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AFTER THE FACT RECORD DRAWING, pg 1 MASON COUNTY PUBLIC HEALTH
PARCEL IDENTIFICATION
Owner Name IGLESIA CHRISTIANA VIDA Assessor Parcel# 42018-11-00010&90080
Mailing Address 6515 20TH ST NE O/M Specialist Name
City, State, Zip TACOMA, WA. 98422 Installer Name
Site Address 7 2/// IA/ fi9,c71!,a_/21 Designer Name
Please complete this checklist to the best of your knowledge. If items are unknown leave blank.
INSTALLATION CHECKLIST
System Type Pretreatment Type
Drainfield Ln. Ft. Drainfield S .f e,, Drainfield depth
,
>5 ft. from foundation?
T T.. - ❑ N/A ❑YES ❑ NO
>50 ft.from wells? - -� _� - - - - - ❑ ❑ El
Z . >50 ft, from surface water? - -N- - - - ❑ 0 ❑
Q Cleanout between building and tank? - - - - - p - • - - - - ❑ ❑ ❑
VNig Tank baffles present? - N - — - ❑ ❑ ❑
a24"access risers over each compartment?- �.-- - - - . ❑ 0 ❑
W Effluent filter installed?- - - . ❑ ❑ ❑
Cl) >,
Septic tank size gal rer m
0 D-box water level and speed levelers used? . ❑ N/A ❑ YES ElNO
OO Manifold/D-box accessible from surface?- ❑ ❑ ❑
CQ Check valves installed? - - ElEl❑
2 Transport Line Size Schedule/Class
Bedrooms installed (if known) ❑ 2 ❑3 ❑4 ❑5 06 ❑Commercial/Other
>10 ft.from foundation?- - ❑ N/A ❑ YES ❑ NO
G >100 ft. from wells? 0 ❑ ❑
W >100 ft. from surface water? - - ❑ 0 0
u. >10 ft.from potable water lines?- ❑ 0 ❑
Z > 5 ft. from property lines and easements?- - ❑ El
c2 > 30 ft. from downgradient curtain/foundation drains? - ❑ 0 0
Observation ports present? - - 0 ❑ ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ ❑ ❑
Pump tank setbacks consistant with septic tank? - - ❑ N/A ❑ YES ❑ NO
• Pump tank size gal Manufacturer
Q24"access riser(s) and accessible from surface?- - ❑ ❑ 0
~
a Alarm or Control Panel Installed? - ❑ ❑ ❑
2 Control Panel equipped with Timer/ETM/Counter- - ❑ D ❑
m
a- Pump installed in ❑ Bucket or ❑ On Block or 0 Other
n' Pump Make/Model ❑ Floats or 0 Transducer
2
d Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
r4t(IC$07 /‘w Ph G Uptlele02R92016
S 'Itie - 43- GIG 2r
AFTER THE FACT RECORD DRAWING, pg 2 Assessor Parcel#
RECORD DRAWING
❑ Drainfield&manifold
orientation&layout
w/dimensions for
re-location.
❑ Trench/bed
dimensions and
critical distances
within layout
❑ Septic/pump tank
Location w/dimen-
sions for relocation 0 .5--,,f
NA. P' v f« p�• GK ,❑ Location of buildings
existing/proposed
❑ O• bservation ports, o- it. P4 ece Y.2 G I F--//_ 00Gte
clean-out locations,
&manifoldsld-boxes
❑ L• ocation of wells,
surface water,roads, `
&waterlines. 112 i'r'e�t/e �/lc�q, !Q Cil-e a G m
❑ Reserve area(s)
El North Arrow 26 `5-f/ qG
gQ .
If needed drawing may be attached on a separate page No. Pages Attached i
CERTIFICATION OF INSTALLATION
DESIGNER/APPROVED O/M SPECIALIST
1 certify that the information contained in this document is accurate to my knowledge. The drawing and information
has been obtained t rough common locating practices.
_ . a„6 L I ZL l Zo Zr
Signature of esigner or Approved O/M Specialist Date
MASON COUNTY PUBLIC HEALTH
This is an after the fact record drawing, which may or may not include a county inspection. This information is to only
document an� existing OSS location and components.
l'N' 5 C OU'l V1 i
Signature of Environmental Health Speciali t Date
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 229/2016
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