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HomeMy WebLinkAboutSWG2019-00447/ASBUILT - SWG As-Built - 10/27/2025 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APIIA1T1 PERMIT INFORMATION . .. Permit Number SWG 2019-00447 Parcel # 62028-75-00050 Applicant Name Mike & Melee Potter Subdivision (Name/Div/Block/Lot) Applicant Address P.O. Box 9283 City, State, Zip Pahrump, NV 89060 Installer Name Mike Blocher(home owner) Site Address l/l n V412vv►' Designer Name Dale L.Tahja INSTALL HECKLIST ❑ Full System Installation ❑Tank(s)Only Drainfield Only Repair 0 Other System Type Pressurized Trenches Pretreatment Type >5 ft. from foundation? - R3k-1...9-\- - r � - -- 0 N/A 0 YES a NO >50 ft. from wells? - ��� `� � ❑ >50 ft. from surface water? - - - - - -- ❑ [� ❑ZF<- Cleanout between building and tank? -OCT Z--' )---; -- ❑ [] 0 C.) Tank baffles present? - - 0 0 0 24"access risers over each compartm nt?- - - - - -_r - 0 0 0 a _- N Effluent filter installed?- 84 - - -- 0 0 0 Septic tank capacity(working) gal Manufacturer 0 D-box water level and speed levelers used? - - ElN/A ElYES ❑ NO oO Manifold/D-box accessible from surface?- - 0 0 0 mZ Check valves installed? - - 0 0 ❑ OQ 2 Transport Line Size Schedule/Class Bedrooms installed (check one) ❑ 2 IN 3 ❑4 ❑ 5 0 6 ❑Commercial/Other 0 >10 ft.from foundation?- - ❑ N/A ® YES 0 NO 0 >100 ft.from wells?- - 0 ® 0 W >100 ft.from surface water? - - 0 i_! ❑ t% >10 ft. from potable water lines?- - ❑ in ❑ Z > 5 ft.from property lines and easements?- - 0 I 0 d > 30 ft.from downgradient curtain/foundation drains? - - © ❑ ❑ G Drainfield level and observation ports present - - ❑ ® ❑ 0 Graveless chambers or is Clean gravel used? (check one) Proper cover installed over drainfield?- - ❑ in ❑ Pump tank setbacks consistent with septic tank? - - ❑ N/A D YES 0 NO Y Pump tank capacity (flood) gal Manufacturer H24" access riser(s)and accessible from surface?- - 0 0 0 a. Alarm or Control Panel Installed? - - 0 0 0 2 Control Panel equipped with Timer/ETM /Counter- - 0 0 0 M O. Pump installed in ❑ Bucket or ❑ On Block or ❑ Other O. Pump Make/Model 0 Floats or 0 Transducer a Tank draw down in/min Pump capacity gpm Squirt Height ft Pump on time Pump off time Daily flow set at gpd Jpdated 8/21/2018 1 Mason County OSS Installation Report pg. 2 Parcel# 62028-75-00050 ABANDONMENT CORD J_. ... Were existing septic components abandoned as part of this project? - - Ej YES x NO If yes, please describe: Were all components pumped out and properly abandoned per WAC246-272A-0300? - - 0 YES NO RECORD DRAINING . This Is a permanent record and must be accurate and descriptive enough to re-locate In the need of maintenance activities end future development. Typical Record Drawings contain: Drainfleld&manifold orientation&layout,Septiclpump tank location,North arrow,reserve drainfleld,existing and proposed buildings,location of wells,waterlines, wells,observation ports,cteanouts,and other maintenance access points. Incomplete Record Drawings may create additional delays in final Installation approval and related permits. Record Drawing Attached T G m:N o INSTALLAftON ill INSTALLER DESIGNER/ENGINEER I certify that i installed the system in accordance with I certify that the system has been installed in accor- 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 cleared/approved by both the designer shown here 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 1 further certify that all information contained on this I further certify that all information contained on this form and attached R cord Drawing is l accura. form and attached Record Drawing is accurate. \AA)..s„ iii It t''r,// Signature of installer vi-_;ate`� pp �. VV.\<‘ -`- 9)\QC,e.� t1�1?01.E 111 �� ., Printed Name of Signee l�//,5� • ty /v c YIAsy �ill MASON COUNTY PUBLIC HEALTH o co. t,...+ ti� s. czY The undersigned approves this Installation Report and a� 4? 1'41_ t1+` Record Drawing on behalf of Mason County Public 5100214 v;is Health: i 0 Dale L.Tahja $ I�(737/Zc— LICENSED DESIGNER Signature of Environmental Health Specialist Date (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 8/21/2018 W 459'Zf.c% c\ „8 • ,Z1 •OO N 0 • • `� iq r i In C < T r o Q j 1N31d3 S`e 3 1 to 0 wi lg y 1 T 1 � i ,V£ `a I' _..: _ _stD_ - -- _Ao ,svtip N -1-vA, . i - 1•C.c. -. T .B- Pb31 ,1 -' N e ill m Z N - w -3" < T 4 r . Q o ern 6 c0 4 e m �- N - 9 <9 n 7 r; 10 .r v ,,� T a N co ks vi t9 "i ",, h k9 0 l 1 z r N. r- ao 2 W t.9 N %1 'Ell • Z I.—. . • . s •Zq£l 3 „)/ 1-11 ''O N ti 4 r gd- 1 Er - • �,.s ��ec� • Res��d \)\%01/4\1.1Vcn • I - ' • fI ..„1. to f a E')0214 � op L.Tat* i l'CENc.. .)DESIGNER � w • %NA...11mm . W • • ;s APPROVED OCT 27 2025 • MASON COUNTY ENVIRONMENTAL HEALTH RET S • e • 1. r