HomeMy WebLinkAboutSWG2021-00448 - SWG As-Built - 12/26/2024 RECORD DRAWING (ASBUILT) pg. 1 MASON COUNTY PUBLIC HEALTH
rP/ARCEL IDENTIFICATION
Permit Number SwG )-G�I -OGUU 0 Assessor Parcel# 220185H 000 3 3
Applicant Name hx((1 SVI19YP_ (0Vlsi-. Subdivision (Name/Div/Block/Lot)
Applicant Address
City, State, Zip Installer Name
Site Address Designer Name �i✓t'1 ��"PY-�� .�O(.
INSTALLATION CHECKLIST
Full System Installation ❑Tank(s)Only ❑ Oriented Only ❑Repair ❑Other
System Type ❑ n Pretreatment Type L1 /LL.
>5 ft.fromfoundation? ----- - - --- QfY1t7 ❑NrA . YES ❑ NO
>50 ft.from wells? - - --- - - -- - - - n ❑- - ---L'� ❑ r-'�' ❑
Y >50 ft.from surface water? -- -- -- - �r�� 2
z _v�e�3 3o-zt ❑ tee'/ ❑
F Cleanout between building and tank? - - - - - - - - ❑ I��/ ❑
U Tank baffles present? - - - - - - - - - - - - -- - -- - - -- -- ❑ LY ❑
24"access risers over each wmpartment By ❑ ElW Effluent fitter installed?- - - - - - - - - - - - - - - - - -- - - - --- -- L
Septic tank size al Manufacturer ,❑�Icr ❑
0 D-box water level and speed levelers used? ---- - ----- - - --- ❑WA MIN' ❑ NO
J
QUQO Mandold/D-box accessible from surface?-- - -- - --- -- -- ----
stalled? ❑ — / ❑
'Y= Check valves in - - - - - - - - - - - -- - - - -- --- - -- - - ❑
C0
Transport Line Size I / Schedule/Class li Bedrooms installed(cheek one) B2 ❑3 ❑4 ❑ 5 ❑0 ❑CommerciaVOther
>10ft. from foundation?-------------------------- ❑ WA ryEs No
0 >100 ft.from wells?-- - - - ------------------------ ❑ (J ❑
-3 >100 ft.from surface water? - ----------------------• ❑ ❑
LL >10 ft.from potable water lines?-- -------------------- ❑ [y� ❑
Qz > 5ft.from property lines and easements?- - - - - ----------- ❑ ,L,..'_1�,// ❑
C > 30ft.from downgradient curtaintfoundation drains?---------• ❑ I� ❑
0 Drainfield level and observation ❑ L7 ❑ports Present � - - - ----------
❑ Graveless chambers or ❑ Clean gravel used? (chef tone) V110V
Proper cover installed over dramfield?- - --------------- -- ❑ I, ❑
Pump tank setbacks wnsistant with septic tank?--- - -- ---- --- ❑ WA yes ❑ NO
1 Pumptank size—gal Manufacturer fA1jqY ___
z
f2C access riserfsl and acco-ill frnm suMane� -- / ❑
tL Alarm or Control Panel Installed? - - - - - - - - - - - - - - - - - - - - ❑ L4 / ❑
f Control Panel equipped with Timer/ETM ounter- - - - - - - - - - - ❑ d ❑
7
a Pump installed in ❑ Bucket or On Block or ❑ Other
Pump Make/Model C hat [R Floats or ❑ Transducer fil
1 Tank draw down m min Pump capacity pm Squirt Height
Pump on time Pump off time W Daily flow Set at b5(�lR apd
ul 1111015
MCPH RECORD DRAWING (ASBUILT) pg. 2 Assessor Parcel If
RECORD DRAWING
❑ Diainfield&manifold
orientation&layout
wldimensions for
re-IOUtion.
❑ Trench/led
dimensions and
moral distandes
within layout
❑ Sept.dpump tank
Placement
❑ Location of buddngs
existing/proposed
❑ Observation ports
dean-out locations.
8 manifoksM-0oxes
❑ Lo[ation of wells.
sWfaoe Water,roads.
&waterlines
❑ Reserve aria(s)
❑ North Ad"
It the designer or installer feel the need for additional mformaboNComments. 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 1 installed the system in accordance with I certify that the system has been installed in eccor-
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 clearad/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 that all information contained on this I further certify that all information contained on this
form and attac ed Record Drawing is accurate torm and attached Record Drawing is accurate.
S'g flnsfaller Date
t 11 l TUtiwa 1 Y;
Pnnfed Name of Signee 1 5
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and ♦ dr
Record Dmwing on behalf of Mason County Public Aoar i eurvTea
Health: "L'iCt'rv5V'514'S1i,WR—
RA7q^ vvl IZ42tfl L, I
Signetum of EnNmnmemel 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 U.I.
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