Sgmre � pei
MASON COUNTY PUBLIC HEALTH
The lmdemrgnod appmvos for,lnstaimbon RnpoR and
Record Drawing on behalf of Mason County Public LM `" icilpR
Healthy
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