HomeMy WebLinkAboutWEC95-00103 - WEC Application - 5/3/1995 NiASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1666
SAELTON, WA 90SM
(206)427-9670
FAX 427-7798
shei:on;t a b--t a R En.,t I v C U
WELL CONSTRUCTION PERMIT MAY-0 3 1"5
Receipt No:
Date of Payment: HEALTH SERviuc
INSTRUCTIONS
). Coaplete Pert On,
2. Pay $60 fee and submit this application a mWmun of 24 houn in advance of initiating construction. make check
payable to: - wason Canty Treasurer
3. Attach plot plan.
4. 24 hours prior to drilling the well, contact the health department and provide start card Masher using am of the
following methods: Fam to: 427-7798, or Telephone: 427-9670 ext. 352 0:00 a�.m'.--5:00 p.m.)
PART 1: APPLICANT/PARCEL IDENTIFICATION L06C�15..1mm:.10.3
..............................................................................................:c::::::::::::::::::::::�
SITE xovsE ADDRESS �n/.290 4/,Os
DRILLING FIRM NAME /)41f/ `i ell START CARD NO.w�O{�S L SQ3!S
PROPERTY OWNER NAME `pGL/VI�pp I�'I/pLC � TELEPHONE ( s01 L 5,-51
MAILING ADDRESS / , J,/VO O ��
L5C Lit 6
ASSESSOR'S PARCEL NUMBER 3 2-
SUBDIVISION (If Applicable) DIV BLK LOT
DIRECTIONS FOR LOCATING SITE
ATTACH PLOT EAN
DATE OF ANTICIPATED INITIATION OF WORK:
-DATE OF ANTICIPATED COMPLETION OF WORK:
PART 2: DEPARTMENTAL USE ONLY - -
.............................................................................................................................................................................
TIDEMARK NO.
CALL-IN DATE - CALL-IN TIME AM/PM
START DATE START TIME AM/PM
COMPLETION DATE COMPLETION TIME AM/PM
,,�Ru pi/ y/
TAGGING AND SEALING SATISFACTORY? Nc
COMMENT
INSPECTOR Cl DATE OF INSPECTION
8/]2/J
Db ortotw.w Hm awr oven nrtcw xw W 059593
D pa = WATER WELL REPORT DNauewautiAs ABV 911
m Cap/•—Owi.r'.copy
D.Ey waN .copy STATE OF WASHINGTON ,Aye RqN P.mM No
41) OWNER: Nine Glean Miller aetr PO Box 841 Belfair, WA', 98528
(2) LOCATIONOFWELL: Cory MasOn .y$ 1N�)d 9_1N see�_T. 23N R,R 1W
(20) STREETADDRESSOFWEUL,. m , NE 1349 Old Belfair Hwy Belfair, WA 98528
(0) PROPOSED USE: amves. � ❑ W-dpe ❑ (10) WELL LOG"ABANDONMENT PROCEDURE DESCRIPTION
❑ IMy
❑ DeWNx Aq WM ❑ dlw ❑ Fam.bn:C®bb'mbr.dwaVr.melm.urW stl m�nw.,ny.,oa RYMwda'}alee
Y4 M btl W rWua W N m.MY F Wi Wtlm Po^.RtlM.MN tl RM pw b win
(0) TYPE OF WORK: (p niwa'Ven WwM *2 .M.N.abamrbr.
MuvlMetl❑ New Ck MCIAtl:OW❑ ap.E❑ YARNu FROM M
Deepened_ ❑ Demo D, 1 d 0
Re¢.ME 0 Paltly❑ d,00do
(5) DIMENSIONS: aamebrolww_ 6 - arnee.
Drabs 120 ue,. Dmmaroagtl.e.ml 120 a
(6) CONSTRUCTION DETAILS: Gravel 30 50
casing ama®: 6 aam.tmm 0 _M1b 115 M1 Blue cla 50 70
a .nom M1b 0.
Tla.maa aam.aom M1b M1 Grave & cla 70 110
ParlpalbM: Yea ❑ No
ap°"°feb"oeO Gravel w water 110 120
Pa,b,eao,N hp yY
Pertanm.amtl pant Rb R
perbnaob aanr 0.b It
Ptllanaortl lrotn 0.b M1
9arN11a: q u M❑ _
baM.mnr'.Name C.nnk
Type Stainless wire an Made wn
Dt.m5Lsotaoa 40 ham 115 M1b--120_M1 y
D4m._61otsus eattt M1b
Growl packed: Yea❑ No® sua d "
Grbelpbmdn M1b _
SurM1oe seal: Yea® No❑ To east capN9 Id It —
lva n sea in Remit UP jut 1
ad aM.reta m,aaii Wueabbwell Yp❑ asp®
TypedwelM pepth yapW
Nenrpd a»ar w anabpa �
(7) PUMP: NmNacnnMa Name
TY : H.P.
(5) WATER LEVELS: , w wtltarbe 5 3 ,A combbn
sum M.I Y4 1
MY M1 abMiwbGWwY
Maven pmewm tiPmaoaam btu Duo WELL CONSTRUCTOR CERTIFICATION:
MesonebrYmmWWhy I mien ted aM/a sooeot
.no.eab all W hhhV.vne bilmnflucron s,sr, ,os.pMaW,s,s useb and
(9) WELLTESTS: damUnb.mmmwabr lerM wlorvered Wlox ebnc level a rm pe
m broanon reported above are true to my besl lnmw and belie,.
Wes.WmpWmsss,ci asp[} MYee.MMami NAME Davie DYi 11 Yield: pal./mb.Mat M1trawdoan aMr M. PexwNriN{Gl .a wj ti�w m+nl
amrea Be/lf�a�iir, TWA 98528
(Signed) ynG
tint jmM)(OnbM1Wn.a ztlp Mran WmpaarladaR(wabrbwl cored hen aN (Signed) i=�,p" • tcnsee N..F062__
Trine Warm T. Yuma M Tine Wow`
Cmgrapor'a -
R
NpaO� SDI1100A Date_May 1995 19_
Dine a rtl (USE ADDITIONAL SHEETS IF NECESSARY)
Balerby _perlmb. 4_Ly(!_xtrawEONnaner 1
AiM pN.lnn.Min.bm sat tl M1b tYa. Ecology is an Equal Opportunity and AR9matl a Action employer.For spa-
AWdtl'noe pp.m. Deb clal acoommodeEon needs,contact the Water Resources Program at(2M9
Temmmase a..tltl_Yse a otbnpul-uu ou made? we❑ No® 607E6M.The TDD number is(206)Q7.6006.
Ecv oSo-tal ins± - • ..�9+•
MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1666
SHELTON, WA 98584
(206) 427-9670
FAX 427-7798
April 5, 1994
Jason Mackinnon
P.O. Box 865
Belfair, WA 98528
RE: BLD94-0117
PARCEL NUMBER 12320-12-01020
Dear Jason
The septic records for the septic system indicated on the building
permit have been located in the file for the other building permit
(BLD94-0243) on this parcel.
Policy requires that the septic system meet all current State and
local regulations. Therefore, before this building permit can be
issued, the following is required:
o Have the septic tank pumped and inspected. Supply a copy
of the pumper' s report to this department;
o Expose the ends of each lateral to verify length and dig
one test hole in close proximity to the drainfield and
have the site inspected by a sanitarian. Dig two
additional test holes in an area suitable for drainfield
repair;
o Apply for an Environmental Health Review.
If you have any questions, please call me at 427-9670 from 8 :00 to
9 :30 Monday through Friday.
Sincerely
Carolyn Jensen �\ AV
Environmental Health Specialist
Enclosure - Environmental Health Review \ \
I`
4�
MASON COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1666
SHELTON, WA 98584
(206) 427-9670
FAX 427-7798
March 14, 1994
Jason Mackinnon
P.O. Box 865
Belfair, WA 98528
RE: BLD94-0117
PARCEL NUMBER 12320-12-01020
Dear Jason
Disregard the letter sent to you on March 10, 1994. Circumstances
may require more than a simple design to satisfy the requirements
of environmental health. Your building permit indicates that you
are getting a permit for a after-the-fact structure. It is unknown
whether the septic system is after-the-fact also.
Policy requires that the septic system meet all current State and
local regulations. Depending upon the situation, one of the
following must be done:
1) Septic system is not yet installed- -
0 approved design required
Note: septic records will not be considered complete until the
system is installed and an As-built is provided by the installer and
signed off by the inspecting sanitarian.
2) Septic system has already been installed- -
0 Have the septic tank pumped and inspected. Supply
a copy of pumpers report to your department;
0 Expose the ends of each lateral to verify length
and dig one test hole in close proximity to the
drainfield and have the site inspected by a
sanitarian. Dig two additional test holes in an
area suitable for drainfield repair.
Note: An As-built drawing signed by a professional engineer or
certified designer that shows the system layout in detail, depth of
drainpipe from original grade, and designates an area suitable for
drainfield reserve may be required in order to establish accurate
sewage records.
Mackinnon
March 14, 1994
Page 2
If you have any questions, please call me at 427-9670 from 8 : 00 to
9:30 Monday through Friday.
Sincerely
Carolyn Jensen
Environmental Health Specialist