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HomeMy WebLinkAboutWEL2026-00010 - WEL Application, Design, Letter - 4/30/2026 415 N 6TH STREET, HELTON,WA 98584 ( EA M ASO N Co u N TY SHELTON:36S0 427 9670,EXT 400 BELFAIR:360-275-4467,EXT 400 Public Health;&.Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 04/30/2026 STEPHEN ARDIRE 1470 W LITTLE EGYPT RD SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2026-00010 1521 W Little Egypt Rd 420194100000 The 2-party water system, CORRECTED Private Two-Party Water System Ardire I Rudoll (Well Site &ADU:420194100000/SFR: 420194100010), 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, EH APPROVED 'A.Anderson 04/30/2026 David Anderson Environmental Health Specialist Mason County Environmental Health MASON COUNTY 415 N 6TH STREET,SHELT967 ,E 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 04/24/2026 STEPHEN ARDIRE 1470 W LITTLE EGYPT RD SHELTON, WA 98584 RE: WA TER SYSTEM PERMIT: TWO-PARTY WEL2026-00010 1521 W Little Egypt Rd 420194100000 The 2-party water system, Two-Party Well: Private Two-Party Water System Ardie/Rudell (Well Site &ADU: 420194100000/SFR: 420194100010), 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 w MASON COUNTY Date Received: 31 oZ COMMUNITY SERVICES AmountRece Received By. Building,Planning,Environmental Health,Community Health 5 -7 cjp cy('Fc _ 415 N.61'Street,(Bldg 8)—Shelton,WA 98584 W E L Shelton:360-427-9670x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 - ��( v TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE lne�n rdlir� FS(vg - �� 5 MAILING ADDRESS-STREET,CITY(,STATE,ZIP i'-17° W. Lt:tHC, , jPr t - / SITE ADDRESS-STREET,CITY,STATE,ZIP i 5A( V\fl t4(- p _ - _t ' PRIMARY PARCEL NUMBER ELL SITE 4Z.o (q - L41 --Oo000 SECONDARY PARCEL NUMBER(SAME AS PRIMARY IF LOCATED ON SAME PARCEL) 420 Vmil.- 4l - (O WATER SOURCE SOURCE TYP I PARCEL I LOT SIZE(no minimum) I PARCEL 2 LOT SIZE(no minimum) New Existing Well ❑ Spring ( 9 r 3 PROPOSED WATER SYSTEM NAME(REQUIRED). Pr v -e_ - wo O -l-7 v s v'1 /wd f>✓l PROJECT DESCRIPTION(e.g.,detached ADJ,new single-family residence,existing connection,etc.) ash t)t-t cc*t c ADL 4 Zola -' -OOOOO DIRECTIONS TO SITE/CONDITIONS/GATE CODE/KEY LOCATION/ETC he cdo * Rd aw.-OK 1.15 wl t les)ilne Will is rte, t� - eA'4-s ick o -t-k9 stvee rA vK CA.v b - Seem M+ke s-h' - k SF- b--c you o ---o e- rLsec. t - 4io W L% is ©�I -Fly R -. av,d i—ke-weU i,5 ` .cc eo 55 *44.e S re - i- Required Submittals/Requirements Checklist: ZOriginal water well report(well log)or DoE water well report for an existing well. Well tag secured to the well casing. 18 Capacity test showing 800 GPD with drawdown and recovery to static level information. MAR 12026 Bacteriological test(Bac-t)results:current(within 12 months)and satisfactory. Septic Records(additional locating requirements may apply if no septic records are on file). By ❑Applicable utility easement documents. ®Notice to Future Property Owners of a Private Two-Party Water System,Water Use Agreement,and Access Easement(s)recorded with the Mason County Auditor's Office. *Note:May be recorded after the permit has been preapproved. I own the proposed two-party water well and have the right to grant access for a second connection.I attest that the well currently has no more than one connection. Print: V r V llr Sign: Date: This form may be scanned and made available for public viewing on the Mason County website Pg 2 Last Updated: 1/7/2026 Please include the following site features for each parcel served by the proposed two-party well: Parcel numbers(s) Property lines/boundaries ❑ Applicable easements with the Auditor's File Number(AFN) Roads and driveways Well location with a 100 ft radius around it Structures*Water wells shall not be located in garages,barns,storage buildings,or dwellings(WAC 173-160-171) Water lines for existing and proposed connections Septic and sewer components(tanks,primary and reserve drainfields,transport lines) ❑ Barns,chicken coops,barns,manure piles,dog kennels,commercial gardens,compost piles ❑ Chemical Storage within 100 ft Landfills(existing or former)within 1000 ft ., O) I . It \t Shp` wing t4CW PLC, r, Pr, Gat • � ���� < � . -,����,�� c './ `'$ Ae. \ 61. °� - _ o W`•.r'$ 'A' � 152.4 \i Lie . . . toO00O �® 1. W. 8 - t h .-..-.--.--....- — L1Zot'4.r000lr is form _. scanned and made available or c �Yviewing on the Mason`County ë5ite Pg 3 Last Updated: 1/'7/2026 Staff Use Only Review Step 1: Well Site Inspection: YES NO N/O ❑ ❑ Sources of contamination within 100 ft of the well?(septic corn onents,chemicals,livestock,etc.) El ❑ ❑ Roads located within 100 ft of the water source?Private! ou /State Distance to road(s) —10 M ❑ ❑ Ground slopes away from the well? tJ ❑ ❑ Well located outside of garages,barns,storage buildings,and dwellings,with at least 5 ft of separation? 10 ❑ ❑ Satisfactory metal or plastic well cap that is mechanically secured or welded to the casing? ❑ ❑ Access ports and openings sealed/screened to prevent contamination;pressure gauge installed for artesian wells? ll El ❑ Adequate surface seal,filled to land surface level?*Leaving voids for future installation of equipment is prohibited. lI lI El El The well casing extends 3 above level group /concrete sla . Lat: y Z08$Z f LI ❑ ❑ DoE well tag attached to the well casing? Lon: — U. ZT.9L6 et ❑ El Variance necessary for well site approval? Tag: B Comments: Pass ❑ Fail Inspector Date Review Step 2: Two-Party Review: YES NO NA (�'�,qp�/,, El ❑ Water well report(well log):Date Completed 31/6/7076 Driller 1'lV[A (c& Qi1S ❑ ❑ Satisfactory capacity test showing a minimum of 800 GPD with full recovery to static level within 24 hours? Capacity test information: Date3lftj?ñ26Driller/Pump Installer(O W 'E. K 50n5 GPM Duration(minutes) Total Gal _Recovery Time(minutes)to Static Z.Z ❑ ❑ Water system capable of supplying at least 30 PSI to each connection?PSI t V l ❑ ❑ Satisfactory bacteriological analysis? Date 3 ( Testing Lab T6i 4', 0►1 (Wfi ❑ ❑ Signed,notarized,and recorded notice to future property owners?AFN_ _C v/3 T' El ❑ Signed,notarized,and recorded water use agreement?AFN 2 Z 3( e3 7- El El Signed,notarized,and recorded access easement(s)?AFN 2 2 3/p 61 7 q ) Il ❑ ❑ The system appears adequate to serve two connections based on the information provided? Comments: "4SpN/ y 2 Approved ❑ Denied Reviewer Date G/Z �JI, 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 perMCC 6.68. Water usage restrictions and additional fees may apply to all new wells drilled after January 19`x',2018 per ESSB 6091. This form may be scanned and made available for public viewing on the Mason County website Pg 4 Last Updated: 1/7/2026 Water Well Report For An Existing Well Your well must be properly tagged prior to submitting this for . APR 1 7 2026 DEPARTMENT OP Asterisks(")indicate required fields.Mail completed original form ECOLOGY WA State Department of Ecology,PO Box 47600,Olympia,WA 98504- State of Washington Use this form if an original Water Well Report was never filed or Is missing from Ecology records. Current Use *Unique Ecology Well iD Tag Number: BQL 963 i]Domestic ❑Industrial ❑Municipal ❑Dewater Dlrrigatlon ❑Test Well 0Other. °Water Right: []Yes(if yes,attach a copy) CjNo Dimensions Property Owner Name:_Stephen Adire Diameter of well 6_Jn. Well Street Address: 1470 W Little Egypt Rd Depth of completed well 65 .(If known)Construction Details *City. Shelton , °County' Mason Liner installed: [Yes ❑No ©Unknown *Site Well ID: Type:DPVC L]Steel (]Concrete Liner ❑Unknown (]Other: *Tax Parcel Number. 420194100010 0 d Perforations 'Date Well Constructed: N/A 0Yes ❑No ®Unknown 'Location(Township,Range,Section) d Size of perforations in.by In. Number of perforations from�jt.to ft. An accurate location of your well Is very important. The Screens Section,Township,Range,and%,Y can be found on your tax parcel legal description or your throughcount 0 Dyes pNo j1 Unknown assessor's office, y Type:(]Stainless Steel ❑PVC 00ther. Diameter Slot Size from ft.to ft. Township 20N Range 04 ❑EWM or III WWM E GravellFllter Pack Section 19 SE 114-1/4 NE 1/4 Dyes Do QUnknown Materials placed from ft to i. Comments: o Surface Seal Could not verify surface seal as well Is In pump house with n []Yes If known,to what depth ft. La concrete floor. []No ®Unknown RECEIVED Materials used if known: r 3 [jeentonite OCement Dept of Ecolocw a Pump ®Yes ONo (]Unknown LType Franklin Horse Power 1/2 Latitude/Longitude 3 Water Levels (Decimal Degrees recorded to 6 decimal places) Land-surface elevation above mean sea level ft. Latitude(Example 47.12345) Casing stick-up 6" above/below land surface 47.20894 A Static Level 5 ft.below top of casing Date measured:3/16/i Longitude(Example 118.12345) o Artesian pressure lbs.per square in.Date measured: -123.22949 Well head has cap? DYes❑No Shut off valve?®Yes❑No o Well Tests: Additional Information(If available,please attach) Drawdown is amount water level Is lowered below static level. (]Location marked on topographic map Was a pump test made?( JYes(attach copy)pNo Q Unknown ❑Location marked on air photo Yield: 11 gallmin.with ft.drawdown after hrs. ❑Consultant well report d E o *Certification:The information reported above is true to the best of my knowledge and belief. 3 []Consulting Firm w pi Drllier ❑Engineer []Property Owner Name: Char Bensching Company: Moerke&Sons Pump and Drilling license Number: 3389 Address of person completing this form: Signature: ^ 1162 NW State Avenue Date Signed: City,State Zip: Chehalis,WA 98532 ECY 070-557(09/2016)1b request ADA accommodation including materials In a lbrmat for the visually impaired,call Hcology 1Vater Resources Program 360.407- 6872.Person with impaired hearing may call Washington Relay Services at 71 I. Persons with speech disability may call TTY at 877-8336341 MOERKE&SONS PUMP &DRILLING, INC 1162 NW State Avenue, Chehalis, WA 98532 (360) 748-3805 PUMP TEST STEVE ARDIRE 3/16/2026 WELL SITE ADDRESS: 1621 W LITTLE EGYPT RD,SHELTON WA 96684 Pump Make&Model: 112 HP 'Pump Set At: Sounder Make& Model: Make&Model: MASTER Measured In: GALLONS MINUTES GALLONS METER LEVEL TO PER MINUTE READING WATER NOTES 0 0 156455 5.3" 000 GAL TOTAL TEST BEGAN 1 11 156466 9.7" 2 11 156477 10.6" 3 11 156488 10.8" 4 11 166499 10.9" 5 11 156510 10.9" 6 11 156521 10.9" 3 7 11 156532 10.9" N 8 11 156543 10.9" 9 11 156554 10.9" 10 11 156565 10.9" 15 11 156620 10.9" E 20 11 156675 10.9" 25 11 156730 10.9" 30 11 156785 10.9" 35 11 158840 10.8" 40 11 156895 10.8" 45 11 156950 10.8" 50 11 157005 10.8" 55 11 157060 10.8" 60 11 157115 10.8" 65 11 157170 10.8" 70 11 157225 75 11 157280 10.8" 800 GAL END o RECOVERED IN 2MIN 16SEC o • SIGNATURE; u o D S S PU AND DRILLING Dl E C a • Thurston County Environmental Health 412 Lilly Rd NE t Olympia,WA 98506 360 867-2631 THUR1DN k t ... COLIFOR I BACTERIA ANALYSIS Date Sample Collected. Time Sample County Collected, 1 11 1.Wllth •_Day Year il. 222222 Type of Water System(check only one box) Private Household= OGroupA DGroupB j ,,0thert •.�„• �:; { Group A and Group B Systems Provide from Water FagG6es Inventory(WFI) Syste►mName Contact Person v t f A Day Phone( ) Ea Cell Phone E-mail: _ fX Eve Phone ( Segd resutis to(Pent full estee ad wand dip code or emQt address) ! i .. . SAMPLE INFORMATION Sample collected by(name) wr k `x Fu Specific lccalior or addresswheresample collected Special instructions or comments. Type of Sample(must check only one box of#i through#4 listed below) 1.0 Routine Distribution Sample , 2 Repeat Sample;(after unsat.routine), =l Chlorinated•Yes No_ ❑DistilbuVonSystem ChlormeResidua)Total Free Chlorinated:Yes No₹ .j 3.Raw Water Source Sample Chlorine Residual Total Free 0 E coil—GWR(NP) Q Fecal--see Gwn spgngs(nut+eraLn) Unsatisfactory routine lab number tittered Yes No (]Assessment Monitoring(A(P) Unsatisfactory routine collect date Dottier 4 Sample Collected for Information Only -A Investigative Construction I Repairs Other_ LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY [o Unsatisfactory Total Co1i rm Present and 0 Satisfactory CI E coG presents (]E cob absent No'Coliform detected Replacement Sample Required []Sample boo old'(a30 hours) ❑TNTC ❑ Bacterial Density Results Total Goliform I100ml E col► '• I100ml Fecal Cohfonn 110pml Hnterococcl /100 mi Method Code SM 9223B 'OSM 9222p I Date and 11me Received :r rg(t 0 SM9215BO t:nterolert • I j Date and Time Analyzed` '( r Date Reported• Sanryretdummher(DoinumCrpisfivedn. ) Lab Use Only 0 8 0 2239637 MASON CO WA 04/23/2026 11:55 AM NOTCE STEPHEN RRDIRE #221235 Rec Fee: $305.50 Pages: 3 1111111 011111 IHI 1111111111111 Jill I11111111111111111111111 Jilll Oil 1111 Return To: ----- Stephen Ardire _, t •' 1470 w. Little Egypt Rd. I APR 23 2026_ if! ' Shelton,WA 98584 L ------_:_ Grantor(s): (1). Stephen Ardmore.__ _.2) _ Dennis Rudol!__ ______ ._ __. Grantee(s): (1)._ PIBLIC s�q�Tzo,rz 4 Legal Description (1)._N330' NE SE S100' SE NE E of CO R/W (Abbreviated form:i.e.lot,block,plat or section,township,range) Assessor's Tax Parcel: (1). 42019-41-00000 NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-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) ._42019-41-00010 _ Tax Parcel: (Connection 2) . 42019-41-00000 The system owner is responsible for keeping this system in compliance. The name of the water system is: Private two arty water system Ardire/Rudolf 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 has not been granted one or more waivers from specific provisions of the regulations. Private Two-Party Water System Page 1 of 3 WATER USE AGREEMENT: Intention and Purpose: The well and water system shall be used and operated to provide adequate supply of water for each of the properties connected thereto,for the domestic consumption of the occupants of said properties, and to assure the continuous and satisfactory operation and maintenance of the well and water distribution system for the benefit of the present and future owners. Maintenance:The well will be maintained so that there will be no leakage or seepage, or other defects which may cause contamination of the water,or injury, or harm to persons or property.Cost of repairing or maintaining common distribution pipelines shall be born equally by both parties. Each party in this agreement shall be responsible for the maintenance, repair, and replacement of pipe supplying water from the common water distribution piping to their own particular dwelling and property.Water pipelines shall not be installed within 10 feet of a septic tank or sewage disposal drain field lines. Water Sampling: The water from the well has undergone a water quality analysis from the State of Washington health authority and has been determined by the authority to supply safe and potable water. Both parties agree to periodic well water sampling and testing. ACCESS EASEMENT: That no party may install landscaping or improvements that will impair the use of said easements. That each party shall have the right to act to correct emergency situation and shall have access to the pertinent parcel in the absence of the other.An emergency situation shall be defined as the failure of any shared portion of the system to deliver water upon demand. Private Two-Party Water System Page 2 of 3 2239637 Page 2 of 3 04/23/2026 11:55:46 AM Mason County, WA Dated on this day of r1 t ,20 Z Signature of Grantor(s): (1) (2 _L� Stephen Ardire Dennis Rudolf 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 v ` day of r ,20_____ t7 1v1 Pcirci 1 e-"iv S a\3ci c\\ __ 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 seat the day and year last above written. ( APA \�� P AL L4 iii Notary Public in and for State of Washington, ^z:V NOTARY m residing at :� Pus�tic N. My commission expires: 21 2v24.3 Private Two-Party Water System Page 3 of 3 2239637 Page 3 of 3 04/23/2026 11:55:46 AM Mason County, WA Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH ,r 4 } .APP.LIC.ANT/,PERMI7"=_INFORMATfOAI=, ,;,: ix . Permit Number SWG 2025-00376 Parcel# 42019-41-00000 pp Ai lcant Name Suzanne Rudoll Subdivision (Name/Div/Block/Lot) Applicant Address 323 E Lantern Loop Rd City,State, Zip Shelton, WA 98584 Installer Name TJ's Excavating Site Address 1521 W Little Egypt Rd, Shelton Designer Name Arrow Septic Designs,Inc . ,INS`fAL . ON,CI�ECKLIST i t 0 Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑Repair ❑Other Type System T e Sand-Lined Pressure Bed Pretreatment Type Y .$ >5 ft from foundation? -- --- --- -- ------- ---- -- ❑NIA ®YES ❑ NO >50ft.fromwells? - -- ---- - - - - ❑ ® ❑ 42 >50 ft.from surface water? - - - - - - - i- - -- - ❑ 'Cleanout between buildingand tank? - - �t}2�3 - ❑ Tank baffles present? - a-"- ❑ 0 ❑ 1=` 24"access,risers over each compartment -- - - - - - - ❑ UI O W Effluent filter installed?- - - -- --- - -- B '- - ---- -- ❑ UI O Septic tank capacity(working) 1.000 gal Manufacturer Hagerman w:eO3 D-box water level and speed levelers used? -- -- - --- - - -- --- ❑ NIA ❑YES Q NO Manifold/D-box accessible from surface?- - ---- -- ----- --- - -- ❑ ❑ UI Check valves installed? -- -- - ---- - ---- --- -- ----- -- O UI Transport Line Size 2" Schedule/Class 40 Bedrooms installed (check one) 12 ❑3 ❑4 ❑ 5 ❑6 ❑Commercial/Other >10ft.from-foundation?- - -- - - --- -- - -- --- - - - ------ ❑ NIA UI YES ❑ No ix:>1ooft.fromwells?------------------------------ ❑ 0 ❑ ❑>1OOft.fromsurfacewater? - - -- - - -- - - - - - -- - -- - -- - •- ❑ 0 >10ftfromPotablewaterlines?- - - - -- - - - -- ----- --- - -- ❑ UI i >5fLfrom property lines and easements?---- --- ---- --- - -- ❑ UI 30 ft.from downgradient curtain/foundation drains?-- --- --- - - ❑ 0 _ .. : Drainfield level and observation ports present - -- -- - - - - -- - -- ❑ UI ❑ fi ❑ Graveless chambers or Clean gravel used? (check one) Proper cover installed over drainfield?-------- ------- - -- - ❑ UI ❑ Pump tank setbacks consistent with septic tank? --- --------- - El NIA ® YES ❑ NO Pump tank capacity,(flood) 1.000 gal Manufacturer Haoerman 24"access riser(s)and accessible from surface?-- ------ ---- - ❑ ® ❑ Alarm ❑'orControlPanellnstalled? • - -- - - - - - - -- - - - - -- --- Control Panel equipped with Timer/ETM/Counter - -- -- -- - - - ❑ ® ❑ Pump installed in ❑ Bucket or ® On Block or ❑ Other a 'Pump Make/Model Liberty 280 ❑ Floats or ® Transducer Tank draw down 2.5 in/min Pump capacity 49 gpm Squirt Height 7 ft l �• a Pump on time..., 12 mm off time 6 hr Daily flow set at . 240 gpd `U U tS�c U U Y'�.;r ti H 9 U U U ' a-rJ 1 U . !U v"+.t' Updated 8/2112018 Printed from Mason County DMS- Mason County 0SS Installation Report pg. 2 Parcel# L(2O j� 14(— ©0000 ABANDONMENT RECORD Were existing septic components abandoned as part art of this project? ----------- ------------- ---- (] YES ® NO If yes,please describe: Were all components pumped out and properly abandoned per WAC246-272A-0300? -------- 0 YES ❑ NO. RECORD DRAWING. This is a permanent record and must be actuate and dcsuipuvo enough to a-locate in the need of maintenance activities and future developmunL Typicei Record Drawings contain:Dratrdietd&manifdd orientr@on a tryout SeptC P tank location,North arrow.reserve dra1rr eld.e7iating and papcsed buffs location of web,watafures, web.observation pore.deanoub,and other maintenance a==points. Incomplete Record Drawings may ovate additional delays in final ham° 'on approval and related permits. fi I i i 1 h i ® Record Drawing Attached CERTIFICATION OF INSTALLATION IY INSTALLER DESIGNER/ENGINEER I certify that 1 installed the system in accordance with I certify that the system has been installed in accor- the septic design stamped APPROVED'b y Mason dance with these tic design stamped`APPRQVEDD b P 9 P by P 9 P by County Public Health.and that any deviations shown Mason County Public Health and that any deviations here have been cleared/approved by both the designer shown here have been cleared/approved by both and Mason County Public Health and meet all State myself and Mason County Public Health and meet all and Mason County Codes. State and Mason County Codes I further certify that all information contained on this !further certify that a!!information contained on this ► form and,attached Re rd Drawing is accurate. form and attached Record Drawing is accurate. { 3 -2S-ZS ii R Slgnatun: f lost lice Date !7� Printed Name of Signee i{ MASON COUNTY PUBLIC HEALTH 4' The undersigned approves this Installation Report and Record Drawing on behalf of Mason County Public ] 51 ooa 9 1' ''4' PAULA JOY JOHNSON `�� Health: LiL �5l=5�G}ul_i�' 1` Signature of Envimnmenta.Health Specialist Date (stamp,signature and date) f' THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE UpGme0 8212016 P1Ul4i From 73 C1.`ilJ( i ` ,4Myi Printed from Moron County lr MS 0 25 50 's5 ,00 i' � C• L 42t1- 4 0GBa2 3. 22a 12bL � � o SiDAe x x �a FCC t c t x3c Pi • .. 3 • PL' 2l IhS Q' s Audio-Visual Alazm— or\. dos o a z , Cleanout s U O 3 1000 G"on Sev C Task •{ x �C 2-GomPartment with rEUeft Filter 1000 Gallon Pump Chamber f ' I� t } , p `TESTY h' i7 7 4 � tl r J c00 Q Rom J2SOfl County. DMS � f � Q �^ ••�rY %� t sIrkwex wi 1 '"'' PAULA JGY JOHNSOM L ljC ''l8t5brSj-&r--t" rimed fro V ors County S