HomeMy WebLinkAboutWEL2024-00027 - WEL Application, Design, Letter - 5/30/2024 SHELTON,
® MASON COUNTY 415N6SHELTON: , 0427-97 ,EXT 4C
$HELTON:360-27 87,EXT 400
BELFAIR:360-2]5-04fi],EXT 400
Public Health & Human Services ELM 360t8 5269,EXT 400
FM 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 (319017590030/319013100200), 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 zt-(
MASON COUNTY o.mR«,i a S ^ 0 -
COMMUNITY SERVICES Amp R« iv
Puilding.PBnning EnvirmmenblHmlrh Community HealN WEE
1'p \ q� � y/
415 N.0 SnceL.(Bldg 8)-Shelton,WA 98584 rrEL ) V .{, / 1/ c)"
Shelton: 360427-9670 x400 Helfair:360 2754469 x4W Elma_360482-5269 x400 V�/
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
AP ANT Co441 T PHONE —
MAILINA ADDRESS-9TREET,C L'") ~ � G�ei]
IWIAWEll-STEEC L�r. P
P IM PAMEEL NUMBER PRELLC'E1
I901-15-9oF3c
SECONDARY PARCEL NUMBER(1F APPLICABLE)
3� °I- - 00 0o
WATER SOURCE SOURCE TYPE PARCEL I LOTAZE PARCEL 2 LOT SUE
❑ New Existing A Well ❑ Spring I e�Gt 2
PRO/PPO^SSE''D r1Iv�XTT1ER SYSTEM NAME(REEOOIREOI
CO IK VYArr^
PROJECT DESCRIPTION
u s-H
I
DIRE NSTOSREJCONdT HS
I D qZ 5f K at L4t 5l OF f l+
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,SeCJCJSewer components and lines, easements,etc...)
weu- I��A-now: �t�, ISag4'1�, - I�. 00g�+ ly1
Sf� A � MnioN CUutyt�l COLS WZ;P, M+kP
MAY 3 U 2024
By
NOV-
Submittals Checklist: (these additional items will be required for approval)
zH atisfacto Bacteriological sample(this may be deferred if well is not yet drilled)
Well Li th pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
,Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document)
p' 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
--------—----------------------Staff Use Only
Review Step 1: Well Site Inspection: �
YES NO NA Dili 3 �t t,!'VX1 W'
C. ❑ 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?
�] ❑ ❑ Does the ground slope may from the water source site?(show slope on plot plan)
YJ ❑ ❑ Is the well cap satisfactory?
Od ❑ ❑ Screened and vented?
❑ The well casing extends Z- above level ground/concrete slab? (circle one)
' ] El El Is there evidence of a surface seal? Lol t1, q?' /j0(3
J ❑ ❑ Does the seal appear adequate? LC#cl: 1. 0SIM
❑ } ❑ Is a variance necessary for well site approval?
/�� 1 1
Comments D►nrhf7Wo( (61eft6) 6 7S hoc r' Cfl
Pass ❑ Fail Inspector Date 6/y/zot�
Review Step 2: Two-Party Review:
YES NO . NA
1Z ❑ ❑ Water Well Report with adequate pump test on file? AIMS Pr4bil' On 5/79'/7007 v/ if(rpm rWid R!t')
No'" toa)
If NO, date of Capacity Test f�/1161101`/ Driller Ltd&1G')'� GPM M5
' ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test S 1 /lnZ �/
El El Received Signed, Notarized, and Recorded Notice? AFN 72UQS'
J0 ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments LOW WoW w PIr'f SW( la red mce,
/X'OnOm ifost -PAbil L'ej4 4114(tyn m
fo ScG c d• P r 1fCf+1 /7�
Approved ❑ Denied Reviewer Dale �/71 �(/ Z
Findings in this review reflect observed conditions as they existed on the day of the site inspection. No claim is made, express
or implied ofthe future success or failure ofthis system. Well site approval does not constitute water system approval. Water
System approval is a two-part process.
AB proposed connections to new,wells are subject to water adequacy requirements at time of building permit per MCC 6.68.
Water usage restrictions and additional fees may apply to all new wells drilled after January 19'^,2018 per£SSB 6091.
Revised: 10/13/2021
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
i WATER WELL REPORT CURRENT
ononaa Pmpy-Em1em 1"opy-ownv;a"e•pr-dalRr Notice of Intent No. W 236131
-!['o'L'i p'r - Unique Ecology Well ID Tag No. APL 133
Construction/Decommission("x"in circle)
Q Construction Water Right Permit No.
1 O Decommission ORIGINAL INSTALLATION Notice Property Owner Name lltedore Cored
Z 7et3Y`1-ofInIem Namber Well Street Address a97 et. 9e11. rn.
PROPOSEDUSE: IF Domenic O IMuwiN O Muniapil city shelton County Hawn
0 Dewaer. C Intention O T.Well O poker
1 nrE OF wr3RK: ownr:nWmer otwcn titmpm lMn onf Location NWl/d-1/4 �11/45ee]_ Twn� R3W ' n�•
t wWM
_ 3V Newn 11 0 0.ewMnwind Ahil a :O Dle 0 am d O On. Laf/LO 5 g
o Deepened -o Cade R son, o Teem ng( 4 r Let De Lm Min/Sec
OtMensrorvs: mrelmwdl.anf _Sa iMrw,amw 380n. Sti11REQUIRED) LR gon De Lon Sec
1 ueuwtrmmpNadwdl 3R0 ft — ! g
CONSTRUCTION DETAILS Tu Parccl No. 119n1_7 5-9007n ` •f'ef�ff ee/I
J cams Sec
0; Diw fiom �n.m_3T�a _ _
InaallN: O Linr insist_" D ee ftom ft m R . CONSTRUCTION OR DECO114M6S10N PROCEDURE
0 Tabled Dion from ft te ft
PeadrsrloM: 0 Yee t*No
hodeFdmutim'. Deun4 by color,ebucl<r,eve otmanaN alabe.nM tlke kind and
noflhe mania mach Estee'SHEET, iNalemoamvy teach Gunge of
� TYR ofperfdruoruud ' iMommion USE ADDITIONAL SHEETS IF NECESSARY.
512E ofpn<'in by_in ald no,ofpufi_ficm_n so 11 MATERIAL FROM to
7 5erena: R Y. 0 No GkK-Pa Ldrlion 376
MawRemb'e NoneTrJanwln - TOPsoil In 2
-
1 Type a Model No. -
1 Diem. -S Daan — t Ran 1-/c 'ftm_�an fl.
d ITun Sla aim Ran��Rm ftSandy brotorl clay
Dnre ear lla4tl: 0 Y. xa No 0 Siaoraerev ind -
• Memrini'limed thin A m ft
A
Susan 3nl:Ja Yin ONd To wM depth? Is fl.
Maeriauie3insY- B®tvvnits $=Owrl
Did any a a a moan ninni vno-f! aYa Ill No
Tyeedrw.b+ Dana orals'- Blue fide sand with
• McNCd dONida rbaa oR
PUMP. M.mlf Iw'I Name r14110 Igo
Type: enh HP.
• WATER LEVELS: LMddudMG elevaion tlovc men aakva ft
5lndc level RE n.beldwmp Mnnal tale
1 Ana,nenure on innyua inelr One
1 A...i1,0onlMbr
n valve eu.
WELL TPSFS: Dnwdnne in anoun wear level a 10w tnldw east lend
Waapunpeatmtle? D Yes fpi No YM.by whom?
r Yield: W Imin wind fl dannionn end M.
J YieM: alAnin wia ft dnt o..R M.
Yw1d. d ran wid a.d ,w n and M. -
1 xmommsdn/n.w..•,nAwbmp„mommwl g/rwn../ewmmen,re!.dl
I�nworcrlenl/ e�q
Tae Wamr Lenl Tin Web l<rel Time WatrlLMl f Y i1'
t ONe oflar if U
ianda ft.169ahanwiN I1a keid .aftn4_ M1
I Ainat gL)min win aem.M n.hr_bn Wi s}`1i1FtOA S[Stc
I Arno.fiew - ¢.p.m as tr,F.l Of -Colo
TevVenn=ofrnb Weiss calandysesz? DYa
and Min 4/74/07 completedme,
WELL CONSTRUCTION CERTIFICATION: i constructed and/or accept responsibility for construction of Ibis well,and its compliance with all
Washington well construction standards. Materiels used and the information reported above are true to my ben knowledge and belief.
EkDriller 0&,.OTnine Nun(prjpt Dnllihy Compenr rinyic nrillinn
Dnllerl Fieihieveir.e Sen.. 6faJs b Add— tan ME .,e& Ram Rd
winoor lrvae LkweNo. 2916 Dy.sWi,,lip Belfairr WA 9Rr2R
uTRAwe4 Conern f
OriW.uovrea rva. Riestodon No DAVISDI1100A Don Man 07
OriaaNa Slauan Ecolop in no Fqua Oppommi y Engloyer.
ECY 050-1-20(Rev 3ro5) The Department of Ecology does NOT warranty the Data andfor Information on this Well Report.
Dacia Pumps, Inc.
3401VE Dauia'Farm Wd
Bej/air,'We 98528
(360)801-6107
Project: Pat Cohn
Capacity Test 692 SE Sells Drive,
Shelton, WA 98584
Well Tag no well log on file
Date 4/16/24
Pump 1 %hp
Well Depth unknown
Static Water Level 118.1'
Draw Down Recovery
Time Water Level GPM 0 126'
0 min 118.1' 0 lmin 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 1%0'
45 min 125.9' 16.5 10 118.9'
1 hr 126.0' 16.5 20 118.9'
i
2 hr 126.0' 16.5 1 hr 118.1'
{
3 hr 126.0' 16.5
4 hr 126.0' 16.5
Capacity Notes:
i
i
26276 Twelve
Trxs Ln NW
sa.c II, SPECTRA Laboratories - Kitsap
Papi,ba,WA
983]0 ...Wean a a.i.�wuura
366 T7Zl41 COLIFORM BACTERIA ANALYSIS FORM
Dale Swiple Collapled Time Sample Counq
5 /7 126ZL calecmo A, R�
Type ofWeter SYMM(MMkanly one box) —
❑Group A ❑GroupB Olhw_
Group and Group B SyMem-Plwidefrom Water Facilities Imwltery(WFI):
IDC _ _ _ _ `Systemrmme: ' �Y\— �s��\S
Correct person: c..e_
Day Phone: ']CeC- z 7_ Cell Ph"
Ernst Eve.Phone:
Sena roam m:mdmtavnn,namwaaamdeaemwm.arewa.wewrwmdal
SAMPLE INFORMATION
Sample calk dby(nan): 1 L.P-�
Spe�afic lo"rzdun where sample cneected: Spetlalirehucapm wcanmente:
0 7-e
Type of Sample(dwa 014 om,boa)
1.❑Routine Distribution Sample WP) 2.❑Repeat Samyle(AR7
Chlorinated! Yes ❑ No prom abaiWtlpneyslem afurunsa mubne)
Umalleacmry rpulbe lab number:
ChYaine Residual:Total_Fee_
d.Ground Water Rule Source Sample
l - I I Unsabla4rymutine muecldah:
l I
Chlorinated.Ye,_No_
El Assessment(
❑Tr5l� (t(AP) Chledm ReeUuat Total Free
4Surface or GWl Raw Source Water Sample(Enumeratipm)
❑ E.cofl ❑Feral Ftww w_ro_ wJ
5,7,pB wC -es,h aarmwan pny'
LAB USE ONLY DRINKMO WATER RESULTS LA USE ONLY
❑amatlafecfory Total ColHwm Pimwn and SedelaMry
❑Ecoa paned ❑Ecokaream
Bacterial Daeay Resuae:Toted CNdomi__mpNlOpm.E.mF npN1Wml.
Fecel Coktam "0Jml. HPC cfWiml.
Replacement Sample Rmpuaea: ❑TNTC ❑Sample lap rid
❑ Sample Voteme ❑Dwell Contemer ❑
)meR Recei - r Rahwce Number
iecepl Temp C•: '23 aaamd "SM ,B TLWMISM9t]]p
T 2024 pa
ronlee-swpa ama.,�rww.
no.�L
mxr�.mun�rr.wn
2209735 MASON CO WA
Iii i4ilwi,m1 uNIII IIIil III111111IUINi`
Return To
Davis Pumps Inc
3W NE Davis Farm Rd
BeaalT, We 98528
Declaration of Water Use Agreement
Cohn Water System
Private 2 Party
A➢RRMATFD I i AI ➢FSf71TP11(INS ADD PARCEL VL\{ < OF TRA(TC ➢EIYC fRRVE➢]
Thc well and wAief syslcin hcaig smiated on
Partrl N 31901-7190030
1q-.l De ription:
LOT3OFSPa2024SURVEt I2)124
Rang:3W Tbwnehip- 19. Sestian: 1
NW V.of the SW TN
02 SR Sea.IMi.e,Shd Wn,WA 9N.4w
Giwu,(li COLA LIVING TRU15T.
PAIRICK G CO1L'J&ti 1'F.PHiAN1E G COI IN TRUSTEES
0.ner of
Parcel#31901-7S90100
Legal D .0 1ption:
L(0T 3 OF SP 92024 SMINTA MI24
Raaae:3W Towashlp: l9N Stt[ii¢ 1
NW'.or du SW 1y
692 S£Selo Det.'c Sbdwo.WA 9N5119
Omnieet.I COHN LIVING IRUSI.
PATRICK G COI IN&STF.I7IANIF.I i C 1HN TRUST'US
(lwrcrof
Pucd#31901.31400➢10
Lagal U.Mp[wn'.
PCL I BLA#05-2N&TAX 72-R-1 PIN (:.L3SURVEYS Z3114&3113&3211"&4WI49
R.Ke:3W I.W'n0lp: PIN Sa w.: I
NW V.of the SW
6911 SE Sea.DrWc Shdwo. WA 9#S84
Has biW gksiggahvl le wnc a amass n1 water hs IhC I'nlimving prices 9MMIC41 m Musser Coolly. Shite of
SV,tshingtuo. hewtndcscrdv:d-
pitted a 31on1-7SwaUU
Lw .I lkC ripllon
I Of 3 OF SP a2024 SURVF V Iv124
RmW:3W Tmrtst 1p: 19N Smlion'i I
NW ',:of the NW 114
M2 St Se0r Dmr, Shellnq WA'MIN
3
P.m9 a31"l-1 LA02110
Laval Descriptwn:
PCL I BLA 1105-28 m TAX 72.R-1 PTN Q"$,Ii(tYETS 23114&31t3&3211911 K 4W 4'9
Raree.3W Tranship: 19N Smim 7 1
NW''A of the SW Y.
6905E Sell.Drive,Shdmrt,WA 985a4
OW'NFRSFIp OF WF91 AND WATFRWORICG
11 is agreed by the parties thai each of said Panics skill tie Ind is hereby granted mi undivided arc-half Interest In
Met to the Ilse of lac.well and wager VS1em. Each Party s1a0 be ennikil to r=)VC a supply of water for one
resibemal dwelling and shall hLMLSh a reasonable supply of potable and healthful water for dun)WK ptupotiss.
C(KT OF MAFNTV'NANC OF WATER GYGTPM
Each pam heroin cos•enalas:ud agrees that they skill equally sham die mimeo arce sad operational costs of the
well and water sy stem.
'^Ff ITlI R E PROPERTY f1W NFRG
The water s}5mm is destgOcd to pmvidc for Iwo xn ices .saldiuoual PLuuung;ud dcmgn approval prod be
obtained from the local hCalthyWiSOCTIOn priorto expoodmg beyond this number of seer ICm DCm9n fl0w
.tardaruds account for dumestic use and wafering of a n'plcal lawn arafrar garden space onh The design assumes
thal all residcr..Cs will be equipped fviW ullm low flow ptmibing ftdugos and that tul Ilse is Will teCp cotuenation in
nand whem•el the sy jwm is used Addttmnvll}.a rater ergs,ub=cd tram the Depar went of Ecology.its
ted any
n:gturcd if the w:ner shun exCoeds Caclrrpuur Statical& This sysWat has ml applied for or L<c l gran
Wat%CIS front specific ptus•istUm of the replalana
GIT3' ANn PIIMPHOfBF
-I here shah be m C ngcrr fog the puspase of umutmimng AW xPurtog the w•e6 did colaparenli to coiapiete and
mniWant a pwpcdy fwaarutung wirer 51stum and appulunance thercta,wiuun Iml foot of the well SIM i n am
drrecuon of both pmpcnxs listed. Sad 2a5enKnl shall.10" the irumWiion, nmintenaeeC ur fepau of the Well.
w:ael system,pump house, pumps, Water atomgc reservoim. pressure links-watoriim,uultw lIoC5 ald/ar amth'og
neuuan w diC apCnrnn of sec Water system.
S AINTENANfV AND RPY IRIR f�RD'fION LINES
All pipelines in ih•water%;'stein shall he nuiNairwd w dot Ihem will he 10 linkage of wepago.or other dileees
whtJl IgilY C3IlSl'ewllWllllnini[In Of dLL Witte[,err 11gm1'r rr dilltrlfle W f1PRnn5 0l pfnfKnl Coavr tepainng or
0onlaumtg coalition distribution pspcla"shall be bottle Cgmllly by bOLh panrcs. Erich{aril'm dds agmenicnf
.Jill be resImisi c:fur lla: uumlinllmi, 111,31"IMI CC,mleilr,and repscc.o.oi of pipe supplying water front die
mmnwn water drstrdmnnnpiping tulle it own lmrdnrinrdwolbnga+d propenY fu9ulrKnt shall hegntnred aobeth
lots to repair,":We or umnnann Ile w•n cTiRic as ricerkd for dislribrllion purponeA Writer piPelwcc'hadl rat be
mstalkd wRlun lu feet of!1 ayuic tank of wddtln lu feel of sewage disposal dminfield 11W,
PRON1RITk'DP ACIFICfV
The parties hell'nl,then Heirs.WCcrfiaD nndrnr milo s,w'ifl mr Wnatnlcl,nryrmtmn or $tier to he is operated
for
maintained upon the ririd cord and within Ind fast of die well hcmlll deMrilKd.sa tong 85 osame , n e rgro to
fu"ucla water for puhln emmmlpbon,Any of lde follo ins; septic Innks and dlawfields,sewer hre"nn Ind
storage lords,wuoty or state malls.railroad tneks,vehicles.Structures.burns. feeding Malaysia.gm g
erclas NCS for nnituaimng fowl or muflad wamon.liquid or dry elelmcal storage, herbicides. insecticides.
hniardnus Avast'or garlaW of any kind.
The parties herein.their kcits.ma:essors anNar assigns ale required in keep the wtuer suppb �myanvdms of�
from impuntics which might be illusions In she public health It Is the PwW se of these gra
is plan cra ccn:on practices bereuualer enumemred sit the use of said gruaonsl]arid which might o ralwalra n'said
warcr suPP4
Exhibit A NOW,THEREFOR!',do gmtuaNsl xgraxtisl and wvwnntisl tint nerd gmnwrt5),ha(hcr7(thin he11s.
succelows and assngm will nw wDIAMC1,mammw.or suffer In be constructed or maintained upon the said land of
ere erantot(sl and wRkaw fitly (5d1 feat of de well herein described,sn ltmgg as Ile same is operated w famsh warcr
for public consumption.ANY P07L\TIAL SOt.RCE Of-Cos,1AM INAHON INCLUDING 13U"f NOT LLMfAED
1T7:e�P°°h,sewers,pities,.Asper'mNcs,drainflelds,mature plla, fenced prstwe,garbage of nnr kind or
dcsnpuoa.any crcLosure or Arm IWDS for tee keeping nr Ares or b riot biodegradable MS QT IFM l coad of
fy
chcmt.;ds,lerbicidcs or LRERaOlcltfas as wit as ang nclosures or svuctmca far the keeping ear rnnlwciranw a(fowl
or mrmuds such as bum,chicken houses.rabbet luuches.p+gperts.IIA awck sheds,arid funlrer aga!ClO rat to pica
apply.dtspooc m seller In be used.applied or d¢poscd,ran biodegradable fendnct•utq Irqual or div ehemu:als.
herbicides or lmttucida*'Run the abnv<dcscnLed pwtmlvr radius Thesc covmamts shall ran with she bud and
shall be binding all all panass Mo uag or aadutnng any ngha, tide,or w ereA w the land described berean at any part
thereof,and shall mswe to the beM]h of each owner drerwf
M MANAGRR
Te oa'ter uCPand P3LYVI4wnr13t d el Dacdptlo°�1.(rf 30F'SPa2a2t SURVEY 12A31Range:3W T0W Is sp:
19N Sadoa:7,is the NW'%of Nr SW'i. is LLe designnau:d`hlumgcr'o(tte sysmm. The vnalgam shall rs
maporndne for arranging submasson of all Iu:e?�ary waters samples as mquard In th Washngton Admtansduuve
Cock,and Mason Count'Rules and Regulations and haudlIng emergcrxes such as system shutdown and rep an.
Ttie NiAl ager slat Pmvdc Mustier Rome.address rid IckPhore onmher to the Health imcer rand shall serve as a
coca,,puson w the Health(lReer Tlae nnnagel shJl argan�c Roll murnwin rte svatcr Nstem records Road rwafy
the dad
Rle
dcd
gluht�Wsu dnt hh are required by WAC Arid all Pansies, a2J(w-291 card Mnmm Count, Rules audd RergliLWOM Wvtemi st m rmonds
shall be available for esisew and im ssx:Ron by Alt pianos Ill this agrccroem and the Heahb Otfhecr
11FIR< '•LIfClG rY ti N Sq .YS -
Tiaeae wverwas and agreerncints shall ran with the tact:ua1 shill be bitting an all panics lnviog or acgwnrtg any
mecca.urle,or ilhrereat Rl this lard descnbed hcmR1 or any Pan Ieamr,And"shall Pic'to aid be for the benefit of
each awocr nhrnwf
h'1 OA Nllh CLIP FOR-"'_"""'•rss•s AN 1 PROPER'1'1!$
Tbc paaues hemw aA=to eslablish the"gill in make+eaaanlhk mgnlulao+asCo opc cc for tdumyirorton, u
termlanuon of sers•ices dbtlls air nor plus wnhm 45 days of the due cline, add hug
mcONxenOR cr[ Pamc,,lull conibmihig Kith dk pluPilmle of ihrs Ilgmemetn lludl he inhj,%l vi tmereat chsrgm
M IM per anmnn logcllwr Willi all collmlion focs
' A
/j
/ ;-L G �� `��rC ZazY
Cahn Water System 1Vaicr System Own, Dale
Ike Ca, A, may
Cairn WYtcr Syetcm%4Cr Syst¢tu Owner I Dam
State of Washington,
County of Ma soy'
I,the undo red,a bhc in and for the named above County mid State,do bemby eprify that
mr this day of 2024-personally appcamd before me -�� + 5!-r jT(1{71� r��h
w me known[o be the i vidual described on and who exewted du:wilbm instrument, aekwwlydge
that he(she)(they)signLd and sealed the smic as fret and voluntary act and deed, for the users and
purposes herein menuoned.
GI71y
'c�,mmjswsjon
o
fficialay and vuu last above wnnen.
r
hington,
.
``„��115 TAN prrr'
c)' �OtutY —
_ 'r MleIIC �eO
iWAS�`vs�
Mason County WA GIS Web Map
�30 SE,LYNCH RD
692 SE-SE LS DR
5113/2024, 1:19:24 PM 1:769
0 0.01 0,01 0.02 mi O
County Boundary
0 0.01 0.02 0.04 km
El No Filled
' Site Address (Zoom in to 1:3,000) Ear., HERE. Gamam (o) Open@feallf.p commom.re. and 1. GIs fser
C nnnearly Swce. Esn.Mav,oriental
Gyrame.p ,ano Me GIS Use,
Tax Parcels (Zoom in to 1:30,000)
Mawr Cotnry M GISN M.pA beraflon
Mam,Caney dinom ims acwmry rellaEili,V or imeliness of w alb IMo,not liab1elo,loaw from ratereamM1Mlp./bw.mesmsunlyxeyev/dieGamerpM1p
ASBUILT FORM Mason GDunly Public Health
PermttNumber swG 49 __ 0003' Ass°ssor'.P..Im 3e D1— S D6&?
(TMelvo-Digu Number)
Applicant's Name �A'� �-OK A/ Subdivision
(Namp/DivisionBloek/Lot)
Applicant Address /pfi S,B• SeR.L.f jw Imoiller's Name 7e WI, I �lllf �,eOXAI:
City,State.Zip UkBCTM, All- fS-Cy Designer'.Name Aw/-RC17,f'9,.✓3
N/A Yes Prior to Completion
I. SEPTIC TANK
.. >5ft.From foundation?............._...............................___ ❑ AR, ❑
>50ft from wells? .....................:...............................—......._ ❑ J21— ❑
>50 ft surface water? ..................................................—.......... ❑ 8r ❑
Building stubout to septic tank:ckynont if not 1-2%?................... ❑ g- ❑
Baffles intact and clean?.........................._..................._......... ❑ ,g- ❑
Dividing wall intact?............................................................ ❑ 2— ❑
Risers installed fro accessT...................................................... ❑ �'" ❑
Screen basket or ent fitteriost�lleB"Wwone) ..........------- ❑ g— ❑
Tank size: I 20Q gaL; Manufacture: dnl� ,td,Q
It. D-BOX Salg t448 aay.+-r
Leveled with water?........................................................... If5i, ❑ ❑
Speed leveler used? .......................................
III. Drainfteld _
>10 ft from foundation?....................................................... ❑ a- ❑
>5 ft from property lines and easement lines? ... ......................... ❑ Er ❑
> 100 ft from wells?.......'1 ..�!:J!`..`::'..........
❑ 8— ❑
> 100 ft from surface water! ................................................. ❑ fi� ❑
>IO ft from potable water lines? ...........................r................. ❑ H— ❑
Laterals level to±l inch&end caps present if not looped?,+�""J^.." 8' ❑ ❑
Grawlless chambers utilized?................................................ 6— ❑ ❑
Gravel clan,properly sized,and proper depth?........................... ❑ 0— ❑
PRESSURE SYSTEMS
Sand quality ASTM C-33?.....................—.................._.. ❑ Elm ❑
Head height uniform >24 mcha? Actual had a-- — ❑ ❑ ❑
Clan-outs and observation ports presew.. ..6 ..1.......... g— g- ❑
Mound: Side Slopc 3:1?............................................. -IT .$ ❑
Owner informed electrical connections must be made by
owner or licensed electrician and inspected by L&IT............- ❑ A-- ❑
IV. PUMPIPUMP CHAMBER
Pump make Pump model sw 153 ❑ ur ❑
Chamber size tz-0O gal MdhutAC= t a-cRe±_M .Mu J' t3 - -- Zr— ❑
-- -- Height of pump off bottom of pump chamber -_- inches �-
Pump chamber draw-down gallons per inch per minute
Pump Capacity gallons per minute
Pump controls:Timer,Elapsed Time Meter,Counter?(Circle all that ❑ tr ❑
apply). If timer:Pump On Pump Off
Riser installed for access?......................._................................ 0 a— ❑
Alarm installed?............................... 0 ca— 0
7and
KLIST Q.
ld& I
d orientation N
t '
ed t
ns and I• ? { ��istances 1fU S7TALyU Asyout
GV�Septic/pump tank
placement \ ,
@Location of
buildings
$`abservation port& a�
clean-out location J - i
ET—Location of wells&
roads
E Undisturbed nativ R\
soil between �� 3 MaORns"
trenches 9S P 6 W aA
S�Iorth arrow Al
'�r'r e�
DWr✓Fym.ii at io�
5 1
CAUTION. Minor adjustments to septic tank location and drainfield orientation made in theft by the installer are gge�nerally acceptableto to obtmai ri i the department and the designer but could in c¢rtain cases corromise the viability a(jthe system. !t u the isuWler's responeibJay
the system viability. A�Eerovrmano�rum om 1Fe a health deyarbnenf ar the designer before makr'ng any deviations from the design that a$ect
Y ity Y fr pproved design must be shown above.
Installer: Check a box from Row"A"and"B",sign and date the WiGttlicallon
A. ❑ 1 certify that I installed the system without any -ii"Tcer ify that all deviations from the design stangred
deviation from the design stamped"MPRovFD"by "APPROVM"by MCPH are shown above.
MCPH
B. ❑ 1 certify that I contacted the designer and left the JW' d not contact the designer prior to final cover because the
system open for inspection up to 48 Ins;prior to cover. designer waived the notification requirement.
1 further certify that all information 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 certificaho p
C�er —Date
S eh Instiller Date
The undersigned approves this installation on behalf of Mason Comfy Public Health
"
Revised January Z1N17 ...
Signature of Sanitarian Date
.....art from Mason County DMS
PIONEER DIGGING. INC. PARCEL#:3 1 90 1-7590020 SOIL LOGS:
SEPTIC DESIGNS CUSTOMER: PATCOHN SL1-o-t951 SL2-o32 wnnu 5L3032 a-o siu
19+cur 32+c1AY 32+cux
To6Yaym DRAWING: PROP. PLOT PLAN XOOT9Y 19 399is Yo32 B wooY9Yo 32
~O1 pw� SCALE: 1"=50'
- - - - -- - - -- - - - - � Ex*TE AffAatl?LEMR: "DKON Of IN1E MOW-
LEwSf.fRi mckf PIPE R mo"OR DI.RW
r -- - -- -- - - - - -- - ,
EXIST. /PROP05rD'fRPN�'ORf-1 /
4y M91IN6 171tNWRI
fWN0f5PW55L9 P
W/ 50' AffEWNfION ZON
MIX 5m
/ / - - --FPROPO , I
X11
/ EXIST.fR7OftI�D f [7
RiMOJEDOR6I \\
000' I I
PROPOS D II \ PROPG`EnWfU
/ atWON BIO-fLIM
t
- - - - - - - - ��C
256'-I"
Jnted From Mason County DMS