HomeMy WebLinkAboutSWG2018-00123 - SWG As-Built - 8/18/2022 tte,tcy
RECORD DRAWING (ASBUILT) pg. 1 AUG DD Wts^• SON COUNTY PUBLIC HEALTH
PARCAVIDENTIFIpIO j
Permit Number SWG LC 1 F --C 0 12. "")fiesss@ssor Parcel # Z Z /C SS/ 0 00 2 Z"
Applicant Name pe._+-ex &ki l S+ Subd visiOk?t(Name/Div/Block/Lot)
Applicant Address XL3'--I `(3vd AV£ Al(
City, State, Zip S1'(, 1e i(VA (I Z1 (5. Installer Name 3 ail c ioY (vvis f.
Site Address "4 7c t Cr' t nif ti Yi WCt le(' n t , (,C Designer Name "T(' \+luvl --£F" 4 A SSG( -
INSTALLATION CHECKLIST
(�/Full System Installation ❑Ta k(s)Only Drainfield Only [:1Repair ❑Other
System Type CiLe ``1C�( / 1 (t) I ( f--i ( f-t ( Pretreatment Type 11 /CL-
>5 ft. from foundation? - - ❑ N/A P.'
SElNo
>50 ft. from wells? - - ❑ ❑
Z >50 ft. from surface water? - - ❑ Et/ ❑
< Cleanout between building and tank? - - ❑ Eii ❑
o Tank baffles present? - - ❑ [/ ❑
a 24" access risers over each compartment?- - ❑ ET ❑
`W Effluent filter installed?- C�L1 .f
�L - ❑ DI ❑
- C
Septic tank size , , C gal L,-Manufacturer L v'-Q t'C. Y-0Lfl Rif ((( S f
D-box water level and speed levelers used? - - 0 N/A ❑ YES ❑ NO
DO Manifold/D-box accessible from surface?- - El ❑ ❑
co Check valves installed? - - El ❑ ❑
thQ
2 Transport Line Size ) Schedule/Class �d��
Bedrooms installed (check one) ❑ 2 ❑4 ❑ 5 ❑6 ❑Commercial/Other
>10 ft. from foundation?- - ❑ N/A [� S El NO
O >100 ft. from wells?- - ❑ ❑
W >100 ft. from surface water? - - ❑ LY' ❑
>10 ft. from potable water lines?- - ❑ (� ❑
Z > 5 ft. from property lines and easements?- - ❑ (� ❑
12 > 30 ft. from downgradient curtain/foundation drains?- - ❑ Ig " ❑
• Drainfield level and observation ports present - - ❑ ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one) .
Proper cover installed over drainfield?- r ❑ ❑
Pump tank setbacks consis nt with)septic tank?- - ❑ N/A OYES ❑ NO
Y Pump tank size I .(L /t t4 4al Manufacturer CV t4 A tr y--t 1 Ill SCR c
< 24" access riser(s) and accessible from surface?- - ❑
~ Alarm or Control Panel Installed? - - ❑ [3 ❑
a
Control Panel equipped with Timer/ ETM/Counter- - LI [� ❑
a Pump installed in ❑ Bucket or [l On Block or ❑ Other
Pump Make/Model Ay"(i`t mit A pIV c i/ L -"\) (1 Floats or 0-transducer
a Tank draw down Cn��-�'1C1.O11 in/min Pump capacity ,j vPA(Jlg t
pm Squirt Height C0� VLC Loft
Pump on time ' C >( C. Pump off time n CtA f 0 Daily flow set at 1)G.,( qpd
Updated 12/7/2015
MCPH RECORD DRAWING (ASBUILT) pg. 2 Assessor Parcel # L Z! G SS / Op) ?
RECORD DRAWING
❑ Drainfield&manifold
orientation&layout
w/dimensions for
re-location.
❑ Trench/bed
dimensions and
critical distances
within layout
❑ Septicpump tank
placement
❑ Location of buildings `Y
existing/proposed
❑ Observation ports.
clean-out locations.
&manifolds/d-boxes
❑ Location of wells.
surface water,roads,
&waterlines.
❑ Reserve area(s)
❑ 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
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER
1 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
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.
/fir' 7/27)2 f // ./
Signature of Installer Date f •� I,���
t5Y u ibkLY1 i Vic
WASJ 1
Printed Name of Signee ��
MASON COUNTY PUBLIC HEALTH •,1••
.►!` Sttw273
The undersigned approves this Installation Report and �, !AMES IL 4�
ER
Record Drawing on behalf of Mason County Public LPCE D DMES!CNfR 'fie
Health: •.tmo ,
PORES: 03/22/
Signature of Environmental ealth 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 12/72015
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