HomeMy WebLinkAboutSWG2026-00326 - SWG As-Built - 11/7/2016 { Y
RECORD DRAWING (ASBUILT) pg. 4 MASON COUNTY PUBLIC HEALTH
Permit Number SWG"101(,,øô 2Q. Assessor Parcel# 21`�O/00 9 0013
Applicant Name .Do aq 1i) )10 Subdivision (Name/Div/Block/Lot)
Applicant Address 1.!) Z/ joi. &1.
City, State, Zip ,,ja 919 �6 Installer Name T J ad S
Site Address 'yam l Dr 5'!t 6 Designer Name I A-
-rani.;:.,,..<sa.xr3f� ^f:p,t:.'>t:�•.. ,. ?six:;:.';ri.:^r:..:.:r -.r•..:.. .. ..:.,..
:.,.:,...,......:.:............:,-,....:.,.-u_La._..,, :.,.:..,_>'�...,.5sc.,. .;i.;,,ft�rVB;..ir-•x;4x tr.F::i;. - - -'�'�s
,
❑Full System Installation JTank(s)Only ❑ Drafnfie d Only ❑Repair O Other
System Type i!'P►'► '.41 ,if fa ,ttiA Pretreatment Type
:..: .......
.._.* YES NO- -- ❑ NIA [g ❑, >5ft.fromfoundation?'--------- ---------------- .
>50ft.fromwells? ------ ---- ------------- ---- - - ❑ ❑
>50ft.fromsurfacewater? ---------------- ---- - -- - ❑ ❑
! 'f.. Cleanout between building and tank? ----------------- - - ❑ ❑
F•K:
j ;;Tankbafflespresent? --- ----- ----------- ----- -- - ❑ ❑
:.1 24"access risers over each compartment?-------------- -- O ❑
• W'. Effluent filter installed?-----------------------=- - - ❑. El
Septic tank size 125zs gal Manufacturer -ei
D-box water level and speed levelers used? ------- ----- - - - NJA ❑YES ❑ NO
Manifold/D-box accessible from surface? -------- ------ - - fl ❑
O'us
Check valves installed? -- -------------- ------- - - -
;; 1 ^Transport Line Size Schedule/Class
Bedrooms installed (check one) ❑ 2 ❑3 ❑4 ❑ 5 ❑6 QCommercial/Other
>10ft.fromfoundejtion?--------- ---------- ----- - - - N/A DYES ❑ NO
>100ft.fromwells?--------------------------- - - ❑ ❑
>100ft.fromsurfacewater?--------------- ------ - - - ❑ ❑
>10ft.frompotablewaterlines?-------------- ----- - - - ❑ ❑ _
z'l >5 ft.from property lines and easements?------ -- ❑ ❑
ft >30 ft from downgradient curtain/foundation drains?------ - - -- C ❑ O
Drainfield level and observation ports present ----------- - - - ❑ ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed overdrainfield?----------------- - - ❑ ❑
Pump tank setbacks consistant with septic tank?------------- NIA ❑ YES El No
Pump tank size gal Manufacturer
24"access riser(s)and accessible from surface?---- - ----- - - - ❑ ❑
Alarm or Control Panel Installed? --- -------------- - --- ❑ ❑
Control Panel equipped with Timer/ETM/Counter--- -- - --- O ❑
Pump installed in O Bucket or ❑ On Block or ❑ Other
Pump Make/Model ❑Floats or ❑ Transducer
Tank draw down in/min Pump capacity gpm Squirt Height ft
Pump on time Pump off time Daily flow set at gpd
Updated 11/7/2015
Printed From Mason County
Printed from Mason County DMS
r •
MCPH RECORD DRAWING (ASBUILT) pg. 2 Assessor Parcel,#
.:,�::':,.:., ....::.........: .....t-._ . , .",.,'..-.':,;:'..:,<:.,::,::•REC.ORDDRAWIN;G=�M�.,�.� .�::,='..�:1�-.�.fi�.a;�,:a:. '::.::�: w �,t,.__��;;�;,{..
❑ Drainfield&manifold
jfp orientation&layout I Gi
/' wldimensions for
re-location.
❑' Trench/bed
'dimensions and �q�1A 1)I'
critical distances 2y I
within layout G�I
❑1'Seepptic/pump tank 1t;
placement Location of buildings r
existing/proposed e1r Q
Observation ports, 1 y�� �► ,L
clean-out locations, N
&manifoldsld-boxes (►�r/�0��
Location of yells, t S 7'.
surface water,roads, -
&waterlines.
{ Reserve area(s) 5x�
North Arrow
if the designer or installer feel the need for additional information/comments,it may be attached.
Record drawing may also be on a seperate page attached. No.Pages Attached
IF. C` T10F'1N T T �•,4;;.::;:;;;: °.' ;. .: . �''�'^'=
INSTALLER DESIGNER
I certify that 1 installed the system in accordance with 1 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 Record Drawing is accurate. form and attached Record Drawing is accurate.
s'
Signature f!n taller Date
LrJ ter
Printed Name of Signee r f 1 ?j r,6
. MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
Record Drawing on behalf of Mason County Public
Health:
/! ?
Signature of E nmental Health Specialist Date (designer's stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updated 12/7/2015
Printed From Mason County OMS
Printed from Mason County DMS