HomeMy WebLinkAboutWEL2024-00027 - WEL Application, Design, Letter - 5/30/2024 ® MASON COUNTY 415 NB SHELTON: ,SHELTO70,EXT 400
SHELTON:360-42TA8]0,EXT 400
BE ELW 380 -5267,EXT400
Public Health 8t Human Services ELMA:360i82L269,EXT 400
FAX:36 27-7787
PAT COHN
625 W Railroad Ave#185
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT., TWO-PARTY
WEL2024-00027
692 SE Sells Dr
319017590030
The 2-party water system, Cohn Water System (3190175900301319013100200), 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
Sincerely,
i Y��
David Anderson
Environmental Health Specialist
Mason County Environmental Health
H50a acl
MASON COUNTY °a,Rw"' S - 2
COMMUNITY SERVICES qp Rem(
¢uAtlinq PbmNg E,rvnmmenmlXmlrh Community HealN �p
415 N.6'"Slreet,(Bldg 8)-Shelton,WA98594 ,cot EE y�jtJ a , OOC)"
Shelton: 360427-9670 x400 Belfar 3601 ADD Elm:360482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
PVP XT � vlgxE —
M]Ill 14 /,ppRE38-STREET. .STFTE.9P
ll �oar� e, S
B ROBRES3-STREET,CITY,STATE,9P
5 SALE
P I PgRCEL NUMBER ry1ELL Srt/Ef1�/� ,
Igo( L qo0 ✓L,
SECOHDMT PMCEL NUMBER IIF APPMAB
3( LE)
o I- - 00 00
WATER SOURCE SOURCE TYPE PARC4 LOT SIZE PARCFL]LOi
❑New Existing Pt Well ❑ Spring a� C
PRO//P0^^SEII WATER$`Y$^T/EN NANF(ROEOUIREDI
W4K ' 1 ^
PROJECT OESCNPTOXU ski
l
oIRECTI NS TO BITH CONDI N9
42 'i OF c H
Site Plan: (may also be attached)
(property,boundaries,structures,well site WIN'radius,driveways,roads,sepliclsewer components and lines, easements.etc...)
wtu- �ocA->'lou: 't'I, IS�l �fl7, - I� oogglZ"1
kaW 'b MM0h4 G(>Uhlty COLS W /tiI�P
MAY 3 0 2024
By
Submittals Checklist: (these additional items will be required for approval)
H atisfacto Bacteriological sample(this may be deferred if well is not yet drilled) j
Well Lth pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
01 once to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document)
ld Septic Records(additional locating requirements may apply if there is a lack of septic records on file)
This farm may b ,scanned and available for public view on the Mason County Web site. Revised: 10/13/2021
Page 1 of 2
--Staff Use Only —
rReviewp 1: Well Siteyllnspecrt�ion:
NA D/F 11 7 1'D»y Wi❑ 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 mad private, County or State.
What is distance to ROW?
❑ Does the ground slope away from the water source site?(show slope on plot plan)
❑ Is the well cap satisfactory?
❑ Screened and vented?
❑ The well casing extends3Z above level ground I concrete slab? (circle one)
❑ Is there evidence of a surface seal? ( q{; 4d. PF013
❑ Does the seal appear adequate? 1.(jQ: (� R66
❑ Is1aa variance necessary for well site approval? ` /
Comments PrOf Ct (6le«c6n) r� �S �✓0►7 ltiC(l.
Pass ❑ Fail Inspector Date OV- l—
Review Step 2: Two-Party Review:
YES NO . NA
�7f ❑ ❑ Water Well Report with adequate pump test on file? AlK 001117 Or/ 5(?f/T007 v/ 16VA74it'60 AY)
c rf60�f (p1y�
If NO, date of Capacity Test VIS1101 r/ Driller 14 AIM) GPM_�G•J
' ❑ ❑ Received Satisfactory Bactenological Analysis? Date of test S! /1lJz N
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN ?2U 4�"i'$
❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments LSW alowwivilt, Mt`f 'ro VV�Pi,'
�� ���
fO G B• f r fC4+1JZ
Approved ❑ Denied Reviewer Date
/ Findings in this review reflect observed conditions as they existed on the day of the site inspection. No claim is made,express
or implied oflhe future success or failure ofthts system. Well site approval does not constitute water system approval Water
System approval is a two-part process.
All proposed connections to new wells are subject to water adequacy requirements at time ofbuilding permit per MCC 6.68.
Water usage restrictions and additional fees may apply to all new wells drilled after January 19tb 2018 per ESSB 6091.
Revised: 10/132021
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
WATER WELL REPORT cuRRENT
Nodee of latent No. W 236131
1 is u 1.'1 p Y Unique Ecology Well ID Tag No. APL 133
Constraction/Decommission ("x"in circle)
Q Construction Water Right Permit No.
O Decommission ORIGINAL INSTALLATIONNofice Property Owns Name Thedwe Cohn
i 2743 Sri-of/ruepf Number Well Street Address 697 qE mtta rtr
PROPOSED USE: XD Dmimlic 0 Ind 0 raalmrvd cityShelbcn County Mason
O Dwau. a IMpmn O TnI Wtll 17 Omr
TYPEOPWORE: Owaieparser drwdllirnpm Dm m) " .Location NWl/41/4l/O Sat Two� R�[.] n�
wwm
l Ip *w wn 0 Sumul,t a mepd:0 Dug 0 Boma 0 Dives LaNL s g
0 Depmwi D Cade R Romy. D AM&I ong( ,4 r Lot De Lat Min/Sec
DIMENSIONS:.Dmnsofwn_6 iodmdraw 380e. Still REQUIRED) Long De6_LongMWSec
DW&*fwdalemd wdl 3RO ft ` }-�
CONSrRUCT1ON DETAILS Tex Parcel No. 319n1_7 L90(190 ` f'rl C4IIYP.{ .
l caw, RWddd
= Named: '0 Lim bcuad_" D.s.fiwi_ft a ft . CONSTRUCTION OR DECOMMISSION PROCEDURE
❑ TNetled ". Dan.ram ft a ft
hrbmadm: DYm 9C No Fn,waw: Dcznec aY wlor,<Wramr,fue o(mmeidW anr:ode,Wae hidum
oimmai USE DDITIOMnparbm t, IF
So . brmhdlage of
i TYR orwrbrdaaea ' � bbnmmroe. USE ADDITIONAL SHEETS IF NECESSARY.
SIZEofpeds in.by_b. odm.ofpmb_ft._ft a_Ik MATERIAL FRDM TO
t a..: :Il Ya O No I.kK Pm I.oceaon 6 .
3 Maufmtmml Num Tghnarn soilTbp
l Type Model No.
l Dun. Sld use R fmm_3'/c�___fl.a don ft
r Dim. Sla ru< fiom a.m . a Sandy I1LONfl clay
i Gn• Halm pad: 0 Yes it No O Sim ofrmwDpd
An lin
Maeridt plsa0 from fl.a ft
A
-Sorhm3u1:]a Ya ❑ No Towbl depM1,��p M1
hfanow uwd in ml Betol to
Did mY mom eonlsin umeNe were}! DYm jg No -
Type'of:wa, Peprvr. Blois fide sand with
McMd ormlisgeaman - -
PuMr: rAUM'muery Nam_L`
a}Ih,
WATERLEYEIB: Lutl-eu?m dadoan dbmmmea�mleml n
Sa4cavd arr abebwapdwdl Da
I Aanldn pmue Ib.pmpme irch D e
I Anesim wYer iswmNld M1y .
� ea
WELL TRINTTS: Onwdnm uamnl wwrbvel a bwmd eebv dtdc lewJ _
WMepmya dadel D Y. fd w Ifyee,eywlaml
YM tl ldn wit ft dawdmvnaMr by
I Yield: nUmin.wim I dmdowdfla M.
Wr
Ypm. ®1./nun.wiY RdmFdwn•an En. -
Remre7'bm%rr rodenvmm wAgpmP mnM�J rwnmrlewl wr®•mdJ well
• xaa.me .
Tom mlad Ti— WmrLeM Time- WYnlsrnl
Ou ofm
I aeiw au�(*plowe wib ea _rt dnwdowedaa M1n
Ait ,4Jmdtwibaanaa ft. MESh.111Rt011 [iLCQ
rm
Amepnedw P. DYe IT f CIIIOLN
Tempenveofwla WuedpnW polYdrtphl 0-YN A3 W
SW Dam 4/7Q/O7 Comebma DMe
W ELL CONSTRUCTION CERTIFICATION: I constructed andlor accept responsibility for construction of this well,and its compliance with all
Washington well construction stenderds. Materials used end the information reported above are Due to my best knowledge and belief.
%Driaer O Enigma D Trdm Nam a Drilnry Co y rmy+a drilling
OI1 M'bmdrrdm Sipdvm �- b Admae 140 NE Davis—Easm Rd
Onlleror ldm Liam M 291A C, ,Sam.z, Belfair WA 91li
IfTMINEE, - Dnumare
Drium'd umed he. aegidmion No. DAVISDI7100A nda May 07
Bdhr'e Slenderer Fcdop ie m Equal OW mi y E.,*,m.
ECY 050.140(Rev 3/05) - The Department.of Ecology does NOT warranty the Data andlor IlHormstlon on this Well Report
Dame Pumps, Inc.
340 9VC'Daub Earm'dd
'&Vair.'Ila 98528
(360)801-6107
Project: Pat Cohn
Capacity Test 692 SE Sells Drive,
Shelton, WA 98584
Well Tag no well log on file
Date 4116124
Pump 1 %hp
Well Depth unknown
Static Water Level 118.1'
Drew Down Recovery
Time Water Level GPM 0 126'
0 min 118.1' 0 tmin 120.2'
5 min 125.1' 16.5 2 119.3'
10 min 125.5' 16.5 3 119.0'
15 min 125.5' 16.5 4 119.0'
30 min 125.9' 16.5 5 119.0'
45 min 125.9' 16.5 10 118.9'
1 hr 126.0' 16.5 20 118.9'
2 hr 126.0' 16.5 1 hr 118.1'
3 hr 126.0' 16.5
4 hr 126.0' 16.5
Capacity Notes:
L(36077MJ41
lve
W TI
II, SPECTRA Laboratories - Kitsap
A ...Ne n..o nareww.
COLIFORM BACTERIA ANALYSIS FORMemple COlkmM Tim O.umy
cted
5 17 2o2y �_ Kcc�>C�,n
Type a Water System(dead mN op bm) —
❑Beare A ❑Gnowe O)Ser
Gmup A ant Group B Syaleme-Provide agn Water FaclWes Imxnbry(w):
IOC _
Syelem Narna:l�'1_ I _S 4��t
Coded Person:
Dayftre Z,L¢r-� ZaZ Gd Phmw
Email: E..Phone:
�rowk b:P�acnenmt,egx,tugxamtl VewM,baxcmW anaml
SAMPLE INFORMATION
SeWle ooYaded M(name): I
SpttMc bcaEm viers sample M"..I Sfadel Mhuctixvm.nmxnle,
soo Z
Typt of Sample(deck *one bm)
I.O Routlre Dlttribueun Sample(AIP) 2.❑RapHSaepb(Afi)
Chlormad'.Yes ❑ Na❑ (rmm WMWaonSyslan dbrunsat muane)
Chorine Res.1:Tmal_Fme_ Upambebry mMhe lab number.
3.GrOUM Water Rule Source Semple ——— ——— —
e Umalelactwyr(mlemllecdm
❑TnggmM (A/P) Chbnnmd:Ym_No_
❑Asseeement(AlP) ChUreRooldwi:Tobl_Frew_
l Surfed orGW1 Rex Sour.Water Sample(EnumerzAon)
S
❑ E.cob [I Fecal fame ro_an_
5. cmncma N,Mrmnmen ony:
LAB USE ONLY ORINKRKS WATER RESULTS LAB USE ONLY
❑Unnllsmmb Total Cdamm Pmaml ant sMb4clpy
❑E.mlip.M ❑rmoabamt
Bacterlel Density Results:Tool C Sb,m _q Ioo a EmIL__arysMBBmL
Fecal Coli(orm dWlooW. NPC ddtml.
Replacement Ample Requlr [❑TNTC ❑Angeea W
❑ Sample Volume ❑Da tagm Cmtvmr ❑
' Reoau l fIS wbxcs
3xdpl Tang C^. !LI p.aM
be6}faB TCWIR/9NBYQ0
1�1' OBZOYi ..ta.nms,,.a.�.ax..,m,p.,.
R�' 0.7 1024
a.rrva.✓.,.,,nr..axnw.•
.-.M�pxaox..n+smaul.0
mx Lea-u(n`Ms—t, rxnrseno.ra
)1O.�2J �r w•ar.eeaw.a..a�wr.
oT'Imnmvvp4y�xyn
220@a MASON CO WA
�'IIIAIMIn I1� ���'1IIAIw°�
Retum To
Davis Pumps Inc
NO NE Da" Fafm Rd
SelfaiT, Wa 98520
Declaration of Water Use Agreement
Cohn Water System
Private 2 Party
ABBRFA7 ;Of TRA B IVF SFRVF.Dt
The well and wnwl system berag sirnated un
Pand N 31901-74i-9pp30
I.V.j De riprba:
LOT30FSP02u24 SURV'EV 12f124
Rode 3W Thwnship-. 19N soe n-I
NW V.of Nu SW Af
e2 SR Shcs Dsfie,Shdma.WA 9Ns"
�runiso(tf COHN LrMKi 2 IMT..
i,AI RICK G CORN&STEPHAME G COI IN TRUMMS
cp Cl
yy Pame1031901-75-901D0
1 Legal Dnerlfniom
LOT 3 OF SP CO24 SURVEY 1L12J
Rugr,3W Townd* 19N socliocl I
NW V.otdw SW 114
an SE Sdh Dml Shdtom WA 9g50+
O4omoo(s) COIfNLIVJ?Ki RL13'f.
1ATRICK G CORN&STRPHAANIE G COHN'IRUS ELS
(t.of
PArM N3190t3i aw2A0
L.,w tv a pzwn�
PCL I BLA 005-28 A TA%72-R-I Pl'N G.I-3SIIRVEYS 23114&31f3&321190&4NN9
Rouge:3W Tox'nWlp! WN S,elww I
NW'A of We Sw V.
6"SR Sufis Dr1w,Shdww,WA WN9
Has been dcMglnhd la Wnr a sonmr wf wnlct let the following pnulN Winged in Mann C'armly, Slek of
"Slunsiott lien lidesclrhl'd'
Parrot p 319n1-7twMUn
Legal DescArAkm
LOT 3 OF SP M2d24 SURVFY IN t 24
RmWN 3W Township: 19N Section: I
NW t:of the sw 114
M2 SF sell On,,,Shelton,WA 98144
g
Pahl M319g1J1-0U2d0
Legal➢eadpnon:
PCL 1 BL A MOS-29 Al TAX 72-R-1 PFN GLSSURVEVS 23114 As 313 6 3211911 6 04149
Raigte:31W Thwnship: ON Secdow I
WIN Y.of the SW'.
690 SE Seas Drive.Shelmn,WA"-"4
OWNERsnwf)F WF1I AND WA'rFRWORU
It is agreed by the panics that each cf sdd panics shall be and is hereby t?anted an undivided one-half laciest In
and In de toe of the well and water system. Each pans shall be ennllcd go roccne a supply of water for are
residential dwnUmg and shall ftunmil a wawmnhle supply of potable and hea11 ful water for demes➢c purpnsCS
jr(AT M AINTFN ANC OF WAFFR MUM
Each yam he"oevenams,and ogres than they shall equally share Ue usvm Mac and OPUINuonal costs of the
well and water w9cin.
The water syRem is dotgu d io Pmrtdc for m•e sin ices .ufditiolatl planning ad dcSrgln apprev'aI muss be
obtmrtrd from the heal luallhJ prior to expanding beyond dus nuadnCg of services. Design flow
nzrdmds accemn fordnmesdc use and wagering of a n•ptcal lawn anloi garden space e1Uy The design assumes
than all n'sidoaoc s will be equipped with ultra low flow ploughing Fixtures and that all usels W11 hecp co�vation in
mud whoever the system is nerd Addtuonally,a wary ngK ObLlincd taco t]w Dcp-nmem of Ecology,Ih
required if Uic wart SytSim exceeds exemption sardards This.rysmm has not applied for or been ginned any
waivers from Sjwc1rc provision uftle regul,7twus
FASFMFN"1'(IF WELL SM.AN➢PIIMPHOUSF
"1]uxe shall be an Caaealfng for the Purpose of i alnuilmng and reparrng the well and components to complete and
maimam a property fmsaiomng water system and appurlenarce thereto,within Ital feel of Ue wcli slm in am'
dnauon of both pmpenes lish:d. Sad easimenl stall dhow the"'S"b tiem ran nloname or repair of the well,
Wmer systcaL W top house•Pumps, water storage mwNoi m.piessam I.7rrYs..watcdue,(MAIN Illrs andlor WrYllung
uocc,9hry in de operatrnn of the water sy Win
'AINTENANCP AN➢ RYp'AIR Op➢LTRIR 1 ON UN)iti
AU pipehincs h,the wawr%)Meni shall be mouudrud w dal [how will be ro 10"llc of seepage,ar other defi%kx
wMrh ircly puv;wnnmimdion of Ux.water,err iryury,ar danugro Ia Pentrns or Property Coal of repainng or
matmahung common disuibutiun pipcliltes shall be burn equolly by both parties. Each Pam•In this agrelneul
shall be responsible for tlx ursnllalmn,nauncmine.Npair,and repheelnun of pipe supply ing wager from the
commmn water drddhollonpiping to their own lmnlculad dwelling old pitifully julemnt shell be granted on both
lots to repnrl.¢place or nunflain IM wmcriilrc as needed for distribution Pitrma ss Wine,pipcllouN nhall not be
Imlallcil.11hun 10 feel dfa sofitk tank tit within 141 fed of scsnage dlspoml drainneld lines
PROHIRIYCO PRAMCa'S
The psatna Herein.Lein hCirs.suceessors ardior assigns,will not Constrict,liftman.or sahrcr to be cownrucled or
Maintained upon the slid land arid whbin Ino fMI of the well herein described.an long as the ware Is operAed to
f-rush water for public comunupoon aas of the following septic tanks and dminficl a sewer lines,undergeta d
storage tanks,county or state roads,railroad tracks,verichs.sirueOn=,barns-feeding stations,giving animals,
codosn,ev for nstitu:timng fowl or animal invwrc.liquid of dry clermcal storage,herbicides. insecticides.
hazardous waste or garbage of any kind.
The parties biucin,then heirs,successors Ittidlor assigns are required to beep the water supplied from said well free
from lmpoune,which might be injurious to the public health h is the purpose of these grants and cavervarns to
prevcm eeTvanr priiaw hereinafter cromcmtcd in the use of said g,ow S)land wldch ought wro lm w said
water supply.
Exhibit A NOW,THEREFORE,to Ppamags)agn e(s)and coveront(s)drift said gramdl(s)•his(hcr)(Thar)heirs-
stissassurs and assigns win out consumes,maintain,orwiller to be mummacred or ammmimi upon the said hind of
the giamor(s)and within fifty(50)feet of the well herein dcKnbed.so long M He ware is operawd to furnish water
for public consumption ANY poTr, IAL SOURCE CR'CO?v-I'AMINAI'ION INCLUDING BUT NOT LIMITED TO:cenpacls,sewer&pnvses;scpbc hints,dminrelds,mamrre piles fenced prslure,garbage of am kind or
dcscnpuoq any cneloswe or sinouves for tM keeping or storage of man bwdegrsdab k femlrmrs,Irgord or dry
chemiads,herbicides or trseMcrds as well as any crclosums or structures far the beepingatoem
or vlmce of fowl
or arivards such as barns,chicken louses,rabbit ti whos.pigpens.hvemaek she&aid further agree(st not to use.
apply.dispose or suite,to be used applied ordis{osed.zoo biodcgmdable fettdites,M lNud or dry chemrcds,
herbicides at imahcides within the dove described protective radmn T h=Co mints shall inn with the hud aid
shall be binding on all parties having or Xqutang any right title,or werest in the Lind described here-or an(v Pont
(hereof and shall usiue to the bericru oreach owner thereof
wwT RtiYSTEM MANAUR
The owrra of Panel p 3I9a1-15-"WIl lellal Uri,ripdae-LOT 3 OF SP OMI SURV CY 121114 Rnnft:3W Tnwrnbip:
19N 5ecdon: 1,In the NW'Y.of the SW Y. is it,designated`Maregei"of m.de syse The aiantger shell be
rcapoatiiblc far aranging 5�uussinn of art ieccsun water samples as mquuW In tie Wa4Nrrgmn Administrative
Codc,and Mason Coumy Rules:tad Regddmm and hunting eaergcw,es such as gestem shutdown and mheur.
The Mio age,shall provide,hoe her isa-e address and telcPhoia nnnihef 10 the Health officer and shag scive as e
Martin personmdue Hedth Oficer Themanager Shall otgnnac:tad mmunin the water sy nem records and Mary
the Hearth offi c�r and all paa[a service cente nana,and tars that arc included is this agre[mem,of the water
246-291 and Mason Cowry Rules and Reguhuion Weser»swm ncoids
quality Was that are required by WAC
shall be available for rcvim and inspection by all panics in this agrccmcia and the HcuhhOlTicer
HE CESCORC NUAcWOM
me,, a,emmms arid agonanem shall inn with the land and shell be binding on all parties having or aoq
Tuaring any
tiehL late,at imaest in Wis land described herein or any pall lereof,and It shell pass to and be for to bercfa of
cach owner tbcrcof
PRh.lh'1 ON hOh PONPORMIN❑PA R'fIFC ANL PROPCR'HRA
The partner IiGda agree to establish the 1919 In woke ntnsdunbk mydWham for the apcmton of tM syalenk such as
teumanuou of services if bills are not Iand within 41 rays of the due date.additional charges for dlsconneMMoq
rLroomt¢ttnn crc panics nor cunrnmiing aid,the pmNnenw of Ihts ugrcenx•M Aludl he aunjccl Io IM4e t charges
td'1556 per munmi rngellwr wish till¢ollalimi fas.
Cahn Witter Svsttm Water System On•net baa
Cohn Water System rSystem OWner Daic
State of Washington.
Cotmry of M(Q.O-
1,die tinders tied, a No ry bbi;in and for the tumted above County mid State,do beshy certify thu
cm this day of 2024,penunally appeared before mu -�- +.41-r a {•ie rD�'1t•�
to me known[o lx the b vtdual deseribcd on and who executed the within uastrumen aekinwlcdge
that he(she)(they)signed and sealed the sane as free mid voluntary act and deed,for the users mid
purpose herein mentioned.
GIVEN under my hr k official • tub-tl�day and vear last above written.
Notary blic in mid for Statc of Washington.
rcsed'
ycotnmispon expires:
���v`pG�F;sslaAt'�N'rrO�4•
t"TS NOTMY -
-
+� elf' • atq..aV`�.
!ryii pf�yyASN v:
Mason County WA GIS Web Map
4600 SE,LYNCH RD
692SE-S LSDR
5/13/2024, 1:19:24 PM 1769
0 0.01 0.01 0.02 mi
0 County Boundary o 001 0,02 0.04 km
❑ No Filled
' Site Address (Zoom in to 1:3,000)
E HERE, Grt,nln, (n, LtenSESOSW wn1Ar o eM IM1e GIS Uw
O u,ny,Swm: Ezrt Maur.EepM1aW Gewr�iw,aM Xn GIS Uear
Tax Parcels (Zoom in to 1:30,000) m�M
Maam CwMy NMGIS Mb Map ApMr:aYon
Meson Coinly JIxL Ima MCURCy MaEiITy.orlimal'aMs MxeEsae IMO,M IieEk b lo¢wsM1Cm relianw m X.Mlpa'IMwxmBeMWMyxflpovldieUeimer.pM1p
ASBUILT FORM Mason County Public Health
PermitN'umber swG 07 -. DOOS A9°�r's Parcel 31 O1— S- Dds2
r� (Twelve-Dip Number)
Applicant's Name r 'o� r.-Oyu Subdivision
(NanV/DivisiodBlockg,ot)
Applicant Address egfi S.B- SdLzx 0 Installer's Name
City,State,ZiP UkWxrK, (,GA- swcy -Dcignor's Name w.IsitC Drf.f��r/6
N/A Yes Prior to Completion
I. SEPTIC TANK
>5 R From foundation?.._.........._................-.........:...�......._ -❑ 8- ❑
>50ftffomwells? ....._.............................._...................... ❑ J� ❑
>50 It surface water?..........................:..........._..... ❑ 0- ❑
Building slubom to septic tank:clemout ifnot 1-2%?................... ❑ g ❑
Baffles intact and clean?............................................_._........ ❑ H� ❑
Dividing wall intact?................................._........................ ❑ gl- ❑
Risers installed for access?.........................._..................._... . ❑ .�- ❑
Screen basket or wtfilter iaat�3?{lGW .all --------------- ❑ a— ❑
Tank size:L�gal.; Manufachue;
II. D-BOX zd w4
Leveled with water? .........................................................- Ail, ❑ ❑
Speed leveler used? ............................................................ Jam ❑ ❑
III. DrainLeld
>10 it from foundation?....................................................... ❑ a- ❑
>5 ft from property lines and easement Imes? ... ................... ❑ S- ❑
> 100 ft from wells?.......��..�!.+.?A r""sue
l� 3}.F... ❑ a ❑.................... . .....
> 100 ft from surface water? ................................................. ❑ � ❑
>10 ft from potable water lines? ...........................h................ ❑ 9 ❑
Laterals level to±1 inch&end caps present if not looped? :` $-- ❑ ❑
Gravelless chambers utilized? ................................................ B— ❑ ❑
Gravel clean,properly sired,and proper depth?........................... ❑ -a— ❑
PRESSURE SYMMS
Sand quality ASTM C-337....................._................_... ❑ El� ❑
Head height uniform >24 inches? Aotuel head a p p ❑
Clean-outs and observation ports present?..Le. ....... 8— g- ❑
Mound: Side Slope 3:17............................................. ..13— $ ❑
Owner informed electrical connections must be made by
owner or licensed electrician and inspected by L&17..........._ ❑ AT' ❑
IV. PUMP/PUMP CHAMBER
Pump make Pump model st 33 ❑ ' p
Chamber eiae lze*o gp1 �••,• _•�,,, .Haw1. {} - ,e!—' ❑
- -m - - - - -
Height of pump off bottoof pumpe)tamber inches �
Pump chamber draw-down &L-J...- gallons per inch per minute --r
Pump capacity Gfa-.yo. gallons per minute
Pump controls:Timer,Elapsed Time Meta, Counter?(Circle all that ❑ 11- ❑
apply). If timer.Pump On 1;(-A. Pump Off
Riser installed for access7......................................................... ❑ .�- p
P . . . .. .. .. ......_ ....._ ❑ ❑
Printed from Mason County DM$ '
CHECKLIST
[J--brainficld&
manifold orientation Pj
&layout
93 Trenchlbed
dimensions and
critical distances
within layout �a
—DG—,n y�-
9-1eptidpumptank
placement \ i
\\ 0 rb' §e
@''Location of
buildings ,
8'Observation port& aa�
clean-out location I o nsT"rr arf
O— Location of wells&
roads r
ce
B Uirdisturbed nativ p\\
soil between Nj 3
trenches. 6la"At
JY�orfh arrow Dwr.+Nmin as
cadw
Cbolh UN:Minor adjustments to septic tank location and dramleld orientation made in the field by the installer oregen erall acceptable -
toobtain r�w�ritlen and the designer bat mould in certain rases comyromise Me viabibty o([he system Il,ie the rnrfaller's rerponrrbday
the stern vwbil A�deross�at:o�rum edher the heath deyartin¢nl ar the designer before making any deviations from th¢design that ofject
sY l9+ Y from the approved design must be shown above.
Installer: Check a box from Row"A"and"B",sign and date the�U'fication
A. ❑ 1 certify that I installed the system without any aril certify that all deviations from the design stamped
deviation from the design stamped"APMov®"by "APPRovED"by MCPH are shown above.
MCPH
B. ❑ I certify that I contacted the designer and left the jdTd not contact the designer prior to final cover because the
system open for inspection up to 48 his prior to cover. deaigaer waived the notification requirement.
I further certify that all infomation contained on this form is accurate. I understand that if the information contained herein is not
accurate,there will bejust cause for immediate suspension of my installer certifncatio
S n lnsuller Date
The undersigned approves this installation on behalf of Mason County Public Health.
rAA�o 9(2o U"1
[Pt
Si Lure of Sarian Dale..iQ taauaryZ
R rated from Mason County DtAyi
�SEPTIC DESIGNS CUSTOMER: PAT COHN nONEER DIGGING, INC. PARCEL#:31901.75.90020 SOIL LOGS:
SLI-o19x 5L2-o329 R9 5L3032o mn
19+1LAY 32+CAY 32+ Y
94f'.Y x DRAWING: PROP. PLOT PLAN 3o M lg 399 M32 aool 32
N.PWr SCALE: 1"-50'
t- - - - - -- - - -- - - -- *SEE ATiPO En Ei1ER: "nExIP10N OP INTENTION '
M% TRANSPORT LIW R AMP OR DI. V
L - - - - - - - - - - - - - - J
E45f. /PROP05En TRANSPORT I.NIr. /
EwSnNG nRaA1NPEI-n:3. Ybr �•_,,,
/ TRc"NOf5rM59H En
�� W/ 90' AVENUATIONZO�
nA \
wwSEPTIC
8 PIIAW tPNK
WMOJEn OR 61mn \ I�
Z
PROPOkn \PROPOSEn WiU
aEN90N VD-FLTER \
E45f.W, L \ /
�p
1
Etc 4
/ oz'
256'-I"
rinted From Mason County DMS