HomeMy WebLinkAboutSWG As-Built - 10/19/2004 RECEIVED
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AS-BUILT FORM Inak
...PARCEL IDENTIFICATION , ' � ' . '�<
Applicant 74�AMA /7gMA LJ • Assessor's
Pazsorcel# 3 7 - aC, - d9oon
(Twelve-0191t er)
Permit Number SING=
Installer Subdivision (Na ID/DWISIONBhieM-o
Dcsigner
INSTALLER CHECKLIST ?.: 4 '
NIA Yes Prior to Completion
I. SEPTICTANK la' ❑
p) >5 R From foundation? . . ... ........ ... .. . . . .... ... ... .... ❑ � ❑
B) >50 ft from wells and surface wate(.t .......... ................ 121' ❑
❑
C) Bldg clean-out to septic tank:cleanut if not 1-2%7 .. •• ::: ❑
• ❑
D) Battles intact and clean? . .... . ............. ....... ...... ❑ ❑
E) Dividing wall intact?... .. . . . ............ ......................... � ❑ ❑
o . .. . . ... .... ..... . .
Rank installed for access. • 7 ��'��,F��
G) Tank Size:. 60 gal.;Manufacture
tl. D-Box ClA) Leveled with water? . . . . . .. . . . . . . .. ..... . ..... . ... . .. . ....... .. . o ❑
' . .. . . .. . . . .
B) Speed leveler used? . . . . . . . . . . .. . . .. . . .... . . . ... . . . . ..
III. DRAINFIELD
A) >10 ft from foundation and>5 ft from property lines? ❑ El
B) >100 ft from wells and surface water? . . ... . ..... . . .. ...... .
•..... . ❑ ❑
C) >IO ft from potable water lines? .................. . . .. ............. ❑ � ❑
D) Laterals level to± 1 inch&end caps present if not looped? ...I......... . ❑ El
E) Gravelless chambers utilized? .. ❑ ❑
F) System dimensions the same as shown on the design? ................... 0 ❑
G) Gravel clean,Properly sized,and proper depth? .........
14) PRESSURE SYSTEMS Cl
1) Sand quality ASTM C-33? .... ........ . ..... .......... O ❑
2) Head height uniform and z24 inches? Actual head height:::::• ❑ ❑
3) Clean-,ms and observation ports present? ❑ Cl
4) Mound: Side Slope 3:1? . . .... ... .. ... .. ..... . . ..............
5) Owner informed electrical connections must be made ❑ ❑
by owner or licensed electrician and inspected by L&17 ..............
IV. PUMP/PUMP CHAMBER 1 ❑ ❑
A) Screen basket or effluent filter(circle one)installed? ....•••••.••..•••• ❑ ❑
B) Riscr installed for access? ... ............ .......................... ❑ ❑
...........
C) Alarm installed? ................................:..�p model
D) Pump make
E) Chamber size__ gal:__gaVmeh; Chamber Manufacture
inches
G) P°mP wntrols:Timer(or) P
F) pump chamber draw-down inches per minute; Height of pump off bottom of pump chamber P Off
i Elapsed Time Meter (circle If Installed); Iftimer is used:Pump On
DRAWING
/ CRECKLWT
(d Drainfield&manifold
orientation & layout ( '
j/Trembillo d dimensions 1 Dr
and critical distances
within layout Sp0 /
p�/ Bot
" Septetpump� /(ousG _ 3U� D. F.
placement. - - -
Y Location of buildings. r j / L�
❑ Observation port&clean-
out location.
O Location of wells&
roads. I I
❑ Undisturbed native soil/
between trenches. �(o
North arrowo-b�—
��
� d- 100r -L a v
1lIS ^1
/ o o ' / fl }{ So q Ca.e-a
I
CAUTION'Minor adjumman to septic tank location and dminfield orientation made in the field by the installer are ggenerally acceptable to both the department
end the designcq but could in amain cases compromise the viability of We system Itistheinstaller'smsponsibiliytoa tain pnorwmen approval from eitherthc
health department or the designer Wore making any deviations from the design that affect the system viability. Any deviations from the aMmvcd design most be
shown above.
CERTIFICATION OF INSTALLATION
rcertify
ck a box from Row"A"and"D",sign and date the certification
ify that I installed the system without any ❑ 1 certify that all deviations from the design stamped
ation from the design stamped"APPROVED"by "APPROVED"by MCDHS are shown above.
HS
ify that I contacted the designer and left the ❑ I did not contact the deli��luer prior to final cover because the
m open for inspection up to 48 hrs prior to designer waived the notfication requirement
r.that all information contained on this form is accurate. I understand that if the information contained herein is not
accurate,there will be just cause tmmediat usp Sion of installer certification.
DES I f� ugnaNrc o er ata
The undersigned approves this installation on behalf of Mason County Department of Health Services.
Sandstrom, Date
C� .