HomeMy WebLinkAboutSWG2020-00337 - SWG As-Built - 9/11/2026 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH
APPLICANT/ PERMIT INFORMATION
Permit Number SWG 2020-0337 Parcel# 222131160030
Applicant Name Peggy Merriam Subdivision (Name/Div/Block/Lot)
Applicant Address 442 South Camino Holgado N/A
City, State, Zip Green Valley,AZ 85614 Installer Name Lessard Earthwork LLC
Site Address 40 E Waterthrush Ln Designer Name Apex Septic Design LLC
INSTALLATION CHECKLIST
• Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair ❑Other
System Type Gravity(Class B waiver) Pretreatment Type
>5 ft from foundation? - - - - - - - - -- -r—�^r�—T t�'j? { ❑ N/A ®YES ❑ NO
>50 ft.from wells? - - - - - - - - - - - - - 1f ,+ -=� II� I❑ IM ❑
Z >50 ft.from surface water? - - - - - - - - - jj,, - 1,t e ❑
Cleanout between building and tank? - r - S V€.P t 2 76--! e ❑
Tank baffles present? - - - - - - - - - - - - ---- - - — ® ❑
L
24" access risers over each compartment? - - - - - - Jti_tI • ❑
W Effluent filter installed?-- - - - - - - - - - ---- =-- - - - - - - - - - 0 ❑
N �7�
Septic tank capacity(working) 1 �l J gal Manufacturer
o D-box water level and speed levelers used? - - - - - - - - - - - - - - - ❑ N/A ® YES NO
DO Manifold/D-box accessible from surface?-- - - - - - - - - - - - - - - - ❑ ® El
mz Check valves installed? - - - - - - - - -- - - - - - - - - - - - - - - - - - ❑ ❑
O<
f Transport Line Size 4-in Schedule/Class ASTM D 3034
Bedrooms installed (check one) ❑ 2 ❑3 1114 ❑ 5 ❑6 ❑Commercial/Other
>10 ft.from foundation?- ❑ N/A 0 YES ❑ NO
>100 ft. from wells?- - - ❑ E ❑
w >100 ft. from surface water? - ❑ ® ❑
LL >10 ft. from potable water lines? ❑ B ❑
QZ > 5 ft. from property lines and easements? ❑ IM ❑
> 30 ft.from downgradientcurtain/foundation drains?-- - - - - - - - - ❑ ® El
Drainfield level and observation ports present -- - ❑ ❑
0 Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed overdrainfield?- -- - - - - -- - - - -- - -- - - ❑ 0 ❑
Pump tank setbacks consistent with septic tank?- - ® N/A ❑ YES ❑ No
Pump tank capacity(flood) gal Manufacturer
Q24°access riser(s)and accessible from surface? - ❑ ❑ El
Alarm or Control Panel Installed? El ❑ ❑
f Control Panel equipped with Timer/ETM I Counter ❑ ❑ ❑
0. Pump installed in ❑ Bucket or ❑ On Block or ❑ Other
n' Pump Make/Model ❑ Floats or ❑ Transducer
2
I1
Tank draw down in/min Pump capacity apm Squirt Height ft
Pump on time Pump off time Daily flow set at apd
Updated8Q1Q019
Mason County OSS Installation Report pg. 2 Parcel It 222131160030
ABANDONMENT RECORD
Were existing septic components abandoned as part of this project? - - - - - - - - - - - - - -- - YES Q NO
If yes, please describe'.
Were all components pumped out and properly abandoned per WAC246-272A-0300? -- - - - - - - YES NO
RECORD DRAWING
This is a porn n.nt record and roue be aocuTe an.ae:<tly4v..noun lo re-locate In Ilre need or malnlenan<e ecilrloes and IUWm development. Trp.cal R.mni
o,a lmyz Ionian D rr, rd&man bid onorlallon&layout sop5opomp lank location-North goer« orve dmnr.le.pt sling and proposed eulldngs.lxabn c''veils.v,ale, ries.
nzO>ev000.pon5 aeanmlz,avd oLnarmanle1 r ce Hw3ss pc:nu lrcomam.Recd d oraeings mar rroalo adddonal teen In That mslallalR.e apao.a and related p0 rn
Record Drawing Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER/ENGINEER
I certify that I 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 hot/
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
I 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.
Signature of/nsjali Date
Printed Name of Signed
MASON COUNTY PUBLIC HEALTH
The undersigned approves this Installation Report and
.
Record Drawing on behalf of Mason County Public . awl M.. endell
Health:? / �,�y� £ j \n LICENSEDUESIONEII
1 D'r 1 I ' \ 7$� }
Signature of Environmen al Health Specialist Date (stamp, signature and date)
THIS FORM MAYBE SCANNED ANO AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE t1 'eaazlrzma
RECORD DRAWING (continued)
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