HomeMy WebLinkAbout065-206-002 EHS24-112 AS BUILTButte County
PUBUC HEALTH
Property Owner:
Property Address:
Mailing Address: a5e4 Pacry Rd., Magalia CA qT9A
APN #:
Designer:
II.
IIL.
IV.
AY
SEPTIC TANK
B
C)
D)
E)
F)
G)
A)
B
F)
G)
H)
D)
DISPERSAL FIELD
A)
B)
C)
D)
A)
B
C)
Rich Pratt
D)
Olo5-0 O0a
E)
F)
G)
>5 ft. from foundation?
CONTRACTOR'S
As-BUILT REPORT
>50 ft from wells and surface water?
Risers installed for access?
Tank Size:
Leak test performed
Bldg stub-out to septic tank: clean-out if not 1-2%?
Sanitary Ts in tank intact and clean?
ADDITIONAL ITEMS FOR PRESSURE SYSTEMS
All items below must be completed by the installer.
PUMP/PUMP CHAMBER
>10 ft from potable water lines?
>5 ft from foundation and >5 ft from property lines?
>100 ft from wells and surface water?
Distribution box leveled with water?
gal.; Manufacturer
Traklt #:
Laterals level to +/-1 inch & end caps present if not looped?
Gravelless chambers utilized?
Installer:
System dimensions the same as shown on the design?
Gravel clean, properly sized, and proper depth?
Observation ports present?
Sand quality as specified on design?
Mound: Side Slope 3:1?
Alarm installed?
Head height uniform and 24 inches? Actual head height
Clean-outs and observation ports present?
Pump make
Riser installed for access?
Screen basket or effluent filter (circle one) installed?
Chamber size gal;
pump chamber
Pump chamber draw-down
inches
teva Gonzales
gal/inch;
Certified Installer
Pump model
Chamber Manufacture
Date Received:
Certification of Installation
Verified in Field: Yes O No O
Inspector:
Staff Use Only
O SAME AS MAILING ADDRESS
NIA
Pump controls: Timer (or) Elapsed Time Meter (circle if installed); If timer is used:
Pump On Pump Off
Yes
inches per minute; Height of pump off bottom of
Form AS
slua4 Date
certify that I installed the system without any deviation from the design stamped "APPROVED" by Butte
County Environmental Helth?
No
Update: September 12, 2014
OUR MISSION IS TO PROTECT THE PUBLIC THROUGH PROMOTING INDIVIDUAL, COMMUNITY AND ENVIRONMENTAL HEALTH
Completed by Installer
As-Built Form
Traklt #: Q5-20%-Qo2
(An as-built drawing is required only if changes have been made from the original approved design.)
3"
CHECKLIST
7 Drainfield & manifold
onentation & layout
Trenchbed dimensions
and critical distances
within layout
Septic/purnp tank
placement.
Location of buildings.
Observation port &
clean-out location.
/Location of welis &
roads.
Undisturbed native soil
between trenches.
North arrow
Deives
As-Built Drawing
Hase
Veay
Deck
Certied Installer
D-B
Perry
fo-extsting tank
Installer Certification
Rd.
I certify that all deviations from the design stamped "APPROVED" by Butte County Environmental Health
are shown above, and (applicable for supplemental treatment systems only) I further certify that |
contacted the designer and left the system gpen for inspection prior to çover.
Designer Certification
Certified Designer
Date
(Required only for Supplemental Treatment systems)
ort
n l certify that I inspected the systern installation and that it is in substantial conformity with the approved
system design.
Date
Update: September 12, 2014