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HomeMy WebLinkAboutWEL2025-00097 - WEL Application, Design, Letter - 10/22/2025 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 I. BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 10/22/2025 TURNER FAMILY TRUST 113 Saddlebow Rd BELL CANYON, CA 91307 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2025-00097 10911 NE North Shore Rd 322245000083 The 2-party water system, Turner Family Trust (322245000083/322245000083), 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 /; MASON COUNTY Date Received' - .�� :_ y COMMUNITY SERVICES07 ' SI AmountRecai O�J�� .i- ' Building,Pinning,Envvon mental .vlth.Cnn,munityHaaitli J Received By. 4eire, 5(QC 415 N.6`''Street.(Bldg 8)-Shelton,WA 98584 WEL Shelton: 360.427-9670 x400 Bellnir.360-275-4467 x400 Elnta:360-482-5269 x4()() O TWO-PARTY PRIVATE WATER SYSTEM APPLICATION rr -. APPLICANT //,ram LTV 1 a! �'4I L\ PHONE K 4r N c.L ` c� MAILING ADDRESS-S'TREET.CITY.STATE.ZIP r 1v - J �'r � (t'!� CV SITE ADDRESS-STREE 1,CITY',STA'PE,ZIP 6 Q(' 1 N E N PRIMARY PARC'EI,f L NIHF:R(N'ELI-Sll'F: I o icH A'r I RJ f 14 a' 7/_ / ��s28 �� 2 22 2y �, re,— P3 (fiti .,ia 1 � t SECONDARY PARCEL NUMBER(SAME AS PRIMARY IF LOCATED ON SAME PARCEL) l WATER SOURCE �r �pf eG 68T7LJ SOP?: PARCEL I-LOT SIZE Int.in I Pere) jPARCEL2LoTsIzE(m(nIacre) New KExisting )C,Wc11 Spring / PROPOSED WATER SYSTESI NAME IREQI'IRED)• •IS T taAe r� / T.rc.I1 Y �e PROJECT DESCRIPTION(e.p.,detached ADC',new single-foray residence,existing connection,etc.) - In! rl 1 S'e 2 b&V.a•.-,,.r v Al Ca#vtt s.J o4 IV L.d. J an,1 DIRECTIOvSTO.S(E/CC.NDITIONS/GAtE(•O0E/KEY LOCATIONETC. Ne� Ole erte4.40 iY11 awe pQae1d i CO a n)nl Mtt,. 12.E 'lea ! "9// N P. it)#444 An, ea_ U ,s i N "41t pa, Steep I a4,.t.1a o 411, .uoi Y*rti (ram 1', de. Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,water lines,property easements,etc.) A9h'ar ✓ 7 12 — 5'71— G 41 2 -k- r)I e--- / ueAd.elt_ /,. f I IJ C /;-.U,,R. P/e g*, ...40./ 4_7/ -71EI 5`r--1-r v r c 4 Required Submittals Checklist: (additional information located on the first page of this packet) 1 Satisfactory bacteriological test from within the last year t `� I Well report with well tag number,well tag secured to well casing,and capacity test showing 800 gal per day Notice to Future Property Owners of Private Two-Party Water System recorded with Mason County Auditor's Office Septic Records(additional locating requirements may apply if there is a lack of septic records on file) This form mar be scanned and made available for public viewing on the:Mason County website. Revised:0I//2025 Page I oI'2 Staff L'se Only Review Step l: Well Site Inspection: YEcgfS NO N/O ^,rCp-frilk ''6 0` - /N pc,m o ''bo* al Sa4,9 , ❑ ❑ Evidence of existing sources of contamination within a 100-foot radius of the water source?(drainfields, tanks, buildings; indicate distance on plot plan) ❑ ❑ Are there roads with( radius of the water source? g Is the road Private, .ount r State?(circle one) Distance to the road(s) —SO CPr ❑ ,,}0 Does the ground slope away from the water source site? Ai ❑ b Satisfactory well cap? 0jff0 Well cap screened and vented? 10�r(l0 Iiit The well casing extends /I above level ground concrete sla ?(circle one) Well tag attached to well casing? Lat: La j 8t fr ❑ 0 Evidence of an adequate surface seal? Lon: —l33-0(Yse ❑ ,, 0 Variance necessary for well site approval?zr Tag: a K� � I o rf 16 t loz$: Receive-- P i v o'FC ►tc# Comments: - f0 („l I + — 4, � gilitt( lD �+/�tt Ceb ill ►` eph e �/ . ass Fail Inspector Date V Z 6/Zo 2 5 V ZZ(70?_5- Review Step 2: Two-Party Review: to t ( N(�, NA -/� W L'Ike/t/ PID Ount2e Water well report(welI log): Date Completed V 1/(U47r ^DXIle K U4�t 1 t„,, ,,.,,,. ❑ Satisfactory capacity test showing a minimum of 800 GPD with / / h lull recovery to static level within 24 hours? 1 1 Capacity test information:Date LIZI ZOZS Driller/Pump Installer f/t�1Ui vviiii, GpM(0,q 7 Q`�y y ` (Z Duration(minutes)_Total Gal / 60 Recovery Time(minutes)to Static CO t6 ,/ 0 ( y Satisfactory bacteriological analysis? Date I(l /?O2STesting Lab )r-fievio tab t�/11sti ❑ Signed,notarized,and recorded notice to future property owners?AFN Z Z 2 86.n ❑ The system appears adequate to serve two connections based on the inibmiation provided? rl ol 10//64 Comments: / 3�I� KO we(� iti, ar wa fr l l rP t- 7(300L S tie tved 60— d tet5 pi-ofei. P. Approved 0 Denied Reviewer /]/ Date (0"` .tl U�o� ({i� Findings in this review reflect observed conditions as they existed on the day of the site inspection. No claim is m or implied of the,fiaure success or failure of this system. Well site approval does not constitute watersystem a LIvaks ti ei All proposed connections to new wells are subject to water adequacy requirements at time of building permit per MCC.68. 4z Water usage restrictions and additional fees may apply to all new wells drilled after.lanuary 19,r' 2018 per ESSB 6091. yF��Ty This form may be Scanned and made as ailable for public viewing on the Mason County ssebsite. �1 Revised:07/23/2025 Page 2 ore NiNIMMINIIIMMINIIMINIMIN 0 DEPARTMENT OF ECOLOGY State of Washington Well Construction & Licensing Well Report Search Results 0 Edit Search Criteria Ct New Search Search Criteria Used: • County:Mason • Well Type:All • Tax Parcel Number:322245000083 .♦.Download all 1 images 1.Download all 1 data records $Print this page 0 Need Help Displaying well reports 14 1 of 1 Sort results by: • Well Owner Name v Results Per Page: 25 # Well Details Location Details 1, PI View PDF Well Owner: Turner Family Trust Tax Parcel Number.322245000083 Well Tag ID:BRK135 Well Address: 10911 NE North Shore Rd Notice of Intent Number: County.MASON Group Number Not Applicable Public Land Survey: SW-SW/S24/T22N/RO3W Well Report ID:2347170 Well Type:Water/Subtype:Unknown Well Completion Date: Well Diameter:6 in. Well Depth:0 ft. (Well Report Received Date:09-05-2025 • Total Result Pages:1 Copyright©Washington State Department of Ecology Privacy Notice I Site Map I Accessibility I Contact the Web Team RECEIVED -WIWater Well Report For An Existing Well SEP 0 5 2025 Your well must be properly tagged prior to submitting this form. Asterisks (*) indicate required fields. Mail completed original form to: WA- State Deparim^:-,' DEPARTMENT OF WA State Department of Ecology, PO Box 47600, Olympia, WA 98504-7600 `-""' ", -' t-:yy'?�;,% ECOLOGY State of Washington Use this form if an original Water Well Report was never filed or is missing from Ecology records. Rirrent Use *Unique Ecology Well ID Tag Number: IBRK (35 Domestic Dlndustrial ['Municipal ❑Dewater [Irrigation DTest Well ['Other: *Water Right: DYes (if yes,attach a copy) ❑No Dimensions *Property Owner Name: (JRNE1 F5AM/iv T{tuS Diameter of well Gin. *Well Street Address:Ipq(l Aft?. Nprti/t stioitt1d Depth of completed well ft. (if known) r Construction Det its *City: BeI�alQ *County: MAAS-DV Liner installed: lays ❑No DUnknown *Site Well ID: 2 Type: DPVC Steel ['Concrete Liner *Tax Parcel Number: 32k3v/y--s U - 000 2.3 DUnknown DOther: k• Perforations *Date Well Constructed: " 1Y7 0 s) Dyes [No Unknown *Location (Township, Range, Section) — Size of perforations in.by in. An accurate location of your well is very important. The 3 Number of perforations from ft.to ft.H Section, Township, Range,and'/4,1/4 can be found on your 2 Screens tax parcel legal description or through your county o• DYes ❑No DUnknown assessor's office. Type: ❑Stainless Steel DPVC DOther: W O\ - Diameter Slot Size from ft.to ft. Township :1`N Range OW ❑EWM or ICENWM Gravel/Filter Pack Section all 1/4-1/4 1/4 Yes [No ❑Unknown N II-- Materials placed from ft.to _ft. Comments: VYe l( r S t 4 c4 h 14 A �42/� v• Surface Seal QN t �'� .� C_�•4q;✓�(� � t�Rt' 9 u DYes If known,to what depth ft. d ['No teUnknown B Materials used if known: t ❑Bentonite ❑Cement 4- • mp e Yes [No DUnknown L Type Horse Power 3 il Latitude/Longitude o (Decimal Degrees recorded to 5 decimal places) i-• Water Levels // QL Land-surface elevation above mean sea level V ft. Latitude (Example 47.12345) LI 7 a 3.7 8 H Casing stick-upp )D above/below land surface v Static Level �t b ft.below top of casing Date measured:wiis Longitude (Example 118.12345) ) A 3 f) , / • Artesian pressure lbs.per square in.Date mea ured: ( 0 Well head has cap?NYes❑No Shut off valve? Yes['No Ili Well Tests: Additional Information (If available, plea. = att: • • c Drawdown is amount water I vet is lowered below static level. ❑ ocation marked on topographic map 4- Was a pump test made?Jes(attach copy)DNo ❑ Unknown ocation marked on air photo EYield: I gal/min.with 1,0 ft.drawdown after I , hrs. Consultant well report 0Cj *Certification: The information reported above is true to the best of my knowledge and belie .,p�CC'//, /r U ✓ OConsulting Firm Driller ❑Engineer IR -roperty Owner I- Name: KeVIN i 0LN/ t- Company: License Number: Address of person completing this form:D" Signature: lc` 1'1 tMr--�._ ( 09/I its EN d 1h S Ue//� / 4,1 rf- 12?J tdoA (M.57073 Date Signed: O S/a f/t2 Ud.y City, State,Zip: e pit. VIA `7.6Z A Is(V 070-557(09/2016)To request ADA accommodation including materials in a tirrmal for the visually intpairrd.call Fcology Water Resources Program 360.407- 6872.Person with impaired hearing may call Washington Relay Services at 711. Persons with speech disability may call"ITV at S77-83 3-6341 6 9 ,l { v. .. ir • ri' F4 T •t ? "u J. E 4 s 3 = , *, # tn too g 1%t. 0 - 00 I North Shore Rd A } V '' ` Recently viewed �_ { 2t,441, A1 - .# 4,- . , 4 isotirt - -...-7- - ..., #,... 1,,,,,,-1-ik, ., iit Alo- i • r. •. • -* . "IP' 400 1111 yr r a 1 � nl j Y � o W �....c. i ......, i a . ,... I 1 , , .. } AAIF u. ill , . ,: ,.. . .., .,: . I, ..t. ,, S V ♦1 ,# �� 1 S. s ,..,. firt . :1,,.: ) goor ,p 4..... .. i. iL I- fi R �` Davis Drilling 340 NE Davis Farm Rd BeHair, WA 98528 Date:4/25/25 Test Pump for: 10911 NE N.Shore Rd, Belfair Well depth: Unknown Well tag: N/A Pump size:3/4 HP Static water level:46' r 0 0 a L. L TIME WATER LEVEL GPM M 0 Om 46' 0 �/�,, 1m 54.5' 12 0 `R/ 0 3m 68' 12 ' 5m 82' 12 RED+ ° 25 10m 105.5' 12 &0 0 30m 140' 12 lhm 146' 10 1.5H 146' 10 4- RECOVERY im 140' 3m 131' t. 5m 123' 0 H 10m 104' 2 15m 89.5' 30m 67' 1H 46' I i - • -; .- - -.- :.;,-. T- ---- i 2 rees.nNW • RECEIVED 1'cea ln Nlt' , slcc' • SPBC'I'1tA'Laboratoril:t. Kitsap I nyleM+,WA t • ._ __•.,l y,...4.r esearoes_ �i I 3839oSEP 0 5 2025 t3�c1�»osul! GOUFORM BACTERIA ANALYSIS FORM --Date 6amda Collected Time Sag* County - r— �: �-- Co1 T.____ WA State Department I 11 I 24 ow! t'/ of Ecology (S!"'" ;I On yes i .-:aD 44' _... d'h — $w .Type of Water Syetem(check only one box) /'►� Group A ❑Orap 8 (�61har-.�,(!:I+ ie i t. ..-_. _ T G►wp A end Oyaap 8 Systems-Peekte kom Wetet Fe (irenlpq,(NIfly 18yehm Name: 1.Contact Person - t =De,Phone: A _/•.-_... Cal P_� ._. -- .ied 0/_ j Ernst: Eve.Phone: • Berdr.,dnb.•(0y4,4,*J.nTh(WM4WIig, 1or.r.Wet.vrtorwN awry It s I ($Y.tJ rsflshj t hs/m4,/ cop.. ' r: SAMPLE INFORMATION_ ._ _�! Semple co/soled by(name): 1 4.4 L. i : Specific location ohms ample cnlartd *dal hebutAons or rommenhc- N } Cif h.e4,_i - - - Type of Sample(dta*only one box)_- _ i- 1.❑Routine OMtrlbutlon Semple(MP) 2.O Repel Sample(AIP) 2 Chlorinated:Yes ❑ hb 0 (boon(stocton system deer tenet ro•M•.e) I, Uneakhctoy routine lab nunber wChlorkae Residue.ToW._ , Free._- ; 3.Oround Water Rule Sour;8i male ic. I' Unsecstadayroutoecokrddate.. o � s � J --- . ocT 447 5 Chlorinated:Yos __No _. / 7 a- ❑Tttgpeod CNP) Chlorine Residual_Total Free_... RF 425 B ❑Assessment(A/P) I; CF/ ri.Surface or GWI Raw Somme Water Semple(Ettumice l I S I I I i ��O ❑ E.cob ❑Fecal ewe es___!k` _ r, 0 15.,c'�J. Sern<MCoeeciedtorWoerM dO4 `0 LAB-USE ONLY:- DRINKING WATER RESULTS LAB USE ONLY d 0 Unit etletealory1optCdaocm Present and 4s..factory Z 0 E.cof prowl 0 E.cas abscnt cDacterlet Denetty Reeutta.Total Colilorm mpnl100m1.E.coF_-—mpnr1000 v focal Conform..._.__ ctul10Drn1 HPC_---cfurtml. Replacement Semple Required 0 INTC 0 Semple too rid • - - 0 u [I Sample Volume ❑Damaged Centener ❑_,_- __ LL .F __...-.. . - --. o r.,lr . tab Memo M;mYet I i - _.VI — - `i-__ l .- -_ ._ g Roc dp Temp C I eMeadCed - i� vt2313)01•COdHTl6.02210 ,r.-. - q� 1IiiNltaj.�TWy N�elseinaitewe..rYr a. rnr�I. O y_3 O na wkre►wwwwer .Mr .,aarnw.„... rr i F1LR 2 +_ �'I(__._.._... �W.ywrwnw.M1�r wwww 7=• I row*•lere'rwrM...e..rrlle/MJrlr.v • 1. e) 1 00N Lds8Myloa ..e•eee.rne..st 1; { I 010• 0 I n...MYLy.n.rNYkr.M•oon....peeen I e� I naked le Nb+MA yM NMI WI MINq.MwM ria �( — I Iu,.w.r rw row rltewsn.ew srw.elMe,« Y,N reft Oni4.114,WeNr. ? 6S4OTJ1ASON CO WA TURNER ' KEVIN TURNER 113 SADDLEBOW RD BELL CANYON, CA. 91307 KEVIN TURNER Grantor(s): (I) •(2) Grantee(s):(1)PUBLIC ltgal Description(I) Cis&c" 71/44 1\ '�.D'isLz] 22 2an9 e (.thhreriotetl form'i e. lot,block,plot or section,township,range) essor's Tax Parcel: (I) 32224-50-00083 • NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM 1(We)the undersiened grantor(s), certify that the water source located on the above-described real estate under Legal Description(1)and Assessors Tax Parcel(1)situated in Mason County, State of Washington.has been designated to serve a source of water to the following parcels situated in Mason County. State of Washington; herein described: Tax Parcel:(Connection I) 32224-50-00083 PRIMARY RESIDENCE Tax Parcel:(Connection 2) 32224-50-00083 ADU The system ot%ner is responsible for keeping this system in compliance. The name of the water system is: 0:A11 UCLSCY SZUCkeiiA. This s)stem is designed to provide for two service connections. Planning and design approvals must be obtained from the department prior to expanding beyond this number of services. Additionally.a%+ater right,obtained from the Department of Ecology, is required if the water system exceeds exemption standards. This system(has/has not)been granted one or more waivers from specific provisions of the regulations. Dated on this 2lday of Jvl y 2Ot� Signatu •of Grantor(s): (I) (LI-. .(2) Page 1 of 2 State of Washington County of Mason • I,the undersigned,a Notary Public in and for the above named C State,do hereby certify that on this a S'3('-- day of c\ t , 20 k-e /i n „(n-e c personally appe be me,who is known to be signer of the above instrument,and acknowledged that he(`she):(t( y) signed it. GIVEN under my hand and official seal the day and yep . 'ov " en. (r lVot. =ttdie in �`�� �N�`9.e10N fX,o�•,t 7I y���� resi tag at a fto r t thLen State of Washington, llHriirit1en,i,, 4.04,0d N,SM/ 'y \\Myicmmission expires: 0 � (7 Y 'el NOTARY • 171724 '' PUBt .. ,' ' a. ,1/IIHISW t��rp;- • Page 2 of 2 2228634 Page 2 of 2 07/28/2025 02:52:22 PM Mason County, WA Cindy Waite 80 E Pickering Lane Shelton, Wa. 98584 \\ 360-701-0205 � `? %/h cindyewaite(c�msn.com �r° � • �� 7/24/2025 �� I RE: Parcel #32224-50-00083 10911 N E Northshore Rd Kevin Turner 13 Saddlebow Rd Bell Canyon, Ca. 91307 The applicant is applying for a two party water system. His plans are to change the water front home to a two bedroom and the proposed ADU to one bedroom. He has an approved three bedroom system on the adjoining parcel(32224-50-00082}. We have to have the two party water system approved prior to changing bedroom designations. I have sent the recording to the applicant Respectfully submitted Cindy ite N. r . r` 11 gw�141 .1 O / ...1. p � V � U1 •A, Wiv .4 • L cu x o 0o w cnn D -� ., a�'. CP c t� mo P ��� �r cam . CD C 0 11 a = o oN r+, I� as o' u, r« o .. o co ( �' fA �� /@in) m �, oa o o mi n1a. o - o rn Do o �,. �' I A, d2Jf c. al aJ = o aT Fr �p C o O Q Q I p aLift 0 I �� a s Q J m m . may a . 140.0 -- D `N., °� / o ao 0 • • i = I D ZE - ,' ' •100.0 • • /\ - V ‘.k. a .. • c7 ". \ / ' ).. ii $ P • • /3 \, ,� A 4) ktisZt,-)05 1O.0 �. a /'� �7 N. • '� � / . g 30.0 as ,�Utl c 0 k il / stdi Z ; �p9 `��. 1, i • 'pia \ ON•SITE SEWAGE SYSTEM SITE EVALUATION AND DISPOSAL PERMIT Af301kt COUNTY DEPARTMENT OF HEALTH SERVICES' 14ERMIT NO_ SWO 93• D'.�(pr� 426 W.CEDAR/P.O.BOX 1666/SHELTON,WA 98584 Date_ II (0 5 PHONE(360)427-9670 Receipt No. ' o Amount$ / E. y YHOkEHIYUWNtH: UAIEt r z --1 O EHt YO A /`i /0_a M y CHECK APPLICABLE ITEMS 6/ m I MAILING A DRE5S: DAYTIME PHONE: NEW SYSTEM --nil — g� CITY;• 31 aL1 5 L�) ;I7 1 ll --- - REPAIR SYSTEM 3( �WQ • L STATE: n ZIP: MAINTENANCE REVIEW -o PROPERTYA 4 SS w , 'r c3166- SINGLE FAMILY �( OTHER _ J Z SPECIFY: 1 c 3 SPECFFI DIR CTIONSOR LOCATING SITE: � F )PRIVATE WELL , '11 ' FOR LC - COMMUNITY WELLIPUBUC SYSTEM _X /�g// SYSTEMWFI# I + ! ! — SYSTEM NAME APPLICANT (Itt I Name of ,NAME f&I�1 r 5c)-0/c'C s C I q r Installer Lot ff.x,%,,' ft. MAILING ADDRESS Y.d r" �, lJc t'-�t C f�j Size: P,c/�sr cya 9� (�, acres TELEPHONE I ' Q Name of /""• 1'275i_4SW Designer f Number o � SIGNATURE I�Bedrooms ` ) X -t ..Q.t� PLOT PLAN C .i y, I Kn - Draw a dimensional plot plan, • 1?including: Z i —. O Precise location of test = I�holes,showing ° A 7 w-_.► •�� Y 0 measured distances to _ property boundaries. �� % , ❑Entry road;o er d �` y h�' • driveways. p r ri �� I '----:CA. ^� XID 1"4 • lJ l. O I NOTE: DO DRAW IN •x • b r�1 SYSTEM DESIGN, 0 3 1995 1 , 1"_ IV U Y I .t- A E OL DO NOT WRITE BELOW DOUBLE LINE. 1� /5 SOIL LOGS Ttf 107.541 �T'ii-0-3a" 10 ��..7 Ja.S , & Is ,� .31 N �i'�/oC27�e T1t'3 aO !a0 S9 TNZ-0-¢r' Z w., Sr"...1 loafs �, a if o, 56 c -Very 30-56 IB LS f3 ��djo�n,n o�casrw a o- #,!� v) lc, ��1��' gzno ti,, 'd.30-70'/l9/� S dr; : ago cr4 Of �On Q/rf ram- S 5 on�f�e s'f� Depth from Original 11 y�I',. 1 V!i ^ Cal Grade to Restrictive v - 0.55 l (�U'�I/7 �f ��Q�/� Layer or Water Table:�%0 c coviarel DESIGNER DESIGNATION SCORES L Peavcy t-24/•M1NIMUM SYSTEM REQUIREMENTS F din Score C/ Designer Level: XOne f]Two SodTyf1� �', 6 Verl�af Separalion� In, Q Septic Tank / ^' Daily Slope ' / s> / Capacity: /I�V Gal. Flow: gbp GPO —LPL APPi• intilt, Parcel Size /, _ Ac ,_{L // Rate Q r GPD/FT2 Area y-j Q FT' Distance to Shorelfne�OAtl. /) Total I f0 Inspector Date .(�,' �iYttso� n !/,4 /95 COMMENTS/C,ND ■NS F•R APPR • 011,1MINMAIMITAIN-4 17' 1 ArM' lariffnitaffilMAMIKTION , , ,..Brfr,.., • 16 dirr; _. , .,. ,_ _wad. . 0 • _ ._ ��/ ff . r ia 4 6 `" _�GllI Ian ,ff a11� • r_ �C1 �i . t :.a L a 1r1. i _•% _ septic systems must be•osigned and installed by contractors certified by Ma:-n Co Q Department 611 Health t:micas,unless prior approval Is 'tad by the department,or the design is by a professional engineer. Cr 1 1 'ermlt approval does not imply Other building site requirements(i.e.RLC,Water Adequacy)have been net, •e from the specified use of the property or any site alteration affecting the system design may invalidate this permit. \, fires 2 years from the date of site review.Denial of this pear may be appealed to the Health Officer within 10 days of denial date. • OESIQ REV V(:{ Approved J Not Apr ved INSTALLATION:]Approved 0 Not Approved M1 DATE;,2 (SY: DATED ,11c, BY: DATE: Y„ jj TOP:Health(lent C:°nv nA1l1 1 r_•n,.�,...,,...,,r,__. r,..•,-.•.... r • / . AS-BUILT FORM - PAGE TWO _ Revisit(' 12/14/S4 ♦ PARCEL IDENTIFICATION Applicant's Name 1//GArc1O e r ___ — Permit Number SWG9 Subdivision � � (Name/vivision/alocK/'Oat Installer's Name 7 . De Wf ef-t5 Assessor's Parcel No. Designer's Name t'rwelve-Digic Number) r AS-BUILT DRAWING • i i4 ..-----' _____ I z 0 CO p m _ t /4 i ♦ lilt z,', 3 CA \i_./I di A 1( 4 0 R4 ...... i<-)/2v 5,k ts-- 'dec./-S. -,..,8 � P� Ead� 1"-- AP t9 CAUTION: Niaar adjustments tOleptiC tank location and drati,fleld orientation made Iarthe field by the installer are generally ar cep[ab2e to bath the department and the designer, but could In certain caeuo compromise the viability of the system. It to th instalier'e responsibility to obtain prior written approval from olthez- the health department or the designer before, making an deviations from the design that affect system viability. Any deviations from the approved design must be shown above. Mi AS-BUILT CHECKLIST 11 N3;4 Drainfield orientation g5 Observation port location AK Undisturbed native soil II and layout between trenches Cleanout location f ranch/bed dimensions and North arrow critical distances within Manifold placement layout Scale of drawing shown k 1,7f Orifice placement on scale bar • k 2 D-BoX/"T"/"L" location H Ca" Lateral placement, with Additional Mound Information 0 121 Septic tank/pump chamber distances to edge of bed r---1 () location r -I Endtslope width !� ,� Location of wells, roads UIt Location of buildings Overall fill dimensions h.....m. _- --- _Al 3aaa9 SD Ocb 83