HomeMy WebLinkAboutAFTER THE FACT RECORD DRAWING - SWG As-Built - 10/27/2028 0-0--ci, 4A-e 4,fr Q
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AFTER THE FACT RECORD DRAWING, pg r MASON COUNTY PUBLI HEALTH
PARCEL IDENTIFICATION
Owner Name SUZANNE CORK Assessor Parcel# 42307-50-00136
Mailing Address 892 LAKE CUSHMAN ROAD 0/M Specialist Name
City, State, Zip HOODSPORT, WA. 98548 Installer Name
Site Address 2( l?. -A,,,, P/ Designer Name
Please complete this checklist to the best of your knowledge. If items are unknown leave blank.
INSTALLATION CHECKLIST
System Type GRAVITY Pretreatment Type
Drainfield Ln. Ft. R7 Drainfield Sq. Ft. 400 Drainfield depth DEEP TRENCH
>5 ft. from foundation? - - ❑ N/A gYES ❑ NO
>50 ft.from wells? - - ❑ E. ❑
z >50 ft.from surface water? - . 0 Ca CI
H Cleanout between building and tank? - - ❑ 0' 0
V Tank baffles present? - - ❑ El 0
24"access risers over each compartment?- - 0 ❑ '0
0.
111 Effluent filter installed?- - 0 0 RI-
(I) Septic tank size 11 60 gal Manufacturer 6✓r,ri.,,47
o D-box water level and speed levelers used? - ZN/A 0 YES ❑ NO
gO Manifold/D-box accessible from surface?- - ❑ ❑ 32-
QQCheck valves installed? - El
2 Transport Line Size li /' Schedule/Class ea 1 s'/'i,.v�
Bedrooms installed(If known) 0 2 V.3 04 0 5 06 ❑Commercial/Other
>10 ft.from foundation?- - 0 NIA ig-YES ❑ NO
0 >100 ft. from wells?- - 0 gl ❑
W >100 ft. from surface water? - ❑ El
LT >10 ft.from potable water lines?- - ❑ Er ❑
Z >5 ft.from property lines and easements?- - 0 a ❑
d >30 ft. from downgradient curtain/foundation drains? 0 ❑
0 Observation ports present? - - 0 ❑ la
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ . ' ❑
Pump tank setbacks consistant with septic tank?- - ❑ N/A ❑ YES RI NO
ZPump tank size gal Manufacturer
< 24"access riser(s) and accessible from surface?- 0 ❑ 0
aAlarm or Control Panel Installed? - - 0 0 0
• Control Panel equipped with Timer/ETM/Counter- - 0 ❑ ❑
0- Pump installed in 0 Bucket or ❑ On Block or ❑ Other
n" Pump Make/Model 0 Floats or� 0 Transducer
d Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 2/29/2016
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AFTER THE FACT RECORD DRAWING, pg 2 Assessor Parcel#
RECORD DRAWING
❑ Dralntield&manifold
orientation&layout
w/dimensions for
re-location.
❑ Trench/bed
dimensions and
critical distances
within layout
❑ Septic/pump tank
Location w/dimen-
sions for re-location
❑ Location of buildings
existinglproposed
❑ Observation ports,
clean-out locations,
&manifoldstd-boxes
❑ Location of wells,
surface water,roads, y� ) n
&waterlines. l t /2C--'7 Je'-C7 4 of 5?• .(
❑ Reserve area(s)
❑ North Arrow
If needed drawing may be attached on a separate page No. Pages Attached
CERTIFICATION OF INSTALLATION
DESIGNER/APPROVED SP ALIST
I certify that the informati bntai this document is accurate to my knowledge. The drawing and information
has been ob • ed thro ctitiVoe 2f ing practices.
co
tz, l
Signature of Design:or,•pprovgd,_ Sped' Date
4/ f ininv •
MASON COUN $IC N NER
This is an after the fact tdid drawing, wit may or may not include a county inspection. This information is to only
document an existing OSS location and components.
Signature of Environmental Health Specialist Date
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 2/2eR018
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