HomeMy WebLinkAboutWEL2024-00040 - WEL Application, Design, Letter - 8/6/2024 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
A BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
Melissa Mae Byerly
3321 NE OLD BELFAIR HWY
BELFAIR, WA 98528
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2024-00040
3321 NE Old Belfair Hwy
123094200220
The 2-party water system, Byerly Water System (123094200220/123094200070), 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,
David Anderson
Environmental Health Specialist
Mason County Environmental Health
7(( ( zoZs
\ Date Received: h
rillir"•` MASON COUNTY CTJ 11/
(3 f eg...4
' ) COMMUNITY SERVICES A Received Received By:
�` � 5 5
;,, `;/ Building,PWnning Environmental Health,Community Health
U:-tfl 1 �
415 N.6ih Street.(Bldg 8)—Shelton,WA 98584 WE L aQ a.L{. oQUu V
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
AP LI e,1 1 a Mae PHONE`�� %00 y /�O$ • 8 1 ' 0
MAILING ADDRESS-STREET,CITY,STATE,ZI J ��,1
M21 ,NE Ot-� i 1- Nv', s1 .ir , VJA
SITE ADDRESS-STREET,CITY,STAITE,ZIP ��no n
PRI ARY PARCEL NUMB (WELL SITE)
1 .� '. 22 ?
SECONDARY PARCEL NUMBER(IF APPLICABLE c,
��`���/ ,�
1��0q - y-. w�'2bZS-a�o31 Fo ,
WATER SOURCE SOURCE TYPE �� PARCEL 1 LOT SIZE PARCEL 2 LOT
0 New If Existing Well 0 Spring �!q' A- 1, 04
PROPOSEtATE�SYSTEM NAME(R QUIRED�
PRO, CT DESIPTI/b/Nl ,{Y�VtJ/Nl iltr fv'` •
1-- podiii rikfa rl 1 r 144544t. .al it CSeCalaar ju
DIRECTIONS-rei- SITED NDITION el- i' k9 32 i My O r
tg- lY•
Site Plan: (may also be attached)
(property boundaries, structures.well site w/100'radius.driveways,roads,septic/sewer components and lines, easements,etc...)
5u a
Submittals Checklist: (these additional items will be required for approval)
li Smiatisfactory Bacteriological sample (this may be deferred if well is not yet drilled)
Br Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
V Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document)
R.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
7 ,
Staff Use Only
. mow-
Review Step 1: Well Site Inspection:
YES NO NA
❑ p ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
❑ tp ❑ 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?
[V ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
i] ❑ ❑ Is the well cap satisfactory?
❑ ❑ Screened and vented? \,
El The well casing extends (c/�7 above level ground Zncrete sla ? (circle one)
❑ ❑ Is there evidence of a surface seal? CfMGf Lo f ' YY' r f(6
❑ Does the seal appear adequate? LA -477- 4V 7-?S
❑ ❑ Is a variance necessary for well site approval? VI b 1tK t(0
Comments //0 lit, (q (y I rki�L� Cl / O 71
y l
XPass ❑ Fail Inspector Date S7k/7C7
Review Step 2: Two-Party Review:
YES NO NA❑ ❑ Water Well Report with adequate pump test on file? (L61PMx Z 14 Ws� -_Z, Cf0 sfd "'
11nn
If NO, date of Capacity Test 4/201 '1 Driller 1 J' O llll GPM 11
Iti ❑ El Received Satisfactory Bacteriological Analysis? Date of test l t?/u1?o(
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 22116 2
Cif ❑ ❑ System appears adequate to serve 2 single-family residences based orris ofmt` 'wooded?
CommentsSe iv-atvecZ S -coo 3
ftASpy��b D9 2025
Nn�NVIIRoNME
(reo
� `y.A1.r,.
Approved ❑ Denied Reviewer4 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 of the future success or failure of this 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 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 ESSB 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
Department of Ecology '� ---- VVATERIVELL REPORT Application No.
Second Copy—Owner's Copy _
Third Copy—Drillet's Copy STATE F WASHINGTON /� Permit No. .... _..___.__....
(1) OWNER: Name___e4ide._........(L��.t'C.L. _.....__ _._ Address.. _....eel,_ 2_ see __•Z&I...__.._ leilZeri J.1L.
(2) LOCATION OF WELL: county.._...,,!!!�/. IL _..__..._..____._.___....._...
alLas ••--•-•--._..3; ..._.,-__..;'a Sea_.__._.._T_._._..N., Fi—._._...W.M.
Bearing and distance from section or subdivision corner
1 (3) PROPOSED USE: Domestic Industrial 0 Municipal 0 (10) WELL LOG:
.: Irrigation ❑ Test Well 0 Other ❑ Formation:Describe by color,character, size of material and structure,and
show thickness of aquifers and the kind and nature of the Material in each
stratum penetrated, with at least nne entry for each chani?e of formation.
U▪ (4) TYPE OF WORK: Own 's number well
(if merore than oneof).... .._____
w.. MATERIAL FROM TO
ir New well Method: Dug 0 Bored Cto
/
Deepened Cable [� Driven ❑ 72ffy/ hf// I� ��"
Recondition q Rotary 0 Jetted 0 raei7e. 91- 9rQ,6/ Z•.1- .13_
(5) DIMENSIONS: Diameter __ 61 inches.
. AA` " 't� t ' - �A E-
X�-yy of wall r� Q� ui1 / .�
5 Drilled__...,,,J.L—_ft. Depth of completed well_.... ' -/ SG /Qd.. 9‘./2?//e/9‘- a/et r3Z) 137
) (6) CONSTRUCTION DETAIIS: i
3 Casing installed:_.._�_•, Diana. from __e2--_ ft. to ..,..27_ft.
Threaded 0 " Dlam. from ____ ft.to ____..._ ft.
5 WeldedX1 " Diem.from ._._____ ft..to _._..__. ft.
Perforations: yes{] No
D Type of perforator used___ ................ _........_._..___...._.
3
SIZE of perforations _— in.by ____ in. I
____ perforations from _.___..__ ft. to ___. ft.
______perforations from _.._ ft.to —_-..__...... ft.
5 perforations from___.-- .__ ft. to ft.
El Screens: Yes Q Nov 1
Q Manufacturer's Name_._
aType _. _ —___ _ Model No 1
] Diam._ Slot don_._...-_ from____ ft.to ._._.......,, ft.
D Diem. ....___..._.Slot size from _._____ft.to .__..._ft.
3 Gravel packed: Yoa❑ No`F Size of gravel:_._—_._._.._...__
a
Gravel placed from..___,.____—__ft.to ...._-...__—___»_ft.
a Surface seal: yes ❑ No(cl- To what depth? _____ ft.
Material used in soaL.....__T.._—.__.___.._._._.—_............---__
3 Did any strata contain unusable water? Yes 0 No 0
a. Type of water?__..._.--___.,.._Depth of atrata.._. .__ _ I
Method of sealing strata oR--.-----__...... _.__._...-- . .._. _._._.__.
r (7) PUMP: Manufacturer's Name_---.-_._..__..._______.._._.—_._.._._
q Type:
(8) WATER LEVELS: Land-surface cievatina
above mean sea levet.— —_____ft.
Static_ level _.__ __�Q .St.below top of well Date....__._._—___.__ 1
7) Artesian pressure ......_.—_._—..-_]be.per square inch Date
Artesian water is controlled by.—...... —.._...,._._., __ ..._.___..
5 (Cap, valve, etc.)
( )
9 WELL TESTS' Drawdown is amount water level Is �r
J lowered below static level Work started_. P,,!?119-7. Completed_.._. .,19..,,c�
Was a pump test made? Yes ❑ No ❑ It yes,by whom?..._ __......._....
Yield: gal./min, with ft. drawdown after hrs. WELL DRILLER'S STATEMENT:
,. ,. n .,
This well was drilled under my Jurisdiction and this report is
U '• " " true to the best of my knowledge and belief.
Recovery dataedfrom(timewell t takenop to as zerowater whlevelen)pump turned off) (water level /r
measur //l //
iTime Water Level Time Water Level 1 Time Water Level NAME `7L,ee' 111 "' r//`•th
_ Person,firm, or corporation) (Type'or print)
u Q�
.] ..Address... . ..r.._.-...4/X 3- �1./1�- �.---......-
u
Date of test . __-..___ [Signed]
Bailer test_1 ,...gal./min.with__—0_ ft. drawdown after______.__hrs. (Well Driller) —
Artesian flow g•p.m. Date..___._._._.__._.^—__.
Temperature of water....___....Was a chemical analysis made? Yes 0 No D License No ... Date ., , 19
(USE ADDITIONAL SHEETS IF NECESSARY)
S.F.No.7334-OS—(Rev.4-fii). 'teiD°3
'Davie Pungio, Inc.
340 WC'Davie Farm'd
Bel air,'Wa 98528
(360)801-6107
Project Melissa Byerly
3321 NE oBH
Capacity Test TAG:NA
Date 5/4/2024
Pump 3/4hp sub
Well Depth unknown - probe unable
to pass 44'
Static Water Level 29.3
Draw Down Recovery
Time Water Level GPM 0 34'
0 min 29.3' 0 1 min 30.5'
5 min 33.1' 12 2 29.7'
10 min 33.9' 12 3 29.5'
15 min 34' 12 4 29.4'
30 min 34' 12 5 29.4'
1 hr 34' 12 10 29.4'
2 hr 34' 12 20 29.3'
3 hr 34' 12 30
4 hr 34' 12 40
45
Capacity Notes:
26276 Twelve
Trees Ln NW
Ste.0 14 SPECTRA Laboratories - Kitsap
Poulsbo,WA ---J •
—Whore experience mailers
98370
(360)779-5141 COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
-r I o I ' `_01.`+ Collected
Mord) Day Year :•SD?TM0.
Type of Water System(check only one box)
❑Group A ❑Group B tErCMher `l—‘V 6•-k
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
ID#
System Name:"532_\ WC- 0 \ ---S_-\qc<,tr
�r A.1V
Contact Person:loa
Day Phone-.340,11091"AttinCell Phone:
Email:, . J AV fY pr..., 0 J 1 4•Phone:
Send results to:(Prtmfua erne,addiaaa end z code or above for we male ow of mulls)
SAMPLE INFORMATION
Sample collected by(name): )
Specific location where sample collected: Special Instructions or comments:
Type of Sample(che•ck only one box)
1.❑Routine Distribution Sample(A/P) 2.❑ Repeat Sample(A/P)
Chlorinated:Yes 0 No❑ (fin distribution system after unsat routine)
Unsatisfactory routine lab number.
Chlorine Residual:Total_Free_
3.Ground Water Rule Source Sample
Unsatisfactory routine collect date:
S
Chlorinated:Yes No
❑Triggered(A/P) Chlorine Residual:Total_Free
❑Assessment(A/P)
4.Surface or GWI Raw Source Water Sample(Enumeration) I S J 1 I
0 E.co/i D Fecal Fiteree Yes No
SrSarnple Collected for Yrformatlon Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
0 Unsatisfactory Total Coliform Present and tp,Satisfactory
❑E.coli present ❑E.coli absent
Bacterial Density Results:Total Cotrform mpn/100ml.E.coli mpn/100m1.
FecalColiform cfu/100ml. HPC cfu/1m1.
Replacement Sample Required: ❑TNTC ❑Sample too old
❑ Sample Volume ❑Damaged Container ❑
Date/Time Received: Lab Reference Number
Receipt Temp C': \\\ Method Code-
SM9223'/QT-COUNT/SM9222D
Del 012024 JUL 0 3 2024 d dhir 1C
e.. .
DOH Lab-Sample#
TAeee reawa retie aiyto the dens beta se en ee role(e)rK
010' r.aeWeabyme lataikriia,own*N nwee apseal rd bertaaLitealeap(
ti *ghat w�owns*Nun ePPa'+d�so.m.l,t«raiee.
DOH Fenn M1319(enecWe er17)
2212627 MASON CO WA
06/29/2024 12 05 PM AGREE
0AV75 PUMPS #196985 Rec Fee $306 50 Pages 4
I MI IIIII111M IIIIi II III III1 IIII IIII11IIIHII1It III!
Return To:
Davis Pumps Inc.
340 NE Davis
' Farm Rd Belfair,Wa 98528
Declaration of Water
jeement
Byerly by*8 irm
Private Par t
d$li$VRATED LEGAL DESCRIPT IO
The well and water system being situatc4 on:
Parcel#12309-42-00220
Legal Description:
TR22OFNW SE'
Range:1W,ibwnsh [,
SE V.of the NW%
3321 NE OLD BELFAIR 11 U Adt WA 985289612
Grantor(s):Janice Byett� n
'
Owns off,\ /
Parcel#l 30 42-00220
TR2Zd11 NW SE`
_ Wsegt:''lWjbwashlp:23N,Section:9
SE%oftheNWY
3321 Nla OLD BELFAIR HWY.BELFAIR WA 985289612
,'
4 • 's s): Melissa Mae ByerlY
�;' / Owns of:
\Y Parcel*12309-42-00070
Legal Description:
TR7OFNWSE.S53/57
Rangy.1W,Towashlp:23N.Section:9
SE Y.of the NW%
3331 NE OLD BELFAIR HWY,BELFAIR WA 985289612
Has been designated to serve a source of water to the following parcels situated in Mason County, State of
Washington;herein described:
Parcel#12309-42-00220
Legal Description:
TR 22 OF NW SE"
Range: 1W,Township:23N,Section:9
SE%of the NW%
3321 NE OLD BELFAIR HWY,BELFAIR WA 985289612
Parcel#12309-42.00070
Legal Description:
TR 7 OF NW SE,S 53/57
Range: 1W,Township:23N,Section:9
SEY.of the NWV
3331 NE OLD BELFAIR HWY,BELFAIR WA 985289612
OWNERSHIP OI?WELL AND WATERWORKS
It is agreed by the parties that each of said parties shall be and is hereby granted an undivided one-half interest in
and to the use of the well and water system. Each Party shall be entitled to receive a supply of water for one
residential dwelling and shall furnish a reasonable supply of potable and healthful water for domestic purposes.
COST 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.
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 AND PUNVIPHOUSE
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 100 feet of the well site in any
direction of both properties listed_ Said easement shall allow the installation,maintenance or repair of the 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
MAINTENANCE AND REPAIR OF DISLTRIBUJI N LINES
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. Water pipelines shall not be
installed within 10 feet of a septic tank or within 10 feet of sewage disposal drainuield lines.
PROHIBITED PRACTICES
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
prevent certain practices hereinafter enumerated in the use of said grantor(s)land which might contaminate said
water supply.
Exlubit 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 shall insure to the benefit of each owner thereof.
WATER SYSTEM MANAGER
The owner of Patter#1230942-00070 Legal Description:TR 7 OF NW SE,S 53/57 Range: 1W,Township:23N,
Section:9 SE'/,of the NW%.,3331 NE OLD BELFAIR HWY,BELFAIR WA 985289612 is the designated"Manage?'of
the system.The manager shall be responsible for arranging submission of all necessary water samples as required in
the Washington Administrative Code,area 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.
ENFORCEMENT OF A .REEMENT 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 18%per annum together with all collection fees.
tL .4b• t�� c..� �//// Y
Janice Water System O ( / Date
fr\WAikk, t /
Melissa Mae B erl y y rater System Owner Date
State of Washington,
County of M 4.s01/(
I,the undersigned,a Notary Public in and for the named above County and State,do hereby cFrtifyfpat
on this j I day of s. \J;..L ,2024,personally appeared before me s_\;t n; - e 1;S 4P
to me known to be the individual described on and who executed the within instrument,and acknowledge
that he(she)(they)signed and sealed the same as free and voluntary act and deed,for the users and
purposes herein mentioned.
GIVEN under my hand and official seal the day and year last above written.
oolIIIlIillf 1/4�
itAa41411/—b444-62 kdag .�� ''ssion
Notary Public in and for the State of Washington, y:•�o ��TARY • :
residing at V r be I COI)crt t ; ,r �g� Z;_`
My commission expires:IQ-(7-��g N Ce9 �cNi�0
�O Mutnb5 �c1C'!�
���r��f I lWA`,`���
ON-SITE SEWAGE SYSTEM SURVEY
LOWER HOOD CANAL CLEAN WATER DISTRICT
4ri.v DATE: �'��Y �� t44y
PROJECT: LHC AREA: #5 UNION
OWNER INFORMATION : TITLE: R MRS, MS (circle one).
FIRST NAME: &R00a7 LAST NAME: Id Y4--"+QL v
ADDRESS:,V 33at oid 13 Ie- Itw'"• CITY: &LFaI STATE: W,I ii. ZIP: 9J,528
OWNER'S PHONE: d t)s- 4S8 ? OCCUPANT'S PHONE: 51/4q' -
•
SITE INFORMATION (Mark SAME if same as above)
PARCEL # / a. 3 0 9 Mit-- 41,Z ---- DD a a D
OCCUPANT'S I'I'I'LE: MR, MRS, MS (circle one)
FIRST NAME: 570}') - LAST NAME:
ADDRESS: CITY: _ STATE: ZIP:
i
NUMBER OF RESIDENTS: X WELL DEPTH 6-8
RESIDENCE TYPE: r ( F - Full Time Residence; S - Seasonal Residence;
R - Recreational Residence; C - Commercial; I - Industrial; M - Multi-family Residence; V - Vacant )
ON-SITE SEWAGE SYSTEM TYPE: 5 Enter all that apply. ( S - Standard tank and
drainfield; P - Pressure Distribution; F - Sand Filter; M - Mound; T - Deep Trench; H - Out House;
O - Other; U - Unknown
INSTALLATION DATE tJ YEAR LAST PUMPED: /9 88 Enter Year or U- Unknown
GENERAL LOCATION OF SYSTEM: 5 F - Front Yard; B - Back Yard; S - Side Yard;
A - Adjacent Lot; U - Unknown
PERMISSION FOR ACCESS TO INSPECT THE ON-SITE SYSTEM (Y/N ) 7
(NOTE: Mason County Health Code provides right of entry provisions. However, our policy is to gain
permission to access on-site systems. Your cooperation is appreciated and saves valuable time and money
for Mason Cou p Applicable codes pertaining to this matter will be provided for you upon request.)
SIGNATURE (Eyx.t,17DATE To LY g, /99'f
Comments:
CDO YOU WANT TO RECEIVE INFORMATION ABOUT WATER CONSERVATION? (YIN)
Revised June 8, 1994
,..
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r . . . } Lower Hood Canal Field Inspection Form
Address: (V F. 3 3 g ! o r J a( ,
Owner/Renter: J l et c,(lc__ B e-s I
• Permission to I ) Date: S. 3 0- ci c(
Inspection and Dye Test Information
Inspector Initials: e 1)5 Level 1C: 3G % / Level 2:
` l 1:
Inspection Dates:
Visual Site Inspection Data: ft
tank and surface water: ,)oo
Setback between septicDrain, Other):
Surfac eWatetType (Marine, Ditch, Curtain
Setback between septic tank and well: ft CO4Nif4 K y c,./e/T«
Setback between drainfield and surface water: (.Co ' ft
Surface Water Type (Marine,dici, Ditch, Curtain Drain, Other):
Setback between drainfield and well: ft
Reserve drainfield area gin)_ curtain, roof foundation) (y/n)
Bedrooms a Interceptor drains (French,
Other(LargeOn-sites,Complaints,other):
. Septic System Status and Priority
System Concfitions: ,4'" rcation: Rs,
• D = Damage.to drainfield
SHE► = Indications of seasonal high water F = Failed
Water over drainfield 'L = Limited(one condition)
WP• = Dense, l �� PF = Pre-fatiare (two conditions)
SD = Slowly draining' plmobing fixtures •
S = Suspect(uncertain COnditions)
PM = Indications of poor system maintenance
HW = Indications of high water usage Failure Type:
Failure Priority: D = Damage to Drainfield
1: Illness or injury related. B = Broken Influent/Effluent Pipe
2: Visual Dye, open or surfacing towage entering H = High Water Table
surface water' outhouses or cesspools with G = Greywater Discharge<3ft vertical separation SflRI. S = Surface Water Intrusion
3: Surfacing, seeping effluent not entering surface O = Other
water.
4: Other unacceptable installations,inteirmitteatlY Other'Type:
eg systems not g surface water,
effluent over tank baffles.
5: primarily aesthetics s(odor).
Observations:
0
......, u1411611,W11
Cr5 wYc--
Dye Packet Results
Background Series 1 Retrieval Series 2 Retrieval Series 3 Retrieval*
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