HomeMy WebLinkAboutWEL2023-00029 - WEL Application, Design, Letter - 5/22/2023 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
MAX OMDAHL
4350 E AGATE RD
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL 2023-00029
4350 E Agate Rd
320242190010
The 2-party water system, McLaughlin/Omdahl Water System (320242190010/320241290061), has
been reviewed and is hereby APPROVED for 2 connections. Please continue to follow best
management practices with maintaining your water system including regular water analysis,
landscaping, keeping wellhead area free of contaminants, and stormwater management around the
water source.
If you have any questions, please contact me at 360-427-9670 Ext.353 or email at
danderson@masoncountywa.gov
Sincere ,
•
avid Anderson
Environmental Health Specialist
Mason County Environmental Health
rillillii
°e:, MASON COUNTY Date Received:
11. l o5lc .2120a.�
,.) �/; COMMUNITY SERVICES Amount Re Lved�^ 5 Received By �
\,:_ Building,Planning Environmental Health.Community Health 4',/�(1".
Y`/ 415 N.6ih Street,(Bldg 8)-Shelton,WA 98584
wEL (X)a- OboaR
Shelton: 360-427-9670 x400 Bclfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
jilteltffNM-7':-
,
APPL rAA/f�1\TT MG HONE
MAILING A.1)4 STREET,CITY,CITY,STATE, 1 E, MAY 2 2 2023 L-- c2-7L1
SITE ADDRESS-STREET,CITY STATE,ZIP ,� BY: -
147)5( e ACACk-Ve .�G� S 17) . Ll� a g4
PRIMARY ARCEL NUMBER(WELL E)
ic444-7f\ C C� \L 3 2 o Zy- z l - cl co 10
SECON RY PA L U (IF APPLICABLE) ✓L O L L 1 7__Gt 6 6(o
11 WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
0 New vk Existing N Well 0 Spring Z , / Z `, / t
PF ELakit TER SYSTEM\NAME REOU1ED) - - L��1 \�xVe ( S I \e l.✓
PROJECT DESCRIPTION 11 n , /v`1 `\ V
a NO\(\\ s'N 1 LAB -4-0 swa,-e QQ-c_a
DIRECTIONS TO SITE/CONDITIONS E ck OJt V i \ o ^[-=wA t vi LiA se 0 A 00 c0
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
n
Submittals Checklist: (these additional items will be required for approval)
Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled)
Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
4%'T
Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document)
Septic Records (additional locating requirements may apply if there is a lack of septic records on file)
This form may be scanned and available for public view on the Mason County Web site. Revised: 10/13/2021
Page 1 of 2
` �t Staff Use Only
W �s - 13lCQch -led 41.�rovl
Review Step 1: Well Site Inspection: - Coat l i (Y) to tSE uki�-, ch ke,7 coy P 6" -101.hPnweb"
Pmfsti+e,'1-e►lc • -A45cols
YES NO NA - buck IGuk m oft -fr ' + '{%1'IW¢�p 'f►rgll t
if
?t,,Y W.1C 3
❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
❑ ❑ Are there roads within the 100 foot radius of the water source? If so, is road private, County or State.
What is distance to ROW?
C(14(-- ❑ Z ❑ Does the ground slope away from the water source site? (show slope on plot plan)
❑ ❑ Is the well cap satisfactory? AnGvnf b.(' tlot I\1151.a/Id Pe'
❑ 4 ❑ Screened and vented? �}`\
❑ The well casing extends v above level ground/concrete slab? (circle one)
We' ❑ ❑ g Is there evidence of a surface seal? Le: to.. 2.1 g3p2 I
❑ ❑ Does the seal appear adequate? °1.411Ce' ilt71"e t‘) t.41: —123.0 III ? 3
❑ ❑ ❑ Is a variance necessary for well site approval? /
Comments () 15 1 ra/ y of _cep?, yc /Gs' h ?oQi
- 4 qc3d hlo cry 4+ (-17. ill $62., —(Z3, 00)P ?3 96` 1,.e//
❑ Pass ❑ Fail Inspector/0-1.--------
Date C/6 ! '-o��
Review Step 2: Two-Party Review:
YES NO NA
❑ X ❑ Water Well Report with adequate pump test on file?
If NO, date of Capacity Test l Z((ZO?j Driller !22 Su r(/G��1 GPM
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test (IZSVXZ3
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 21 q;FS
❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments AV l'Bile 501/1/69.3 or AI a iron . cafreaeel b y panne o 1vnc's
art( k le Al CIO rre '. vW` 'r-etikirl V Pce,`r r 9/7I zo63
Approved ❑ Denied Reviewer Date /f Y���zj
Findings in this review reflect observed conditions as they existed on the day of the site inspe z •l '' is made, express
or implied ofapproval does not constitute wa •s
p the future success or failure of this system. Well site e val. Water
pp _Me
System approval is a two-part process. SCC
All proposed connections to new wells are subject to water adequacy regtlt i f at time orb4fl Oyennit per MCC 6.68.
Water usage restrictions and additional fees may apply to all new wells drille �uV,y 19', 2Tt018 per ESSB 6091.
p�q NMFNTAZ/ILI1Lai
Revised: 10/13/2021
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
26276 Twelve
Trees Ln NW
Ste.0 't SPECTRA Laboratories - Kitxap
Poulsbo,WA _
_Wiese sip;runer mailers
98370(360)779-5141 COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
1,)41/2.3 Collected
❑AM
Wart Day Year 3: l/) `id Pi S C\
(
Type of Water System(check only one box)
El Group A • 0 Group B J OtherPt f t,0‘C,71_('
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name: f r >56 c y�c+Are i
Contact Person: [
• Day Phone: -, M,, �1r,. ,/� Cell Phone:o 3 6 u�o( (�t O T
Email: QV'�?""••1' (fir"-Lem Ewt�;ie: ��
Send results to:(Print full nano.address and rip code aem above for efectr$ copy l results)
SAMPLE INFORMATION
Sample collected by(name):
1p1 uYISG
Specific location where sample collected: Special instructions or comment:
rS c.t-t''Ce
Type of Sample(check only one box)
1.❑Routine Distribution Sample(AIP) 2.❑Repeat Sample(AIP)
Chlorinated:Yes ❑ No❑ (trorr distribution system after unsat.routine)
Unsatisfactory routine lab number.
Chlorine Residual:Total Free_
3.Ground Water Rule Source Sample — ——
I S Unsatisfactory routine collect date:
/ /
Chlorinated:Yes No
0 Triggered (AIP)
Chlorine Residual:Total_Free_
❑Assessment(A/P)
4 Surface or GWI Raw Source Water Sample(Enumeration) I S I I
❑ E.coli ❑Fecal t-merei Yes No
5.Itjelample Collected for Information Only:
LAB USE ONLY DRINKING WATER RESULTS USE ONLY
❑Unsatisfactory Total Coliform Present and isfactory
❑E.coli present ❑E.coli absent
Bacterial Density Results:Total Coliform mpn/10oml.E.cof mpn/100m1.
Fecal Coliform cfu/100m1. HPC cfu/lml.
Replacement Sample Required: 0 TNTC 0 Sample too old
El Sample Volume ❑Damaged Container ❑
D •
r Receiv : Lab Reference Number
16fi3 12-oo ZZ.b Ot `ol
Receipt Temp C: Met od Code: OT•COUNT/SM9222D
This repel a fleeted alley ter M tied the pereee or aanvery b
Dttp 2-512-le � Mwnttleediewed.Are we. Jyser*dour*other than al to
reopent is Mrtewdad r you y C teoered M repot h
rye rKKih ee tends mmeetlM/tl 3667)%ut erd
DOH Lab-aartple p *am we repot won*
mn.,aas.Mtl.a y Am,*emCd eel tree eeapett)to
010- Os'o i eaiM by to Ybaretc y.The recce Mel not be re.akeed emept
r A►.r.etw prep e>mrer edam eoaavtl by Spectre lebarediee
DOH Pam 5331.319(eetea WI?)
Davie Pwnpo, Inc.
340`NC'Oauie Farm VI
'13e(fair,'Wa 98528
(360)801-6107
Project 4350 E Agate Rd
Capacity Test Shelton, Wa
TAG:NA
Date 4/21/2023
Pump % hp
Well Depth +65- unknown
Static Water Level 54.2
Draw Down Recovery
Time Water Level GPM Time Water Lever
0 min 54..2 0 0 64.7
5 min 63.6 7 1 min 59.6
10 min 64.7 7 2 58.2
15 min 64.7 7 3 57.5
30 min 64.7 7 4 56.9
1 hr 64.7 7 5 56.2
2 hr 64.7 7 10 54.8
3 hr 64.7 7 15 54.2
4 hr 64.7 7 20
Capacity Notes:
Well seal with catch rope- unable to take well depth measurement with obstructions
I
a
2196858 MASON CO WA
05/08/2023 01:43 PM DEC.
DAVIS PUPPS INC 4186643 Roo Fee: 60 Paffes: 4
PININ11111111114111111111111111111111 IIIUNIINfl
Return To:
Davis Pumps Inc.
340 NE Davis Farm Rd
Beltair, Wa 98528
Declaration of Water Use Agreement
McLaughlinlOmdahl Water System
Private 2 Party
ABBREVIATED LEGAL DESCRIPTIONSAND PARCEL NUMBERS OF TRACTS BEING SERVEDZ
The well and water system being situated on:
Parcel#32024-21-90010
TR I OF NE NW EX CO RAN'TR2OFSP#384
R3W T2ON Sec24 NWI/4-NEI/4
Grantors:MCLAUGHLIN,PHILIP 31&JANEEN A
Owners of
Parcel#32024-21-90010
TR 1 OF NE NW EX CO R/W TR 2 OF SP#384
R3W T2ON Sec24 NW1/4-NEl/4
Grantee:Jaeessa Orndahl
Owners of:
Parcel#3 2 0 2 4-1 2-90061
TR 6-A OF NW NE'TR I OF SP#2111 AF#531308
W"T20t.Sec24 NWI/4-NEII4
Has been designated to serve a source of water to the following parcels situated in Mason County,State of
Washington;herein described:
Pared#32024-21-90010
TR l OF NE NW EX CO RM.TR 2 OF SP#384
11331 T2ON Sec24 NV.1/4-NE1/4
110,
e ,
Parcel#32024-12-90061
TR6-AOF NW NE TR 1 OFSP#2111 AF#531308
R3W T2ON Sec24 NW1/4-NE1/4
OWNERSHIP OF WELL AND WATERWORKS
It is agreed by the parties that the owners of the Parcel#32024-2I-900I0 TR 1 OF NE NW EX CO R/W TR 2 OF SP
#384 R3W T2ON Sec24 NW 1/4-NE1/4 shall retain l00"/.ownership of well and water system. Each party shall be granted
use of well and water system. Each Party shall be entitled to receive a supply of water for one residential dwelling
and shall be furnished a reasonable supply of potable and healthful water for domestic purposes.
LOST OF MAINTENANCE OF WATER SYSTEM
Each party hereto covenants and agrees that they shall equally share the maintenance and operational costs of the
well and water system herein described. The expense of water quality sampling as required by the State of
Washington and Mason County shall be shared equally by both parties. if either party were to sell their parcel any
new owner(s)would have to create a reserve account with a mutually agreed upon banking system.
NOTICE TO FUTURE PROPERTY OWNERS
The water system is designed to provide for two services. Additional planning and design approval must be
obtained from the local health jurisdiction prior to expanding beyond this number of services. Design flow
standards account for domestic use and watering of a typical lawn and/or garden space only. The design assumes
that all residences will be equipped with ultra low flow plumbing fixtures and that all users will keep conservation in
mind whenever the system is used. Additionally.a water right.obtained from the Department of Ecology,is
required if the water system exceeds exemption standards. This system has not applied for or been granted any
waivers from specific provisions of the regulations.
EASEMENT OF WELL SITE AN)PUMPHOUSE
There shall be an easement for the purpose of maintaining and repairing the well and components to complete and
maintain a properly functioning water system and appurtenance thereto,within t 00 feet of the well site in any
direction of both properties listed. Said easement shall allow the installation,maintenance or repair of well,water
system,pump house,pumps,water storage reservoirs,pressure tanks,waterline,utility lines and/or anything
necessary to the operation of the water system.
All pipelines in the water system shall be maintained so that there will be no leakage of seepage,or other defects
which may cause contamination of the water,or injury,or damage to persons or property. Cost of repairing or
maintaining common distribution pipelines shall be borne equally by both parties. Each party in this agreement
shall be responsible for the installation,maintenance,repair,and replacement of pipe supplying water from the
common water distribution piping to their own particular dwelling and property. Easement shall be granted on both
lots to repair,replace or maintain the waterline as needed for distribution purposes.
PROHIBITED PRACT10E,5
The parties herein,their heirs,successors and/or assigns.will not construct.maintain or suffer to be constructed or
maintained upon the said land and within 100 feet of the well herein described,so long as the same is operated to
furnish water for public consumption,any of the following:septic tanks and drainfields.sewer lines,underground
storage tanks,county or state roads,railroad tracks,vehicles,structures,barns,feeding stations,grazing animals,
enclosures for maintaining fowl or animal manure,liquid or dry chemical storage,herbicides.insecticides.
hazardous waste or garbage of any kind.
The parties herein,their heirs,successors and/or assigns are required to keep the water supplied from said well free
from impurities which might be injurious to the public health.It is the purpose of these grants and covenants to
poor
r �
prevent certain practices hereinafter enumerated in the use of said grantor(s)land which might contaminate said
water supply.
Exhibit A NOW,THEREFORE,the grantor(s)agree(s)and covenant(s)that said grantor(s),his(her)(their)heirs,
successors and assigns will not construct,maintain,or suffer to be constructed or maintained upon the said land of
the grantor(s)and within fifty(50)feet of the well herein described,so long as the same is operated to furnish water
for public consumption,ANY POTENTIAL SOURCE OF CONTAMINATION INCLUDING BUT NOT LIMITED
TO:cesspools.sewers,privies.septic tanks,drainfields,manure piles,fenced pasture.garbage of any kind or
description,any enclosure or structures for the keeping or storage of non biodegradable fertilizers,liquid or dry
chemicals,herbicides or insecticides as well as any enclosures or structures for the keeping or maintenance of fowl
or animals such as barns,chicken houses,rabbit hutches.pigpens,livestock sheds,and further agree(s)not to use.
apply,dispose or suffer to be used.applied or disposed,non biodegradable fertilizers,any liquid or dry chemicals,
herbicides or insecticides within the above described protective radius.These covenants shall run with the land and
shall be binding on all parties having or acquiring any right,title,or interest in the land described herein or any part
• thereof,and snail inure to the benefit of each owner thereof
WATER SYSTEM MANAGER
The owner of Parcel#32024-21-90010,TR 1 OF NE NW EX C0 R/W TR 2 OF SP 11384,R3W T20t Sec24
NW 1/4-NE1/4 is the designated"Manager"of the system.. The manager shall be responsible for arranging
submission of all necessary water samples as required in the Washington Administrative Code,and Mason County
Rules and Regulations and handling emergencies such as system shutdown and repair. The Manager shall provide
his/her name,address and telephone number to the Health Officer and shall serve as a contact person to the Health
Officer. The manager shall organize and maintain the water system records and notify the Health Officer and all
parties,service connections and lots that are included in this agreement,of the water quality tests that are required
by WAC 246-291 and Mason County Rules and Regulation. Water system records shall be available for review and
inspection by all parties in this agreement and the Health Officer.
HEIRS.SUCCESSORS AND ASSIGNS
These covenants and agreements shall run with the land and shall be binding on all parties having or acquiring any
right,title,or interest in this land described herein or any part hereof,and it shall pass to and be for the benefit of
each owner thereof.
4 .
ENFORCEMENT OF AGREEMENT ON NON-CONFORMING PARTIES AND PROPERTIES
The parties hereto agree to establish the right to make reasonable regulations for the operation of the system,such as
termination of services if bills are not paid within 45 days of the due date,additional charges for disconnection,
reconnection,etc. Parties not conforming with the provisions of this agreement shall be subject to interest charges
of l 8%per annum together with all collection fees.
IcLaughlin/Omdahl Water System Grantee Date
0o3
_____. _ ____ _____. _ a___
__
IMcLaughlin/Otndahl Water System Grantee Date
State of Washington,
County of AOC>{\,
I,the undersigned,a Notary Public in and for the named above County and State,do hereb certify that
on this day of t' ,2023,personalty appeared before me ry � h It(I /
to me known to be the individ I described on and who executed the wit in instrumert,and acknowledge '- .a-ra 55°'
that he(she)(they)signed and scaled the same as free and voluntary act and deed,for the users and 06'1 o-il l
purposes herein mentioned.
GIVEN under my hand and official seal the day and year last above written.
\\ottwtt unto.
ifikt4,64Ai \\ NL L M k 1/1/4
�,. c�` �1 2 p�
re Public in and for the State of Washington. ;�;oc�,�'L 1► s�;G�S.
FE Q:V N(TARY :�
residing at ;t =U r !6- R 2
My commission expires: l -1 2 0
---9i• .Numbed N��%.•
//ii,OF.WAS\,\\\\\
Pr N
1 .
Qr°pc,,'° 2?. •it
Q o-•25 &SL Shod
,p 442. .0-it" &SL 0cl. , 1 .�. 40•
fig
S IIIot
�� GeoP
',
-,;• 411';!,% 'Ill peA,1 , . /
,:,. . • jto. 7' ate 9.-4)4.41. ':.V. SC. , Ola SA+0 be alookAdokt.4
r.. ,,,....f.,i it ' �r
%tr •4' Z Ifb�S�r� I_•h� kkk
.1 t,-.,....1,..
:..,_....____.::.._,..•, _ _ — _,�gala
OP • ,
'wt I`j{�^\14)
OIaSIae-• •z ,. 4 {� t
R Ytf'( Q64 4t�E1
f 1 138+/-
•
APPROVED
MC PUBUtC HEALTH
he JUN 0 7 2016 ift
ALP
t
Printed From Ma om ogf'
Panted from Mason County DMS
•
SECURED LID WITH GAS TIGHT SEAL
1 24'DIAMETER
ACCESS RISER
-s l FINISH GRADE
74-•r It ta1.4( v:iv\c EFFLUENT KILT R
OSI4'BIOTUBE
t<
1'7E t _� TO PUMP
I �--r- — CHAMBER
FROM SEWAGE /
SOURCE FLOATING MAT
APPROVED
EFFLUENT
FILTER
SEDIMENTS
•
---- APPROVED
SEPTIC TANK MC PUBLIC HEALTH
JUN 0 7 2016
ALP
RISER/TANK CONNECT/ON DETAIL:
RISER GLUED To
RISER ADAPTER
CAUUc
CAST-IN RISER ADAPTEF
•
•
Printed From Mason County DMS
Printed from Mason County DMS
RECORD DRAWING (ASBUILT) pg. 1 MASON COUNTY PUBLIC HEALTH
PARCEL IDENTIFICATION
Permit Number SWG 'M(p— 00147
Assessor Parcel# -3Zci Z2—Z 1—q60 i O
Applicant Name ‘___O S Orv&8 ..kt Subdivision (Name/Div/Block/Lot)
Applicant Address L 'sO F— . -t
City, State, Zip S{K.e(t-ems, t40. g2s4 J Installer Name { cl-(ke cA,beI'iseekbAti YtL
Site Address ScjAve 0..1 o,Letil't
Designer Name 7-o/e- e4 ftvteorcoA�
INSTALLATION CHECKLIST
tlir Full System Installation ❑ Septic Tank Only 0 Drainfield Only ❑ Repair
System Type Pc-eU Vf'. Pretreatment Type
>5 ft. from foundation? - - ❑ NIA uffYES 0 NO
>50 ft. from wells? - - ❑ Ur ❑
Z >50 ft from surface water? - - El uu 0
N Cleanout between building and tank? - - 0 06 0
0 Tank baffles present? - - 0 Ig ❑
P .24"access risers over each compartment?- - 0 de
0
W Effluent fitter installed?- - ❑ W ❑
rn SAS
Septic tank size t ZOO gal Manufacturer •
13 D-box water level and speed levelers used? - - tiff WA ❑ YES ❑ NO
kis Manifold/D-box accessible from surface?- - ❑ tir 0
CO, Z Check valves installed? - - ❑ flif 0
. GQ
2 Transport Line Size Schedule/615s 0
Bedrooms installed (check one) ❑ 2 '3 ❑4 ❑ 5 ❑6
>10 ft.from foundation?- - ❑ N/A ( "YES ❑ NO
0
>100 ft from wells?- - 0 te 0
W >10o ft. from surface water? - - 0 ne CIa-. >10 ft.from potable water lines?- - El
ZQ > 5 ft.from property lines and easements?- - El ❑
ii > 30 ft. from downgradient curtain/foundation drains? - - ❑ ❑
Drainfield level and observation ports present - - CIfsira ❑
IX Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- - ❑ Ur ❑
Pump tank setbacks consistent with septic tank?- - El NM [MYES El No
ZPump tank size 1716n gal Manufacturer S P
Q 24" access risers)and accessible from surface? 0 ,l�bi( 0 0
lr Alarm or Control Panel Installed? -
a1/- 0 g 0
Control Panel equipped with Timer/ETM/Counter- - 0
4- Pump installed in 0 Bucket or 0 On Block or Ni Other ?0,4.47 S410
2 Pump Make/Model %-(rb M0.�� S W 33 [ Floats or ❑ Transducer
a Tank draw down I -3A1 in/min Pump capacity 140 gpm Squirt Height )1 ft
ill ■ Pumpgo$n�time MQ+• . c(:''�( Pump off time C kc Daily flow set at • O gpl4l
P n ited d E� � f+ i �ason ounty O MS revised 122/20/4
Printed from Mason County DrMi6
RECORD DRAWING (ASBUILT) pg. 2 MASON COUNTY PUBLIC HEALTH
RECORD DRAWING
0 Drainfield& �.
manifold orientation .+.0 y� '>,�,re` 1' Abated otte4.
&layout r_?
El
I •� Sep�''c T�.t�
Trench/bed ?K„p t- K
dimensions and L, . f t
critical distances 1:7°. (1, �+t L`within layout LU ff / ram] �r •� (fV� Septic/pumptank • ,a0 og _C•• tjplacement 'V [' •Location of tbuildings `�, Q��� ' �y ,,p
El Observation ports& " 90y obserlokbA/ Lateral
clean-out locations GkO.k.�Ouk-S
0 Location of wells,
surface water,&
roads
Undisturbed native � /���� n�
soil between /35O /rf I
trenches
El North Arrow 3 z o Z LI z r eroa 10
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
Se
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER •
I certify that I installed the system in accordance with !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 tha : information contained on this i further certify that a!!information contained on this
form a,• : ;/:_-: • •J,-" ing is accurate. form and attached Record Drawing is accurate.
i,
. Z^� "alt
ignatura of installer Date •,
+&Lr Printed Name of SigneeMASON COUNTY PUBLIC HEALTH The undersigned approves this Installation Re ort and Record Drawing on behalf of Mason County Public �11..��10.016.0,
if .:" L 1 T F 7r 7
Health. I j
qr /G` k
Signature of E
Lai_itt anz
ronmental Health Specialist Date (de• •ner's stamp, signature and date)
P l nted rO F> t w 0JBLIC ViEW ON THE MASON COUNTY WEB SITE revised 1rzz2014
Printed from Mason County OMS
o
r1 _
W
-.... 5
rryy r
V_ �
7
ry
m
• C
ry
11. O
• �° go >
Gt. •
OW
OIL
7, _....... ct \
€ e -
sty All
,
Vali ...
r
•
i a � �
L u
17- F-- !i '-
coW W W 4
PROV1 1 4,1"„Z; , ,",. • .:
z cc
� ig Mr
APR
` ft
•
•Uj .% W Z Q ? Q QAf1� 2 � r ;I'
/'V'��
oc O_ J E-- w O OOUNTY ENVIRONMENTAL HEALTH 4 p.. 1.VUU � � � ? jxXZJJ . � -• IS \\,1/
00 D — a. al c,) ty) C.2•..-,..,-..-.27.t ,1 .7. V . IA
pUUoceZp2u) tuW oo6 f.so ,o, <.,�
otiww _ Az
ULI �j � N M •
at1- � NCCQQUF- > � loOD60 p
ntetti '�t •" Qunty OMS i
Printed from Mason County DMS iI S
Mason County WA GIS Web Map
S1*n
It
3/27/2023, 7:15:56 PM 1:6,143
D0 0.05 0.1' 0.2 mi
County
Boundary I t r r , ' , , ,
0 0.07 0.15 0.3 km
No Filler!
Tax Parcels (Zoom in to 1:30,000)
scum Est.HERE.Gowen.Yyrn op.increment P Carp.,OESCO.usas.
WS.NRCAN.000/om.KiN.Kalmar NI_OaOuem Suvey,Ear
Oa��a Con Owl
Oki naa0y Wig Kam),(c)Opan6Yaay� 0a0o
p aatrra anc
Printed From Mason Cou tom, C1MS un E ',ftmaao„ar,,ag„ ,t„�a „
Printer!from Mason County DMS �""""0' �E'""'°D"`