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HomeMy WebLinkAboutWEL2026-00003 - WEL Application - 10/1/2026 MASONCOUNTY 415 NfiTHELT0N: ,SHELT0N WEXT 400 SHEL BELFAin FAIR 360-427-9670,EXT 400 Public Health & Human Services360-275-4467.EXT400 ELMA:360-482-5269,EXT 409 FAR. 360.427-7787 10/05/2026 Stacey Kronquist 1208 116TH STREET CT NW Gig Harbor, WA 98332 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2026-00003 231 E Nelson Rd 122294400041 The 2-party water system,Two-Party Well(SFR+ADU): Kronquist Water(122294400041 / 122294400041), 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, D vidD AndZn Environmental Health Specialist Mason County Environmental Health OMASON COUNTY " Z 4j COMMUNITY SERVICES w.at Q a'+4•a a.�nEwaaaaxwhCaan..,ee.. 7 LISN.CSea1.(aWY9)-Shtlm4WA%W WEL V6 — OV 3 AeYor 3QP4274K10x400 Belk 3QO1034467.100 Ela360-482-3269 elan TWO-PARTY PRIVATE WATER SYSTEM APPLICATION r cal Q ADDII -srna mv.ar,m71? NA p 6 rJ^ aA VP WVE®RIMOlmq (.�D L StCnNDA vrua .wMl ARV ruuw rAYRLI.ST s. rA*Cfl2 QNew isting ieIlSrwing ! 3pcqe nnwsmwA sssrar .aapousaw eaorcr ssoavna+aa. Aaua. •.r sl oa crwsaroae' F CATS ,tsarraA„aalam O LGU fiuv e Required SubmittatslRequiremeots Checklist: Original water well report(well log)or DoE water well report for an existing well. aWell tag secured to the well casing. K capacity test showing goo GPD with drawdown and recovery to static level information. JV Bacteriological test(Bee-t)results:current(within 12 months)and satisfactory. F-Septic Records(additional locating requirements may apply if no septic records are on file). ❑Applicable utility easement documents. Notice to Fume 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 bas been prcapproved. I own the proposed two-party water well and have the right to giant access for a second connection.I attest that the well currently has no more than one connection. Pri . Sign: Date: This form may be Sc and made available for public viewing on the Mason County website Pg 2 Last Updated:1172026 Please include the following site features for each parcel served by the proposed two-party well: Parcel numbers(s) Property linesrboundaries ❑ Applicable easements with the Auditor's File Number(AFN) M 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 R ❑ Landfills(existing or former)within 1000 ft Site Drawing SV �W t +4- P D� y'Or ec This loin may be scanned available for public viewing on the Mason County we rte Pg 3 Last Updated: 1/7/2026 tr— Staff Use Only (�] ,� y�[,r�y,� Review Stepl: Well Site Inspection: ShoQ �S` +W � "" r , r.ce _YES i3 N/O � �LL larYt� �(+gsF ❑ Sources ofcontamination within 100ftofthe well?(septic components,chemicals,livestock,etc.) ❑ ❑ Roads located within 100 ft of the water source?Private/County/State Distance to road(s) Py� ❑ O Ground slopes away from the well? IYl O O Well located outside of garages,barns,storage buildings,and dwellings,with at least 5 ft of separation? 3 ❑ ❑ Satisfactory metal or plastic well cap that is mechanically secured or welded to the casing? W ❑ ❑ Access ports and openings sealed/screened to prevent contamination;pressure gauge installed for artesian wells? ❑ ❑ Adequate surface seal,filled to land surface level?"Leaving voids for future installation of equipment is prohibited. O O The well casing extends ' I above level gr1concrete slab. Lat:')fi3E1tl Tt ❑ ❑ DoE well tag attached to the well casing? Lon: —l2Y 9LO'f a�sass Tag:ME us ❑ ly ❑ V ance nec for well site pproval'+ fn.i %p.s tines b€.f€d less e Sy fF fvm +..e* Vents: 9 Zf/an =T iat w 5C,C771WW-0if 3//'77074 ss ''Fail Inspector Date Review Step 2: Two-Party Review: YES NO NA ��� ❑ ❑ Water well report(well log):Date Completed ` / / ZDriller I'�� ❑ ❑ Satisfactory capacity test showing a minimum of 800 GPD with full recovery to static level with' 24 hours? �7y�� �� r Capacity �test 7information:Date pQ( Driller/Pump Installer ' GPM Duration(minutes) Total Gal Recovery Time(minutes)to star ❑ ❑ Water system capable of supplying at least 30 PSI too�e/acch connection? ] 0 ] ❑ ❑ Satisfactory bacteriological analysis? Date) t Jwt& .Testing Lab (.D(/W7 ❑ ❑ ❑ Signed,notarized,and recorded notice to future property owners?AFN it ❑ O [,a Signed,notarized,and recorded water use agreement?AFN ❑ ❑ Signed,notarized,and recorded access easement(s)?AFN ❑ ❑ The system appears adequate to se a two connections b ed on the information provided? 1010��Ie76 lrece v flofne-fo o wu4y_T Comments: JCt[APProved ❑ Denied Reviewer `V ( ""� zi ( ' i o the lure Findings in this review reflect observed mtditiovasthey existed on the day o die t>' No s ade,express or implied f fa success or failure ofthis system. Well site approval does not constitute water m• app qt n All proposed connections to new wells are subject to water adequacy requirements at of/mlBiry permit 6.68. Water usage restrictions and additional fees may apply to all new wells drilled after January iø,2018 per 1791. 46 2q This form maybe scanned and made available for public viewing onMason County website Pg 4 Avee Last Updated: 1/7/2026 O, Please print,sign and return to the Department of Ecology 1 ' Water Well Report Curren' RF�Fi�F 1pI6 odsmd -eeaeey, rt mPy_...a :w eepp_aalu.. Notice of Intent No. 'onsenduct Unique Ecology Well ID Tag CoostrnetionDecommission 9 BY No. nT.A 27R Construction Water Right Permit No. Decommission ORIGINAL INSTALLATION Notice Property Owner Name Sta v Rmerniiwt yre7 ofln(ent Number Well Street Address 231 E N218gI1 Rd. PROPOSED oeWaxer 8 D,igi oo p❑ wain ❑ Miweipel N ❑Dewaa ❑IrtipOn ❑rmwal soma City(:r, apvi a✓ County TYPEOFWOR5[: Owner'smmberofwell(ifnmellunarc) LocationsE.1/4-1/4 M•1/4 See_3gTwn ' R4qZ =. C Maw well ❑Reconditioned Armen✓:❑Os ❑stared ❑ d5ven O ❑ nN Wood- ❑Remy ❑5m1N LabLong(s,t,r Lat Deg_ Lat My✓Sec C DlMpnslons Dimidcnf-11 6 mdw;Jn11sd_64—A. still REQUIRED) O DepOtormmvlelal wen 64 h. Long Deg Long MiNSec COMSTROCTION DETAlls" Tax Parcel No. 1 2 2 2 9-4 4-00 041 cwec [�Wnvw _Al Dimn Rvm Am9ft. Ivn.lw: �QLL imalled Dims from L ft CONSTRUCTION OR DECOMMISSION PROCEDURE W mrew DiumfmmRm__R Pedontiom: O Ya No Fomunm: On[Ah lrylo'rdvrxkr.sin of mertnaland slwcmre.uW askiw mJ C afis fonurawd nomre of We material in mdi mamm pm, UIS,MibAD at least me entryhr.at ct ngc of Type infwm,tivn iwi[Ne all worn en[dm¢tN. USE RDDITIONPL SHEETS Ir NECESSARY. SIZE ofpan_in.by_in"and no ofperfa_Rom_t.to_ft. MATERIAL FROM TO yScreen.: tYcs ON, GtK-Ps[ lamtion P' V Munonnurers Name JO__aataa C - Two ta1n Laser Mwel No. Uiam._5 _0 rmm 59 rtm ft C Si anm Brown till 3 19 to Gravimeter p¢Mem Q Ya No ❑Size ofgnve/md MamUsplxN! ftro R to Surf.a Seal:;W Va DNo Towlwdepi?_18_R QMamial we in eaI Bet.v.e4e Did any errata anmm unable wane ❑Ye, fl No .s Type nrwaer. UUdhadwU MMN or,wine sow oB PUMP. Mmufwurers None C C Type: . H.P. WATLRLEVELS: lnwmtrflm elevafmnvbve mat en level Sane level 20 fl below tcp ofwell Dam_ Anaian pmme The.pa.equa•emelt Dam Ailcim water is wn4alle by O re Z WELL TESTS Dmwtlpmm ie vmavA wmttlevel is lowemibelw emli[lettl N Was Wtry mninade?5y Yn O N Ilya, et by wIi d Yield: aI./mm.will ft Jnwdown a(rn bra. Q Yield; Pllmin.wiN ftdnwdownana M, Yield: Ilmin,with a Jrawdown afterbn a xnw ma„ny m mse,r m in £i,,.,&we$wen wi P wD r.aer lma,nrmre✓>wm i.//l mpm rnlevell Tim Warn Level Tine w.ler level Time wav Lod LU aaofaa eanwm.t ie M/wmwil6 35 n. mwuwwnwer_.}_m,. 'ashin 1 State Akt t_edJrin.wimaumsnn M1fw gy C AMvim flow up,m D,a 0 remvm tmn ntwam_w..nMww malniemwn:' I]Ya 5a Nn Mm1Dab ComplmJ Dale t, OWELL CONSTRUCTION CERTIFICATION: I constructed and%oraccept responsibility for construction ofthis well,and its compliance with all . W Washington well construction standards. Materials used and the information reported above are true to my best knowledge and belief. O Daletlb,dtnenrminee Name(Prim Tr.a Dnnlnaeanmany Dacia DrilllAg Dril lir(n&nce,nninn Sign.am Arne. _)4 is ra=m Rd omlam .mee LraazNo. 1'/nfi ter/ aryl Sat. zip_Epl€-;rr ISM 9AS2a II TRAINEE. Conmtlora udMveU.—d No— I Resimninn No. DAVISDI11(OA Due,Tyj.. 05YO5 DAtd'.sPan Ecoogy n an Egv,l Opportunity Employer. [CV 050-I.N5(Rev 2/03) Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA.98584 Customer: Keith Chamberlain Well Tag#:ALB238 Site Address: 231 E Nelson Rd,Allyn Depth: 64' Date of Test: 8/29/2025 Static: 20.5' Pump Set: Unknown TIME GPM LEVEL RECOVERY 1 Min 13 29.9 TIME LEVEL 2 Min 13 36.7 1 Min 39 3 Min 13 39.6 2 Min 33.6 4 Min 13 42 3 Min 29.7 5 Min 13 43.3 4 Min 27.2 6 Min 13 44.4 5 Min 25.4 7 Min 13 45 6 Min 23.9 8 Min 13 45.5 7 Min 23 9 Min 13 45.8 8 Min 22.5 10 Min 12.5 46 9 Min 22 15 Min 12.5 46.5 10 Min 21.7 20 Min 12.5 46.7 25 Min 12.5 46.75 30 Min 12.5 46.8 35 Min 12.5 46.85 40 Min 12.5 46.9 45 Min 12.5 46.95 50 Min 12.5 46.95 55 Min 12.5 47 1 Hr 12.5 47 1 Hr 10 Min 12.5 47.05 Total Gallons Pumped: 837 Thurston County Environmental Health 412 Lilly Rd NE•Olympia,WA 98506 360867-2631 YHURSION COUNTY COLIFORM BACTERIA ANALYSIS The SWO U ly mMwd enN mr r.r tZ .I � tipsOh lweoi WoW Sysem(aeca o.N ae mx) - Ho.mt ❑CeoupA ❑Gmup8 Wier C C a Crap Acrd GouPBSPtems-RauiAe h«n WalllFgg4eWoventary,QNFy�-u SYekm Nsnr. Cadaot Pen: or Vv • DayP .e: u) 2.oL(_ 1 Rae: oetc- E.al. pLet Ew S&N re*b:IRM nY 1,F I� at.a M• Po Box 641• \i WA 5�s SAMPLE UlFORMAItH Samp1 moped by(nw )S ..S� SpecificI thn or addrew wlae eanpb SeS Sped «pemwnb: , 2.31 t . !tsor.. . Typ.ofs.i4pl.toast thec St one box ofel*w ,gh Rd lSod bebw) t(puNw Dlebiml on Sampk 2.Repo SamPW(star urwat mu M) Chbrinaled Yes_No_ ❑Disbibumn System Chorine Residual.Total Free_ Chbinabd.Y. No_ 3.Row Weter Source Sampie Chdine Residual'.T0(aT_Free_ ❑E cdh-GWRUJP) ❑Feral-suture.c.n scn In rec l Unwlvtcbryrou Il mmt«. — FeaS'.Yo_No_ - ❑Ameearenl Mpybmg(A'R) Urapahcbry rootwosadoS: ❑ONe, I B a Sample CdMbd br lnbmeEon Orly 4Or Atfy� M.*M_ Ca' i,cbon l R.$rs_ 0Th LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑UnuftutacNry Tool COWonn Pnsnl ad Ilimlafacen ❑EmapewN O EwIabamt oCPammdabcbd Rspawerem Sanpls Rpubtl: ❑SanpbbaddN0houn) ❑TMC ❑ Bnri Dmeiyy Rewbs:Total Cofibnn 11 DOml. E c0I n00ml. Fe CoWomi IIOOml EDSrararl /t%0 ml. Metlpd SM9220B ❑SM92TA pa.p,Tmelrmed: Db.192158 ❑Enbrderb t'a}-r'24 L I D eaid Th. oNeed Wb RpoYd l- BnµNUMlownnsWawAaut hots Iy at GIB PA FiiI.3IIfld �32cRh� 2246443 MASON CO WA GE STPCEY KR0N26 OUrsi *228647 Rec Fee 06.50 Pages: 2 Return To In iiiiiiiiiiiiiiinrjj iiiiiiiiuiivi u.. FFIuiA inHi tairill Stacey L Kronquist PO Box 641 Allyn, WA 98524 OCT 05 1016 RECEIVED Grantee(s):(1) Stacey L Kronquist (2) Grantee(s):(1)PUBLIC Legal Description(1)TR 4-A OF GOVT LOT 6&TAX 411 D-4-A S 501170 (Abbreviatedform:i.e.lot,block platorsection township,range) Assessor's Tax Parcel;(1) 12229-44-000041 S NOTICE TO FUTUIE PROPERTY Y 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) 12229-44-00041 Tax Parcel:(Connection 2) 12229-44-00041 The system owner is responsible for keeping this system in compliance. The name of the water system is: Kronquist Water 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. Dated on this 24th day of February 2026 Signature rani (s): (D (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 FLIj..iv day of '2 .2O 2G E Skcc y jcro1rf L.i5l— ,personally appearedbeforeme,whoisknowntobe 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. ti\�nA =WITCHERCHER Notary Pub rc m and for the State of Washington, blicresidingat P rr7L Lain H� ingtoner 24022578 My commission expires: 7-Z Expkas28 Page 2 of 2 Mason County OSS Installation Report pg. 1 MASON COUNTY PUBLIC HEALTH APPLICANT/ PERMIT INFORMATION Permit Number SWG 2026-00247 Parcel# 12229-44-00041 Applicant Name Stacey Kronguist Subdivision (Name/Div/Block/Lot) Applicant Address PO Box 641 City, State, Zip Allyn WA 98524 Installer Name Maples Excavating Site Address 231 E Nelson Rd Allyn Designer Name Arrow Septic Designs Inc INSTALLATION CHECKLIST ❑ Full System Installation ❑Tank(s)Only ❑ Drainfield Only ❑ Repair Other Transport une Replacement System Type Existing Glendon Pretreatment Type lic .from foundation? --------- ---- --- -- - -------- ❑ tuA ❑YESNO ft.from wells? - -- ----- -- --------- -- ❑ ❑ft.from surface wateR -- ---- - - ---- - ----------- ❑ ❑nout between building and tank? -----------baffles present? -- - ---- ----- -- ---- ❑ ❑ ❑ccess risers over each ment?--------- ------- ❑ ❑ ❑ent filteri . ---------- - --------- - -- ---- ❑ ❑ ❑tank capacity(working) gal Manufacturer d D-box water level and speedlevelers used? -------- - ------ ❑ wA ❑Yas ❑� NO 0a O . Manifold/D-box accessible from surface?-- ------------- -- ❑ ❑ 92 Check valves installed? -- --------- ---- -- ------- -- ❑ ® ❑ �n. Transport Line Size 1" Schedule/Class 40 Bedrooms installed(check one) ❑ 2 I 3 ❑4 ❑5 ❑6 ❑Commercial/Other >10ft.from foundation?------------ - --- - -------- - ❑ N/A ❑ NO ifrom wells?------------------ ----------- ❑ ❑ ❑from surface wateR-- -------------------- ❑ ❑rom potable water lines?------ --- ----- ------ ❑ ❑ ❑om property lines and easements?-- ------------ ❑ ❑from downgradient curtai ation drains?-- ❑ ❑ld level and o ion ports present - - ----- ❑ ❑ ❑ v ambers or ❑ Clean gravel used? (check one)over installed overdrainfield?--- - - --- -- - -------- ❑ ❑ ❑ Pump tank setbacks consistent with septic tank?- -- ❑ NA ❑ YES No Pump tank capacity(flood) gal Manufacturer Q24 access riser(s)and accessible from surface?------------- ❑ El Alarm or Control Panel Installed? --------- --------- ❑ ❑ ❑ Control Panel equipped with Tmer/ETM/Counter-- ---- - - ❑ ❑ ❑ - Pump installed in ❑ Bucket or ock or ❑ Other Pump Make/Model ❑ Floats or ❑ Transducer Tank draw intmin Pump capacity gpm Squirt Height ft a ump on time Pump off time Daily flow set at gpd updss amrm.e Mason County OSS Installation Report pg. 2 Parcel u [t22-1 —I-N'— ABANDONMENT RECORD Were existing septic components abandoned as part of this project? - --- - --------' YES ❑ NO If yes, please desaibe: Ot& C'c&o mss*^ B/,F� n l � J Q Were all components pumped out and properly abandoned per WAC246-272A-0300? -------- ❑ YES ❑ NO RECORD DRAWING This is a prmane+rc rteaN and must be accurate and deacn$ve enough to r.-oca*N the need of mdinren.nce,cavities ma nMre devsegw.c Typi®I Rema Dnvtgsnan. uraiMad a mano4 oMnOton a WroN.St9to umptank Iotn.NOM wmw.resent draiMSd.Sig and pvposcd buildings,1¢aSo a w*,watuMrs, wens.abw,don pwR.dean jS,and oNer mWlknan¢e¢ese grin&. Inmmplele Record Dmnngs may vent adtdonal dela,in fn.J incdlWEm approval and rdaitd permits. ci$ Y` G-k Itvt -``rew�sfc L\ti - ref oJmJcJ- �. - $D ic5e� asvB sc9A- des c. Q U r 1w i*r ( uas ba,-b.ot�aA ice. Record Drawing Attached CERTIFICATION OF INSTALLATION INSTALLER DESIGNER/ENGINEER I certify that I installed the system in accordance with l certify that the system has been installed in accor- the septic design stamped APPROVED°by Mason dance with the septic design stamped-APPROVED-by County Public Health and that any deviations shown Mason County Public Health and that any deviations here have been clearedlapproved by both the designer shown here have been cleared/approved by both and Mason County Public Health and meet all State myself and Mason County Public Health and meet all and Mason County Codes. State and Mason County Codes I further certify that all information contained on this I further certify that all information contained on this form and attached Record Drawing is accurate. form and attached Record Drawing is accurate. • R.4-Z(, Signature of Installer Date Printed Name of Signee `'i. MASON COUNTY PUBLIC HEALTH :,� The undersigned approves this tallation rt andy' rA 516 3,9 :k�rh PAuu J0 JOHN Record Drawing on behatlof Mas r8 my 1le9eEffDESNCiI•_ �zf/ zc o��D�u„ Signature of Environmental Health Specialist Data H^Ir, (stamp, signature and date) THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Deaaea w2tnpl' 1 i3: Eri 2G sD RO :a0 r has afi" ra ' gMGE 17z2r1-44 oOC41 �U�Cr-202 to + ; • _ A q$G24 I 4 11 T I V IY�: D^1'S� dRRK gL a- RB3r5� 1� R9df5 -neat aQ, ae� + 5�•i-f C`� 3t^'4p 5=>.'F LDRo-�'t r5 (.. � Z}�Z% ``.ttT C.CfdiT ) 1 {� Jt J9 .fada� • 1 f 5, r Lor-` • S• k " �I y ® O Auaio-V X arras _ i y O2 Clea^—cut i — Ifl 500c =tee='!'-ssti '• cJ° - "' r O N¢Water 7 x'00 ATU Tank N ye nett . I X'S15 i ( ® 100 Gafon Pump Chamber .O Vve Coatol3oa �cxI I +'^ = O7 Jpwx o� kx9R-Eecow ss� a.L J v eY' ce.w.�i55:n.,ed .. i , • NelGhbrr well _ 5:o a `1 . .- _,a _� � PNUTA JOY JOHNSON-� : ..; `��-� �� �Pa73' S3B � P2J f1/M-y O-F-T�EISeH-Tc5 ` --- D LC @ 5 O •� - p:Tti Zg$�P 5 BFJ Du) � �. ""'"`•xrrotc to ins�ller*• ®�� � `" Sleeve waterlinc W§m within 30' $Fp . of septic trevsporQine.Maintain SONCpNNryFNVj?9?068CS� 10'nnnimum between water ? Zttt line and septic tanks/dminfield. OJq MfNTq(f,�jWGZao5^ w�M. Neil 36tL�-'Plc Nelson Road sit D W 7C Y Q O n 7 m D 4 9 s 0 Z Cfo f __ N 10 O N W Z Q a V O C) 0 o o o 4 A -4 m O y a F G o z O A Fj Z I A 7c N_ 2o n D Q � � 3 ° (D Q O) C = 7 W aS�FtrNF O NO N A (n SN�RttrNF I 150.011 —H 00 ]SSES ON Hof] 9V ;TT INA 900 z/90/0T yt,,��tc�s�aaasz "cam" O O h 'I WW2 � z z zz O °�g b1 u'5 O m LLZA _ :: 11 _ ��uIE U F t 0 4 Z ``` I 0 LLL IL Z 11' 4" I / 3 Sil I r r 21) Y( W djj \ N p o w� 'Si co 2 W O m 0 N Q E.d Printed from*" ➢"YRt�1Qvs 3NI�-fl e0s :oT 90 so 0O0 zoo Z IssEs 'on nor) 9e ,IT 'ad stoz/so/or AS-HI7ILT FORM x.rralva Applicant J� hYbv�c�u Asswot'3 Parcel# Izzz9-*)- 0oo4{ Pemft Number 8WG (rwe Installer -L:,,c C n\,-,.e re. Subdivision Sts�VEY zit___ ( beaaee�— Desigis ___ I ,_ ESIr'c?JJ7DI�) WA Yea Prior toCompletlon I. SEPTIC TANK ._ A) >5 ft From famdation?.......................................... 0 Its ❑ B) >50 itflumwear mdrmBoeaI" ............................... D a' ❑ C) Bldg rub-out tonSYolrream-ootffmel-2%t .................... 0 Il( ❑ D) Bathes mmct and cI ? ......................................... O L9" ❑ B) Dividing wall inmet?............................................. O 0>J ❑ F) Risers Iastallcd formoer? ........................................ O O ❑ G) isnkSim:. t,2 ga:Mamtomrs re,.4 F4i{ I1. D-Box A) Leveled with fate? ............................................. . . 0 ❑ B) Speedleveler used? ............................................. . O ❑ III. DRNNFIELD / A) >10 ft from foundation and>5 ft from property Imes? .................. 0 B" ❑ B) >100 B from wells end swface water? ............................... 0 d ❑ C) >lo ft from ponhle water lmeyl ................................... ❑ Il' 0 D) Lafera6 level to±Imth Ac end cape present ifW koped? .............. . ❑ ❑ B) GraveUeesvhembvsuf1l d? ... .................................. 3 0 0 - F) System dimensions the sameasshowm on thedesi®o?................... ❑ .. __. S' ❑ • 0)..Gralgelcleaq properly sized,and proper depth? ....................... ❑ Nr ❑ H) Paaeatme anomie . • 1)- and quality A39M 633? .................................... ❑ 1W ❑ 4 mre? 3) Clw eanls and obeuvation tp . nt? .. hood be... �.......... ❑ t ❑ 4) Mound: Side slope 3:1? ... ?.. .......................... ❑ 5) Owner informed electrical connections must be made by owner or licensed electrician and inspected by LAI?.............. ❑ ❑ N. PUMPIPUMP qCp A) ereeen en baslmt eeaS4sr- è' one)Stalled? .. Nrtp.l?f.'&i :.... O f9� ❑ B) Rlserinsml edforaccda7.. .. ........................ ............. ❑ ❑ C) Almm installed? .... ....... ........................ ... ....... ❑ ❑ D) Pimp make Avra.,..u.k.'c : Pmop model E) Chamber size I.'ZOO g4I; zr galfmch; Chamber Manufacame Ptok 1-{,11 F) Pump chamber draw-down inches per minute; Height of pump off bottom of pump chamber_inches O) Pump mot-Is m or) Sie M cIrcIe If Installed); If thin is used Pomp On Pump Off Printed From Mason County DMS o.d PrintedfrorptWdiPujC"QtfYYS 31.111-a .Gs :ol 90 50 00 Feb 01 05 t2:27r H-LINE 300-426-0509 p. l ( / . ' J , � k ) § } W k k \\ w ` & / 2 ( ! m ) ) q k ) �� . : p � � Z , 2\ , § o ~ I . © \ ' 3- } _ \ � © « y / / ô hi b 4J ii § X � k )\ m Ui §k U = ( \ / § ( - } 2 Printed From Mason County DMS E00 (SSES 'ON 902j 9V :TT INA 900t/9010T I A - O 2UI-1 - -. W W O 2 . W 2 O Ka 2 b ; Z 2 z W 'C F Cl W O O Z T1 N Q Q z i o z m $ W o o d _-_ _ ��♦ i COQ > O V II ¢ a r r ' ' I.>—' ' \ r r �fg C N . , X( z g i ` o F 2 ¢ o o: ga = g J w =wI Li r 3 SLL w a ,. .� Printed frorTL44 cn urithQWS gull-9 maggot 90 90 200 eoe0 ]sstc -oN nor] 9VITI IVA 900Z/9O/OT O W oriuislai &layout a 1bod and akkal N fliccs Wain lgoa �/�U..i✓ o Septidpumplanr 1�s �s:5v.a . See c� c p O Location ofbmldmgs. O Otwgka port&cam- oW lot O I.ocftcn ofwaik& ruadt• O Und!»mbedoatiw soil . . .... ._.. . bei traaehet. O North a row aroryemrscaym eeklo�o.rmiedArtraano.meat eY"No arr e�arW aeea.r� .erne Will. aalimeo�roaaerraaBgarayrba rar. .'� ae�atieaaa�rYd rpprsnat aredie<sv ;r «ra+brQeweo.++=s�m.wt�soarar.ra.rtanrma:e. va.emreo.seRwo•w+ray..rtee ktsfale --CLeck a boutfi n Row"A"and`r;sign and date thecat oetion. - ..—..-.__. _ . .__.... ._., A. I eatlfV>h6I menLLed me aysltm wuha[any U I certify Wet aR deviaflms fmm the deilgp se®ped d ftam%t d*%WM=roped"nmtov®'by "All%Qv®'by M®AS at 3hmvn above. B. certify that I contacted the designer and left the U I did not cont ct medes1ner prior to foal covet because the / system open for Inspection up to 48 bet prior to designer waived the notifeation requaameit. cover. I cinr ate cat 14 mM all mfo®atifoaninedcontained oo this in a accurate. I sand that¢ contained berth,is not Ifixtata.mere dinbjetnnae formin suspmsioa ofmyrateRa cad t /t U tgoatum t11er . Dfle The anderswood gBNoves this ivsWlaboo an behalfof Meson Comfy tot ms. /CA Printed From Mason County DMS e 'd Printedfrora pug�yute"S 3WI1-9 cos :ol so so 300 • Ilieunw 1830160 W]W N �A •iPZT XE$SUIT 'LSIt M nwn Ca, Unroll To: syaa'j Ab'I Sr NN—A f 4 4r NOTICE OF(IPERA TION µO AIAINTENANCE OF ONJTT£SE I MAGE SYS I EAI I(W) a the m ledry phrn 15ia notice oil record lint the following daubed real 1We CavYY,Sole orw"Wnglon:to we:twa...iwawta..Ya�r it 4-A OF eedJ1 fan" b 1 T>,x 411-1)-4-A ; SJP ' Zo/Z42 W hadag the T..Famd MobW of. Sec h•v2 i&c,ns O� Run5Q /2229-44-'M4/ �y 1 wank receive arses sewage nyWan IbM wu nyprovd and patdued m the carman that it araaran art-gDny olvatioe and ntaitnmea a to ueue it would cuniwe to lumen ma a provvi14c.adegttale YetteK and diapoal ofnwage. Opatm and rnaWmaae of the oo-aee sewage treanea aid diapoyl ayµan mw to done in WCWdaw¢with the Mown County Dgwtnba oil IWth Servxen Opwriuo and Manaaawec lyw raa. A wpY o(Ihe progrwn u anmWAe roan OIGce ofInviraartmW Ncebh of MaaW Cony Depwlm cnt ofHSth Service. Faibna to padapla.the o7 a*ion and maintawrs yrory.n idnnilld shone wadd be a vitWon ofJw mtlitiar U SW Whic4lW on-It.aw.o pens waiaud and could rnWt in ayra balllg dad'W aaa fauna.' Thee eow .Wi shag nr with 101ha IoW and dry be biadng to all peroa having a acgonng ally 'IM,tide W rare a lb.1 land deviled barn W any pert Iieeof,and doll uwre Io the bar i,ofaeb eww thaw(. re 9Wrw+• aim Lna NYyYt�Jtiarndbraabw.astl�oay.�1 — bat( aaLl °r .rCS.RnwIIYwPwNbbaa k!!� - fm icon yy rarbaaaraa Yw baYaibnl bnaii corn i..a ty wl Wb.wrwy iu ragawYlWr ar.a..r w wlaw�IdaaaeLw eiNlrrnnsmnl. (IITF]1 ay o„ &s aril wgW1 leant 118haY.dbaaWa (Waiagd,ra�aniv. '� E,p. r-ir.... wigO �gt� Printed County DMS - -- Printed from-Magnn Z^ n s