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On-site Sewage System As-Built Record Goldendale Office Klickitat County Health Department White Salmon Office 228 West Main Street 501 NE Washington St/ PO Box 159 MS-CH 14 White Salmon, WA 98672 Goldendale, WA 98620 [PHONE REDACTED] [PHONE REDACTED] WAC 246-272A requires a complete and detailed record drawing submitted to both the Health Department and the OSS owner upon completion of new construction, alteration, or repair of an OSS system. Property Owner: Parcel Number: Site Address: SYSTEM SUMMARY # of Bedrooms: GPD: Trench Type: Installer: Trench Depth: Trench Width: Installer Phone: Total Linear Feet: # of laterals: PLEASE INDICATE THE TYPE OF CONSTRUCTION Tank Capacity: New System Repair Tank Manufacturer: Alteration PRESSURE OR DOSING SYSTEMS Date of Completion: # of orifices: Size of orifices: Pump Tank Capacity: I certify that the information and drawing above, are true and accurate, and that the on-site sewage system was installed according to permit requirements. Signature: Provide well, building, property, and utility setbacks in the drawing below. Show length of all transport lines.