HomeMy WebLinkAboutSWG2002-00035 - SWG As-Built - 2/3/2005 FROM :DON I FAX NO. :5598979557 Jan. 12 2005 12:09PM PS
RECEIVED
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FROM :DON I FAX NO. :5598979557 Jan. 12 2005 12:10PM P2
FROM :Ro95 E%C FAX NO. :426 03.50 Jan. 12 2005 12:58AM PS
MASON COUNTY DEPARTMENT OF HEALTH BERVICEE
CA NO. BWO �+
e
426 W.CEDAR/P.O. BOX 1666/6HELT0N,WA 98G6A geceipt No.
PHONE(360)427-96,70 S = I
P Ty ow Nln� Are C_I O Z� ,CHECK APPLICABLE ITEMS �/ m
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MAILING ApeQFSS: DAYTIME PHONE:
,.`1\ K q� -, V _— _ REPNf SYSTEM
TABLE 6 REPAIR
STAr A0��11 MAIIJENANCEREVIEW
PROPERTY ADDRESS! WWII,
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CIFICOIR CTIO RlpppCCCAAATING SIT PRIVA7EW0.L g
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SY3fEMWRY _
SYSTEM NAME I�
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Name � an . v II`)
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OFFICIAL USE ONLY BELOW THIS LINE I II�/Yy✓..
DEPARTMENTAL SOIL LOGS DEPARTMENTAL COMMENTSfOONDITIONS f�
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I=Very G.pdyeBy S=sand L-loam Si.sh C=day E=EAwailY
NSPECfOR 'm name) INSPE
CTION SIGNATURE DATE PE31MIT EJ(pIRATION DATE
2 NSPECTOT.M rattle
Aa systems rega>eon""Op"ion am Maedehaw(Ow as 9"onsd'n mom CoY ly On-SYe SLaMuds.
Aa on.sYa wwape.ya a v,must be do and by a Macao CoBney,Coffed D.O.u a Prolessiorn'Etgnex,Wen Prb appw Is premed otherwiva
Am onsaa wwape syatams iron be rtt caw by a MYasn OBYnry Owthad Instuer.Wne wwr approvd'u planted omeewee.In sash oases a preormw Ty emcee
mewing behove,hole,dapaAment vW am a nanmwrwr lemgYww.
OnaAe wwape9ydam dBeQi epelevel deH nA MPIy Other baklMp W NpalalnpM(i.3.RLC,WYer MpYKW hate been mN.
Any ade�n�geefrom Y»aaxlsed YsedNa plopny or enyeite alWalien slMrerp the rysem YeBlpn meY inWtlW Vua pwmiL
The pmlaaRYe9a yeas avn Mdah dsae review.DenW dmis patent M oaleem Me Neelpl OMnerw9nb to ad tleniY dale.
,EBIO WApPROVA[Bv: DATE INSipp��ppT NAPyPa�oL" I Z. DATE'
TOP: Health Dept.Copy MIDDLE:Designees Copy BOTTOM:Applleant'e Copy
FROM :DON I FAX NO. :5598979557 Jan. 12 2005 12:10PM P3
OBS IXG FAX No. :426 0^>3B Tan. 12 2205 10MAM P2
FROM :R
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Applicant �ian 1` 1v1�1t1� Asaesaor's 134/ OaUZo
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Petm u NNO ilAitNumb � 3\
Installer ��L� (��� \ Subdivision ee,m,wewm wu p
Designers
WA Yes Prior in,Completion
1. SEPTICTANK
A) >S R From fsca41111907.,,.
B) >50 ft fib o wilts oc b&cj*amt4 —
B) Bldg wwuboarelapBc Adc w&W ....1....................... —
D) Baffles iomct and Clran7 .. ......... ..... ...................... ---
B) DNidll4 well ianW7..... .. _. _— —
r) ]Risen installed for aeces87 ... -
0) Teak Slu:��_gal;Mwdwntn RA
II. ) l.
ALev
A) ayeled wiW wara(t ... .. .. .................................. �C_ —
B) gpoodloyelar wed? •-111. ORAINFIELD
A) >10 ft from fomdeuou ad>5 ft hm property lima? ...............
B) >100 A does wells and surface wafer? ............................
G) >t0 ft been potable warn Bnot7 ...
A) Leaenla level W± I Web&end CW protein If tut bepg7 ........... --
B) fhwelbu Chimbenuogrod? J=—
p) Symm&casious the same m sham us the dedpd................ —
O) ?ravel dran,plop riy sized,and proper depth? .................... —
iD ►esasuaa9rattae
I) Seed quality AS1M C.137 .. ....... ........ .:.........lr... —
2) )lead height milarm aed 2U Inched? AMW faced hol�t1_.. _
3) Qnn-eats and oheetvadoa ports prtsmrl ...... ........... ... --
4) Mosad: 91de910pe30 .... ...... ................... .. ..
5) Owner afomsed elwblW cmmecti m must be made by ✓
owner or licensed elecbiolen and Impected by Lt17 ........• ...
IV. m
P UMP CHAMBER
A) W pump model .�E_N II
A) Pumpmaks w�\__� —
B) chambusiao 1a7 9d; Manufacture 1. 13 _
1 C) meight of pump of bmmm of pump chamber ieci»s
D) Pump chwilffdmw.dewa Ballone per Won
E) pump Capacity gallons per minute
f7 pump coshols:Timor 8hpxd Time Miler (errors If Installed)
runt is r uad:Pump
On`Pump Off
—
Water gaze basket o(RjEj drab aM)WWkd7 ...............
fi) Wau Installed for semis" . ......
1 ) A-UMbIullad7 .. .... .... . ......................I...........
FROM :DON I FW NO. :5598979557 Jan. 12 2005 12:11PM P4
vuudes we ttgop `nnnoved'by ""m0vW'by MC3DHS are Shown sbove.
devDIM 4om the ddlp stamped
MCDFLS ��nn ,
8, p 1 oettfy thu 10011MO d toe deeipar and loft the p _daiptawttved the not}icaton t uk entvc becawe the
syehm open for ytopectlou up to 4t hro prior to
Covet. .. ..
I f tha OeNfy the W Infomistim witudned m this ale a . 1 d If the Inf01mation ototamed hemin Is not
aauhate,there will be lust Musa Poe 6umedide Iu1� 0,(JN}' r ton. I
' ,,M1 ep_.SuMmoriA,youter
The undenigh> J apprmcs this uistallatioa on behalf of Moon 0r"+00' t of Lt'i S,,4
'Um'
41176 091390 0 I
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f0020 24 00020
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To Highway 3
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Rob's Excavating, LLC Invoice
1871 E Johns Prairie Road
Shelton, WA 98584 -
DATE CE 40
11/22Y2004 INvoI
Bill TO _112218
Inzunza,Don
PO Box 2354
Shelton,WA 98584
--[
NO. �onreseiii�
Dt
DESCRIPTION QTY RATE AMOUNT
11 E MIIO(ELSON ROAD
Install 3-Bedroom,Shallow Pressure Septic System 5,675.00 5,675.00T
Sales Tax 8.30% 471.03
Thank you for your business. Total $6,140.03
Phone 360-426-8897 - Fax 350d26-0330 _
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