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HomeMy WebLinkAboutWEL2025-00112 - WEL Application - 11/21/2025 J` : MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 11/21/2025 HEILMAN AUSTIN D & BRITTANY L 67 E SOUTH ISLAND DR SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2025-00112 67 E South Island Dr 220033490074 The 2-party water system, Two-Party Well (SFR + SFR): Sandys Well (220033490074/220033490073), 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 • -.. Date Received. -,\ MASON COUNTY !Q / 7 02 OoZ'S COMMUNITY SERVICES Amount Received Received By: n Environmental Health Community Health 6V() I'C o 9 o IFF v Building,Flaming, Y 415 N.6t Street,(Bldg 8)—Shelton,W A 98584 W E L a o a.5- Oe) I la Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE.Aushin k 13r1+7l4� 3 60 LI QD— Sr/h i I- /1,4,,� �J MAILING ADDRESS-STREET,CITY,STA STATE, W/ ! I gc t g il ,.,^6 7 F su01 ?cIc .d tOr ,�� l C� � ` \ttU.J/ SITE ADDRESS-STREET.CITY.STATE,ZIP / A ����� (, 7 F_ sal sl <) Or . �pDt,/ ,/1j, �� OCT 1 7 20i� PRIMARY PARCEL NUMBER OO(WELLSrr ) 2. 3 - 3N - w074 SECONDARY PARCEL NUMBER(SAME AS PRIMARY IF LOCATED ON SAME PARCEL) 2 z 00 3 3 100 7 PARCEL I LOT SIZE(no minimum) P n WATER SOURCE SOURCE TYPE L New �xisting I SO 14/ell C: Spring /_ q 41 kvecS %, yy Acra°s PROPOSED WATER SYSTEM NAME(REQUIRED). SaVtd y3 we41 .1 PROJECT DESCRIPTION(e.g.,detached ADU,new single-family residence,existing connection,etc.) Stiffly i i, wA tw To t4, & ct 4' pe j A rulure vcxd' DIRECTIONS TO SITE/CONDITIONS/G TE CODE I KEY LOCATION/ETC. Vid I i S for ! vl T, Sca�ii. ve,51 C1'►^Gr 01- 1L 3 oirr.y4i C)h Tkii pro/ 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.) S'e (*, c h eJ Required Submittals Checklist:(additional information located on the first page of this packet) ❑ Satisfactory bacteriological test from within the last year ❑ 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 are no septic records on file) This form may be scanned and made available for public viewing on the Mason County website. Revised:07/23/2025 Page 1 of 2 A -------------------------------- ------ Staff Use Only --------------------_----_------------- Review Step 1: Well Site Inspection: —►►1vIf+p k tI ,C,o'vl1016 YES NO N/O w ft I5 oFIAY/l(b 44, 171 ❑ ❑ Evidence of existing sources of contamination within a 100-foot radius of the water source?(drainfields, tanks,buildings;indicate distance on plot plan) 0j 0 Are there roads within a 100-foot radius of the water source? TT Is the road Private,County,or State?(circle one) Distance to the road(s) r0 ❑ Does the ground slope away from the water source site? ❑ ❑ Satisfactory well cap? V0 Well cap screened and vente L . ❑ The well casing extends above level ground/c• crete sla•. (circle one) p ❑ ❑ Well tag attached to well casing? Lat: y ,2g3oI El ❑ Evidence of an adequate surface seal? Lon:— Z t_gig t( ❑ Variance necessary for well site approval? Tag: A FF Z I g Comments: I I /1 / ?S: (ctnrgv, tti({1'. 1, (t kicke (auk,oat Uccp$. - IICIoSr4 11/Za 170e - ICJ({?per(keiftZ ,ff uAktial 2 f1-of 4e11 AV. Ptvvto C7 Pik iu . c 04P&Cu'' a F /einnpaeI funt WI 6,0. ll/t//Zaf' ass li—fail Inspector Date f U Review Step 2: Two-Party Review: YES NO NA '/ �� El Water well report(well log):Date Completed O5/7t/1Or Driller C grope 7 1"'4// '/4. 9. El El Satisfactory capacity test showing a minimum of800 G D with full recovery t tatic level within 24 hours? Capacity test information:Date ?(f$(Z ?$Driller/PumP Installer I1i'caa 0,"1 r!!4 GPM 1 Z I) Duration(minutes) 65 Total Gal gge RecoveryTime(minutes)to Static tJ ig ❑ ❑ Satisfactory bacteriological analysis? Date ///6f7ij esting Lab (/ 6 c Vn$' ❑ ❑ Signed,notarized,and recorded notice to future property owners?AFN Z ,6 ❑ 0 The system appears adequate to serve two connections based on the information provided L Comments: NOV 2 1 MAsoN 1025 CO U f ili Approved ❑ Denied Reviewer .„.---` Date T TR 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 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 196, 2018 per ESSB 6091. Revised:07/23/2025 This form may be scanned and made available for public viewing on the Mason County website. Page 2 of 2 Fie Original with WATER WELL REPORT Notice of Intent IA/i �/}►�- `o Departmentof Ecology UNIQUE WELL I.D.N �� ' " -- a 18 Second nd Copy-Owners Copy STATE OF WASHINGTON Water Right Permit No. Third Copy l?ripers Copy / / -..5. Address H. er— (1) OWNER: Name Address S ' /� aW 114 �114 Sec3T_=N.R._ (2) LOCATION OF WELL:Courtly(2a) STREET ADDRESS OF WEL areal addressl C TAX PARCEL NO.: )4. 3 y-Q wM'Lf (3) PROPOSED USE: 'jCDomestic ❑ industrial ❑ Municipal (10) WELL LOG or DECOMMISSIONING PROCEDURE DESCRIPTION p o n: by color,character,sized material and structure,and 0 Irrigation rr ❑ Test Well ❑ APR ` ,q ar1 t of the material in each stratum penetrated,with at least ❑ DeWater one entry for each change of information.Indicate all water encountered. (4) TYPE OF WORK: Owner's number of well(M more than one) MATERIAL FROM TO �d New wa, Method: SEPT. `/r ._ ,�.i.. , oFr' Two i I Z C, Deepened 0 Dug ❑ S N I E R I 0 Reconditioned Cable ❑ pA Z U Decommission 0 Rotary _• ❑ Jetted $4 �eM1 Tr LLB �tj •� Inches CC��/ of tr ft,�L[ (5) DIMENSIONS: Diameter of well n �� 6r$�+�1 wL CS 2i '3 Drilled /0? feet. Depth of completed well `1 C) I VolS /Nerr�f Red 3 4-i (6) CONSTRUCTION DETAILS if AA ..S v../+��p rev. LooS.. WeldedCeiling Installed: / Diem.from♦ (8 ft to to IT,,.,it �b y LOA.is(.( `t .'Z IS sO ft.to ft. S E. D Liner installed Diem.from ft. ey 5 4'i cis• or Oyu"( ❑ Threaded Diem from n.to [^1I N� �,a,..It CiC�y / # 7 S Perforations: uYss�No nI',s� Cdc.'>r l3LI,)E e� Type of perforator used II-Le ph e a( Avdt r+/ / 5 In.by In. 's 1 SIZE of Perforations .444•n _5`4�1;! ,L G 0e tf e 1_ perforations from ft.to n' 19 A c lc .• 7 `4 4AT _1/AR r Kte 15 , 05 I 9n Sn,diGir•*+d�1— lPli,,0v Screens: ,�lrYes 0 No 0 K-Pac Location Loci ! 46 a Se. t Attell4t t/Q.s /i() Manufacturers Name Diem. Slot Size i 20 from //D k,to Q k• PO Diem. Slot Size from n.to k. Gravel/Fitter pecked: 0 Yee XNo Cl Size of gravel/Mod Material placed from ft.Io ft re t `' t 1 '1/ Buffet*seal: , 1/es 0 No To wttpt dee? 1 it r fz APR 3 rt Material used in seal fSs.,.rTQ�ti,"1' 20QQ Did any strata contain unusable water? ❑Yes i*k:i th of strata �A4fiTtitrltn Type of water? De n. Method of sealing strata oil FCOI n II (7) PUMP: Manufacturer's Name TyPs: H.P. ft. . Completed Dd (a) WATER LEVELS: Landp�umace elevation above lop ot�I D m/t 4I) Work startedll — ArtSta sic level _ iQ lbs.per square inch Date Artesian pressure Artesian water is controlled by ( valve etc.) WELL CONSTRUCTION CERTIFICATION: I for construction of this well,and Its I constricted and/or accept responsibility(9) WELL TESTS: Drawdown is amount water level ie lowered below static level compliance with all Washington well construction standards. Materials used made? 0 Yes ❑No If yes,by whorn4 and the information reported above are true to my best knowledge and belief. Was a Pump tenhis. 4 O 5 Yield: oallinin.win k drawdown alter �� ,}/�+ License No. Yield: - _gal/min.with n drawdown alter tits Type or Print Name Yield: gal/min.with n.drawdown alter Ma. (Licensed Driller/Engineer) Recovery data(time taken as zero when pump turned off)(water level measured from Trainee Name License No.t well top to water level) tilling Company �� W I l� T me Water Level Time Water Level Time Water level (Signed) Lcense No. ( /need 1 r1 / �/�/i( t Address fr"` 49( (.1)6/0 04 �( i l Date of test egist / a -i 1f ,A 3(1r,° Bailer test gal.hnln.with 41 1 ft,drawdown alter INC,. Contractor'ststretion No. V ` f / Date _ Airiest gaidmin.with ft.drawdown after hrs Artesian flow g.p.m. Dale (USE ADDITIONAL SHEETS IF NECESSARY) Temperature of water Was a chemical analysis made? 0 Yee two Ecology is an Equal Opportunity and Affirmative Action employer.For special accommodation needs, contact the Water Resources Program at (360) 407- ECY 050.1.20(11/98) 6600.The TDD number Is(360)407.6006, Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Austin Heilman Well Tag #: AFF218 Site Address: 67 E South Island Dr, Shelton Depth: 110' Date of Test: 9/15/25 Static: 88.6' Pump Set: 101' TIME GPM LEVEL RECOVERY 1 Min 12 92.8 TIME LEVEL 2 Min 12 93.4 1 Min 89.8 3 Min 12 93.6 2 Min 89.05 4 Min 12 93.6 3 Min 88.85 5 Min 12 93.6 4 Min 88.8 6 Min 12 93.65 5 Min 88.75 7 Min 12 93.65 6 Min 88.75 8 Min 12 93.65 9 Min 12 93.65 10 Min 13 93.7 15 Min 13 93.7 20 Min 13 93.75 25 Min 13 93.75 30 Min 13 93.75 35 Min 13 93.75 40 Min 13 93.75 45 Min 13 93.75 50 Min 13 93.75 55 Min 13 93.75 1 Hr 13 93.75 1 Hr 5 Min 13 93.75 Total Gallons Pumped: 888 Gallons Vanguard Laboratory V2635 Parkmont Lane SW,Suite A Olympia WA 98502 ygooAlw 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected , o Mason 09/15/2025 •PM Mont. Day Yea Type of Water System(check only one box) O Group A ❑Group B 0 der Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): IN -- -- System Name. Austin Heilman Contact Person:Arcadia Drilling,Inc Day Phone ;360 )426-3395 [ eH Phone:( ) Email Eve Phone( ) Send resin to:(Print full name address and zip code cr a--3. ar'etagarcadadrilLng corn AND Ienr(arcadradrJ4rg: SAMPLE INFORMATION San-;e collected by(name):Sam Specific location where sample collected. Special irstructans or comments. 67 E South Island Dr, Shelton Counts please Type of Sample(select only one type of sample from types 1 through 5 below) 1 ❑Routine Distribution Sample(NP) 2.0 Repeat Sample(AIP) (frcr-; -c uyon system after unsat routine) Charira ed Yes--No_.--- Unsatisfactory routine lab number. Chic ine Residual Total—Free_ _ -- _ _—--_ 3 Ground Water Rule Source Sample Unsatisfactory routine collect date: . i i I —I (- Chlorinated Yes._ _No_ .__ O Tnggered(AY) I CHorine Residual Total Free— ❑Assessment(APP) 4 Surface or GWI Raw Source Water Sample(Erumeration) ) C ) J E.cob 0 Fecal F sexed Yes _No__ � 5 ©Sample Co'tecwd br information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY _ ❑Unsatisfactory Total Colifonn Present and 14 Satisfactory Q E con present ❑E.cot'absent i100m1. E.coli_ �•0 1100m1 Bacterial Density Results Total Coliform_1. 11 mi. 1100m1. HPC_____Fecal Ca,form - — Replacement Sample Required: 0 TNTC 0 Sample too old 0 Sample Volume ❑Damaged Container ❑_____ -- Dae T:me Rece.tc •r/ �r °I 1 •-I, Lab use omiiiiiii, i. w Date Repo''% DOH DOH Lab-Sanpleu 285-n°Ilbz r. trM.... .0t2 .T .0;„I ...y-(';}�.Jtil .e I.e,yyneeec ac aleM,teroe x...Sr..pp, -- r.,,er4e atxa e�"" Return To 2232238 MASON CO WA 10/17/2025 01:03 PM NOTCE 91( CYO D.r1 HEILMAN #215238 Rec Fee: $304.50 Pages: 2 Uj1 E S �s(rz>1o( >>r 1 1111 111 II�����I�I�IIII�i I��I IIII I��II�I��I I�Ii�I� �I���������� ���� F.IneLtc" j W C Grantor(s): (1)41/5b in1) i 4/'1%✓1 ,(2) Fj l(1} ►Yl t1tk I ma✓1 Grantee(s): (1)PUBLIC TR 7_C of &ov t- L.at Z�l FAG of-5 fit,25zc( Legal Description(1) t•, •lr!hu..nBr ►1,mi•.:jur.gli.wI►riri.•...ai:-.z,;ii...ii :aeLerai,•R.•.. (Abbreviated form: i.e. lot,block,p at or section,township,range) Assessor's Tax Parcel: (1) 22 OO 3- 3 t -9OC7`I Sec ia� 05 13 l 20 ATE NOTICE TO FUTURE PROPERTY OWNERS OF PRIV WO-PARTY WATER SYSTEM I(We)the undersigned 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 1) 22b03-7)4-9 007 y Tax Parcel:(Connection 2) Z Z na, - 314 — 91007 3 The system owner is responsible for keeping this system in compliance. The name of the water system is: 5 AVldy S Wt k This system 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 water right,obtained from the Department of Ecology, is required if the water system exceeds exemption standards. This system(has/I as no I been granted one or more waivers from specific provisions of the regulations. Dated on this £ day of ©C4 eX ,20 ZS . Signature of Grantor(s): (1), ��'�� ,(2) Page 1 of 2 State of Washington County of Mason I,the undersigned,a Notary Public in and for the above named County and State,do hereby certify '' that on this I day of OC r Noe r , 20 ZS , A09,:in D. oi► 15644Am i-• Hc1tM4rk personally appeared before me,who is known to be signer of the above instrument,and acknowledged that he(she)(they)signed it. GIVEN under my hand and official seal the day and year last above written. otary Public in and for the State of Washington, residing at 5heMo0 My commission expires: fVO✓crnbei 18,zc z . 4i NOTARY PUBLIC STATE OF WASHINGTON LIZBET JORDAN-ESTEBAN Lic. No. 25001320 My Appointment Expires NOVEMBER 18, 2028 1 1 Page 2 of 2 • - s P' f13,13 (13.13 ,1lJ / i We V.‘%AN/ °.-# 0MA/4' oetot / I rt iet { 5`6N" 44/f �` 7 1 • • DOwil F,. tJ w.� 10 275 ►ko z75 ilne.t 21 -3-J- 7 txrp 0: pAac� 2. 314- 10073 !rrrs r h v�r`'a i 0111 r- .:j ?.. . "pi R f-'' ' j'2,Za$ q *R-4.-0 1 G") II. .4 i8CA - IttiV- Q IA* iii 0 ".F. ,-; -6 RP :6-91% o Amy m (A0 N r • v g, 1 $ N 1 m N W ni Da* " . . 6 g tWU6�A`� o s '�' u''F� 6 sr w bibiligtl, f of s:Il ® 7 r'._ ^' it lies I v "' O u Q .> %t. 00N"A ),tu ,, A I U a4 /H V W .t Q ® \\ _ 4 q Ili Ilpi ®--,Y w § il ti, § 25 4, 1:: ,:\>, D. poi - p 1...,_ N 4L.54 I f u+ v $ ®_rz 1 il , ''' tgi.t M \ 1,.....- V.4 -1111 1 / i \ 1 9 o N 0131'00' E R)41118 gi 412 n a . C , rn .00 � Pi 1Oi. c Pli v o �, ' I r- srD Niio 0 -4e 1 . Pi: I. • ''' V fig' I fill 2 u m t TVs o °� �0 -i ri le ?y•hit ''. F/47 s If E 0 ,'lb to ii Prins F b1 i aunty DMS ? v (e, ZZoo3' G47Y A If3- I3 ,P` 1(..=?t a-r ?1ov,e) # Z2 et,3`3(1c co-7b LorD • +4-42,s'r , ) •• _S c 404 o ellv v • - .04 .11:[;_4( 6,1..1 04 \ 4 n1 a --w N a i2 J- -1- / � ' • . SS'r--� µ to,7 Tt `� if — b \ i it 161y..—VS —, � oa --du 1 Na c-, 01 0 3 0 CDd V „ j 1 te4-0 z Zo I Lam" WAs^'T 10S. • - .. N 4 Printed From Mason County DMS . Printed from Mason County DMS • • • ON-SITE SEWAGE INSTALLATION STAFF INSPECTION REPORT i tt w4 .3<, , � STAFF CHECa TSC Yes No C,rnments I. TANK A) >5 V ?Jo b d A) >5 ft.from foundation? "'i foviovi- B) >50 ft from wells and surface water? V - — C) Bldg stub-out to septic tank:clean-out if not 1-2%7 V D) Baffles intact and clean? -It_— E) Dividing wall intact? ✓ F) Risers installed for access? ✓ j II. D-Box Leveled wi water d/of� ed lev r(circle)? t/ 1 III. DRAINFIELD A) >10 ft from foundation and>5 ft from perceived property lines? ✓ B) >100 ft from wells and surface water? ___Z.- C) >10 ft from potable water lines? ✓ ' D) Laterals Ievel to±1 inch&end caps present if not looped? B) Gravelless chambers utilized? F) System dimensions the same as shown on the design? _AL _ G) Gravel clean,properly sized,and proper depth? ._..1Z— H) PRESSURE SYSTEMS I) Sand quality ASTM C-33? N A 2) Head height uniform and z24 inches? 3) Clean-outs and observation ports present? 4) Mound: Side Slope 3:1? 5) Owner informed electrical connections must be made _ by owner or licensed electrician and inspected by L&l? W. PUMP/PUMP CHAMBER A i A) Screen hacket or rent filter circle one)installed? - i B) Riser installed for access? ► 1 C) Alarm installed? ► ' D) Pump on timer or demand(circle)? ►is V. As-BUILT REQUIRED? 'V VI. OTHER COMMENTS/OBSERVATIONS I 1 1 i i j The undersigned has reviewed this installation and verifies these findings on behalf of Mason County Department of Health Services. , d 'ii p �:� : .an Date C:\MyFites\finalcheok-wpd Revised 9/26/97 Printed From Mason County DMS Printed from Mason County DMS AS-BUILT FORM February 18 99s Revised F , r l ,Bjf' ,yt�nri .- Y• J / i� (.rX§s n;...:dy. :,,: .r 0 $'��',:- ,rL `Z.., : ;o-.,6 s i' , i. "#�''::''.tii. Srr : is - y r dcG Applicant � M 1 "''1. LI t �`. r `. Assessor's Parcel # f;:' :J co 3 / 0D0 < (Twelve-Digit Number) Permit Number SWG'Li- 1(a3. - + f)`,r 6..� ni_ It- t7- `�j �� ��:"� coo r � Installer f f� '°`� v C. Subdivision (Name/Division Block/Lot) Designer - - • ti' s L )] .Y � � JtOA ' .xn x.�'•H iC0.5Y :.::.. NIA Yes Prior to Completion I. SEPTIC TANK _u ______ A) >5 ft.From foundation? $ >50 ft from wells and surface water? . . . .C-a.'. • • • •• • • �_ C) Bldg stub-out to septic tank:clean-out if not 1-2%? D) Baffles intact and clean? _� E) Dividing wall intact? �, F) Risers installed for access? t G) Tank Size: 12,-e" .) gal.;Manufacture ATI_A a Cam•-' II. D—BOX A) Leveled with water? _ - B) Speed leveler used? III. DRAINFIELD A) >10 ft from foundation and>5 ft from property lines? _ B) >100 ft from wells and surface water? __k_- C) >10 ft from potable water lines? D) Laterals level to± 1 inch&end caps present if not looped? �— _X— E) Gravelless chambers utilized? F) System dimensions the same as shown on the design? G) Gravel clean,properly sized,and proper depth? H} PRESSURE SYSTEMS �_ 1) Sand quality ASTM C-33? 2) Head height uniform and 224 inches? Actual head height . • • — - __&- 3) Clean-outs and observation ports present? 4) Mound: Side Slope 3:1? 5) Owner informed electrical connections must be made by owner or licensed electrician and inspected by L&I? IV. PUMP/PUMP CHAMBER Pump model �-- A) Pump make _ B) Chamber size gal; Manufacture _ T , C) Height of pump off bottom of pump chamber inches D) Pump chamber draw-down gallons per inch E) Pump capacity gallons per minute F) Pump controls:Timer(or)Elapsed Time Meter (circle if installed) Ng. , If timer is used: Pu... li n Pump Off 1 r : +�� < G) Screen basket o ircie one)installed? . ? �4 • c4 H) Riser-installed for access I) Alarm installed? Prin 1 Fr ,in Mason t ,nlrnty_ ii ---- Printed from Mason County DMS •, h • CHECKIZT ❑ Drainfield&manifold orientation & layout ❑ Trench/bed dimensions and critical distances within layout ❑ Septic/pump tank placement. 4.A tL°c ,4 kk Pobt!'V ❑ Location of buildings. ,Z- c illx, s',ik ❑ Observation port&clean- r o� ;7 out location. .* • i ❑ Location of wells& ..'�`� •t • roads. �..-4 4't45'`.\ D-fir* rb ❑ Undisturbed native soil� between trenches. • ` ,, ❑ North arrow3 _ _ t • qnc p s3R�P. ., ?„,-ts 4 l A rent-At_ iter i-e ti.9+0 LIG Sts^-,-01++r tt- . --D24,f ill Fc c L A'S (pC Y? to S c.c , CAUTION:Minor adjustments to septic tank location and drainfield orientation made in the field by the installer are generally acceptaltle to both the department and the designer,but could in certain cases compromise the viability of the system. It is the installer's responsibility to ob • poor wntteis approval from either the health department or the designer before making any deviations from the design that affect the system viability. Any deviations from the approved design must be shown above. :, . :.tea•:.....,;.... ..�.„:r-:n,,.n,....�::':?iY•a',,�, %3 ��':7: .i.. :%:/��,,[.:i� � `q'r.. ;>:::.::> - ,..o:- i :w:. ` o'�`'�t�15 Sf.A mow, S•':•:j:`, .,.Y,k:: r . 'F�?�e:y oa �ii - �� .� l��:: .<x:•",.'.;i:r£::or:5.'::-.oxCe. Installer Check a box from Row"A"and"B",sign and date the certification A. ❑ I certify that I installed the system without any /'Q / that all deviations from the design stamped `" certify deviation from the design stamped"APPROVED"by "APPROVED"by MCDHS are shown above. MCDHS B. I certify that I contacted the designer and left the system open for inspection up to 48 hrs prior to 0 I did not contact the designer prior to final cover because the designer waived the notification requirerlent. cover. I further certify that all information contained on this form is accurate. I understand that if the information contained herein is not accurate,there will be just cause for immediate suspension of my installer ce"' cation ,� ���� r Z i Si. :ii of . %ler to The undersigned approves this installation on behalf of Mason County Department of Health Services. dr- z.,%sateleia-iz- ISa; .ed From Mason Uounty DMS ``;., .ante Printed from Mason County DMS '7.3 ' . _ Pwc&( : ZZoo3 3y. 0a '7 . ,/3.13 I")N.0Alt Q Nr e�v.ces - ,zit..yw. coov‘.1. vi.ez..,,utc.b. y�aso� '��.IYY D lbw. 1Nta}s 10�. 1 itan Scr•1rt_"►u1L Date Aux,ile&aadk.G Sett . . cV y� 11194 EArdiorar /gDi ?S Zed & 0 So yob &ALL. 1:AD Printed From Mason County t Printed from Mason County DMS _ ,r -- " . AS BUILT FORM - Revised Feb"" IS.199E . .. .i: .. .. '.. ._. . 0 ...... -.,R ..n.o.. ..'+N a i ✓•fll� ..5t.. o .,.,,..,.R ..al... d.. ....,. ..,. ... i:.v , r3 f j,l Av,��6 l l 4:O Applicant 'DaAi (,d(41111t4 Assessor's Parcel # ,- o e) , 3 70 i' Permit Number SWG 7 q - 16 3 y (Twelve-DigIt Number) Installer Q Subdivision C, �7� (Name/Divislorv/BlooWlAt) Designer (net cier.g&A-czZ .' �/.�.. * INSTALLER CHECKLIST SC 'x? ;,OA N/A Yes Prior to Completion I. SEPTIC TANK L A) >5 ft.From foundation? t, B) >50 ft from wells and surface water? C) Bldg stub-out to septic tank: clean-out if not 1-2%? i D) Baffles intact and clean? — E) Dividing wall intact? F) Risers installed for access? G) Tank Size:_/)9 gal.;Manufacture /' 1/ II. D-BOX A) Leveled with water? 4 B) Speed leveler used? III. DRAINFIELD a A) >10 ft from foundation and>5 ft from property lines? v B) >100 ft from wells and surface water? 4 C) >10 ft from potable water lines? D) Laterals level to+ 1 inch&end caps present if not looped? E) Gravelless chambers utilized? �e F) System dimensions the same as.shown on the design? 1.G) Gravel clean,properly sized,and proper depth? H) PRESSURE SYSTEMS 1) Sand quality ASTM C-33? 2) Head height unifonn and z24 inches? Actual head height . . . 3) Clean-outs and observation ports present? 4) Mound: Side Slope 3:1? 5) Owner informed electrical connections must be made by owner or licensed electrician and inspected by L&I? IV. PUMP/PUMP CHAMBER A) Pump make ; Pump del B) Chamber size gal; Manufa e C) Height of pump off bottom of pump chamber inches D) Pump chamber draw-down__ gallons per inch E) Pump capacity �� gallons per minute F) Pump controls:Timer(or)Elapsed Time M r ( rcle if installed) If timer is used:Pump On p Off G) Screen basket or effluent filter(circle o )installed? H) Riser installed for access? I) Alarm installed? �'��,QA�� Pri �c� pet , i C�� Di I V Printed from ':' son County DMS CHECKLIST CAI Drainfield&manifold orientation & layout ❑ Trench/bed dimensions / and critical distances . 1 i.( within layout ❑ Septic/pump tank — _ — — — U placement. / 1 ll, ❑ Location of bu,1. i gs. , i ,4 C) _ I ty lly _ xla Observation port&clean- out location. q' .• 4 6i h3 r w cy ❑ Location of wells& — roads. 0 Undisturbed native soil between trenches. 6 ❑ North arrow r.> i ii;Yr4) i,..,_) :if -------------------•---_ l'r /I i.1t' , CAUTION:Minor adjustments to septic tank location and drainfield orientation made in the field by the installer arc generally accep a to both the department and the designer,but could in certain cases compromise the viability of the system. It is the installer's responsibility to obtain prior wntapproval from either the health department or the designer before making any deviations from the design that affect the system viability. Any deviations from the pproved design must be shown above. yu. c Y R .£,.Y o ox> o $Jillot• x�61111 r .. .' 3 9 >F$� ' ro #!K A y t o ti Installer Check a box from Row"A"and"B",sign and date the certification I A. .iff I certify that[installed the system without any 0 I certify that all deviations from the design stamped deviation from the design stamped"APPROVED"by "APPROVED"by MCDHS are shown abo1e. MCDHS B. ❑ I certify that I contacted the designer and left the ❑ I did not contact the designer prior to fmal cover because the system open for inspection up to 48 hrs prior to designer waived the notification requirement. cover. I further certify that all information contained on this form is accurate. I understand that if the information contained herein is not accurate,there will be just cause for immediate suspension of my installer certificatin. (62-- �( 'AAl 's, J— r 78 Signature of Installer Date The undersigned approves this installation on behalf of Mason County Department of Health Services. gi :e. ttarlan lt- 7/ ate Printed From Mason Co4aty DIVIS Printed from Mason County DMS