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HomeMy WebLinkAboutWEL2026-00024 - WEL Application MASON COUNTY 415N6THELTON: ,SHELTO70,EXT 400 • BH STREE ,SHEL ON, A9 400 BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360482-5269,EXT 400 FAX:360427-7787 10/0512026 Dinkelman, Scott 717 214th Ave SE Sammamish, WA 980740 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2026-00024 3061 E Pickering Rd 220041100070 The 2-party water system, Two-Party Well (SFR+ADU): 3061 Water System (220041100070/ 220041100070), 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 da nderson@masoncountywa.gov Sincerely, David Anderson Environmental Health Specialist Mason County Environmental Health OMASON COUNTY Date EW: COMMUNITY SERVICES mw°(R cared: ,,11 NB yed„yBR,,,pgrm:,NmR4a x°amc°RNRMIwm V o I 415 N.6^Street,(Bldg 8)—Shelton,WA 98584 WEL - � y Shelton:360427-9670x400 Belfaic 360-275-4461 x400 Elmo:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION moa Scott Scott APPLICANT Dinkelman 14252330097 .0 ADDRESS. smeeEcnESTATE,m xo 717 214th Ave SE, Sammamish, WA 98074 3061RE Pickering Road, Shelton, WA 98584 PRLNARY PARCEL NUMRER(WELL SHE) 22004-11-00070 SECONDARY PARCELNVMRm(SAME AS PRIMARYIP1ACwie00Y SA ff PARCEL) WATER SOURCE eRCE TYPE PARCEL LOT S@E(welhlu (nn mlmnuinp ❑ New O Existing a Well ❑ Spring 1.5 Acres PROPOSED wATRR SYSTEM NAME(REQUIRED). 3061 Water System PROJECT DESCRnmoN( 1.debthd ADU,...w a.d.m+r rtNmv.NM°e owir+^^Q at) Detached ADU in garage loft. DIRECTIONS TO SITE I CONDITIONS/Wm CODE I KEY LOCATION I Rte. The site is located at 3061 E Pickering Road,about 2,000 feet north of Harstine Island Bridge. The gate code is 6390. Required Submitfsls/Requiremeuts Checklist: _ ❑✓ Original water well report(well log)or DoE water well report for an existing well. 0 Well tag secured to the well casing. El Capacity test showing 800 GPD with dmwdown and recovery to static level information,as described on page one of this packet. o Bacteriological test(Bac-t)results:current(within 12 months)and satisfactory. E Septic Records(additional locating requirements may apply if no septic records are on file). ❑Applicable utility easement documents. ❑Filing requirements,as described on page I of this packet'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. `"a°71.=DIM man 8/23/2026 Print:Scott Dinkelman S°°" ,�°R�mm�a. Dinkelman D+1iA'f6MdTVI Date: This form may be scanned and made available for public viewing on the Mason County website Pg 2 Last Updated:5/7/2026 Staff Use Only Review Step 1: Well Site Inspection: YES NO N/O ❑ ❑ Sources of contamination within 100 ft of the well?(septic components,chemicals,livestock,etc.) ❑ ❑ Roads located within 100 ft of the water source?Private/County/State Distance to road(s) Si ❑ ❑ Ground slopes away from the well? ❑ ❑ Well located outside of garages,barns,storage buildings,and dwellings,with at least 5 ft of separation? ❑ ❑ Satisfactory metal or plastic well cap that is mechanically secured or welded to the casing? 19 O O Access ports and openings sealed/screened to prevent contamination;pressure gauge installed for artesian wells? IX ❑ ❑ Adequate surface seal,filled to land surface level?"Leaving voids for future installation of equipment is prohibited. ❑ O The well casing extends above level ground concrete slab Lat: y?,2syf c ❑ ❑ DoE well tag allaclied to the well casing? Lon: —121.fZ Tag: 9RKIfo ❑ ❑ Variancenecessaty for well site approval? Comments: 0 Pass O Fail Inspector Date 9/2// tot6 Review Step 2: Two-Party Review: K.�i/� YES NO NA 4W*W wit moil M efffr{M7�+ 9 7l fM ❑ O rWater well report(well log):Date Completed ______________Driller L'c'/ 6kt bl'f' ❑ ❑ Satisfactory capacity test showing a minimum of 800 GPD with full recovery to static level within 24 hours? ( f P S 100 Capacity test information:Date 10/Z lit Driller/Pump Installer �' GPM Duration(minutes) Total Gal 9D Recovery Timee((miinutes)to Static ❑ ❑ ❑ Water system capable of supplying at least 30 PSI to each connection?PSI St ❑ ❑ Satisfactory bacteriological analysis? Date I I ft esting Lab ❑ ❑ Signed,notarized,and recorded notice to future property owners?AFN Z7- O VFD ❑ r Signed,notarized,and recorded water use agreement?MN 0CT O ❑qqq ❑ iol Signed,notarized,and recorded access easement(s)?AFN dt'^v 0 5�� JLI ❑ ❑ The system appears adequate to serve two co lions based on the informatio"n�•pr�'M /BONN f oz77 : a da c c Comments: Approved ❑ Denied Reviewer Date /OSZ© Findings in this review reflect observed conditions as they existed on the day of the site inspection. No claims made,express or implied ofthefuture success or failure of this system. Well site approval does not constitute water system approval Aland Mded coal ees mayto new to all are new wells drilledto water after y requirements equ r 8 per imeESSo bui609lding permit per MCC 6.68. Water usage restrictions IaPPY 1 er January This form may be scanned and made available for public viewing on the Mason County website Pg 4 Last Updated: 5/7/2026 Please include the following site features for each parcel served by the proposed two-party well: ❑� Parcel numbers(s) El Property lines/boundaries [ Applicable easements with the Auditor's File Number(AFN) p Roads and driveways ❑+ Well location with a 100 ft radius around it 9 Structures*Water wells shall not be located in garages,barns,storage buildings,or dwellings(WAC 173-160-171) El 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 0 Chemical Storage within 100 ft 0 Landfills(existing or former)within 1000 ft Site Drawing ( i weu , •,, IU , �-r I I t� is orm may be scanned and made available for public viewing on the Mason County we site Last Updated: 5/712026 Pg 3 Water Well Report For An Existing s Well Your well must be properly tagged prior to submitting this form. Asterisks (*) Indicate required fields. Mail completed original form to: DEPARTMENT OF WA State Department of Ecology, PO Box 47600, Olympia, WA 98504-7600 ECOLOGY State of Wafbin ton Use this form If an original Water Well Report was never filed or is missing from Ecology records. 'Unique Ecology Well ID Tag Number. HOC Cpp rrent Use `®omestic ❑hdustrial ❑Municipal ❑Deweter •Water Right: Dyes (If yes, attach a copy) ❑No 3 dilation OTest well ODther: .Pmpedy Owner Nam&'5tC k 11 ItZ9'1 b \ `t'U' Dia10 ' Z 1 G YI )t'S Emmemetets &rof wall In. 'Well Street Address: Deph of completedwell_it.(if known) *City: count: NN& Construction Detalk 'known •Site Well ID: RD Unerinstelled: DYes ONO . .kn \ 0"10 Type:DPVC OSteel ❑Concrete Liner Tax Parcel Number. ❑Unknown DOher.__ *Date Well Constructed: Perforations Location(Township, Range, Section) DYes ONo Unknown z Size of perforations_in.by_____in. An accurate location of your well is very Important. The Number of perforations_from_fL b_ft Section,Township, Range, and ''/e,%can be found onyour Screens ,,./' tax parcel legal description or through your county yy+DYes ONo Irnknown assessors office. Type:❑Stainless el OPVC DDher__ 54\ ZG WM orIWWM Diameter__SlotSize_from_it.to?L Township__ Range_ Section, 114-114 �—V4 Gray.UReer Pack DYes DNo nknown Comments: Materials placed from ft.to_____ft. Surface Seal DYes If known,to what depth ONO nknown Material used if known: OBentonite OCement er Resources P m — Ynes ❑No ❑Unknown Latitude/Longitude Type Horse Power_ (Decimal Degrees recorded to 5 decimal places) L Water Levels J latitude(Exa pie 7.12345) Land-surface elevation above mean sea level 5 tt. Latitude P Casing stick-up above/below land surface Static Level J2._ft below top of casing Date measured:'z& Longttude(Example 1 345) Artesian pressure lbs.per square in.Date measured:_ —r-9299 G o Well head has ca 'es ONo Shutoff valve7�yes❑No Additional Information (If available, please attach) Well Tests: ❑Location marked on topographic map 3 Drawdown is amount water level is lowered below s tic level. Location marked on air photo u Was a pump test made7'Yas attach copy)ON0� D nsultent well report o 'Yield:_�gaUmin.WI h_ft.drawdown after 1 0 •cerdflcation: The information reported above is true to the best of my knowledge and belief. $ ❑ConSD511ig Finn ❑Driller ❑Engineer ropertY Owner � Cora -j Name:S[D Address of persol�omp in�t fo "b License N 3OCo1 F 1'1 Signature ) 0) Date Signet City, State. Zip:l �L , W �,..,n,nsw,mNmfilro rcau:n ADA momnnuhdion inchdingmnlerinisin n famW fnrthe visuollyimpnirtd call EcoioEy Wnler Remumes Progam 3M11A0r- _ . .. 1„ u win,soh riknbiliry,nav cull TTY N RTr-a33-6341 OAT 022026 � � RF�EIVE'U John's Plumbing and Pumps,Inc. Invoice 63045658 'f Z 4715 Lacey Boulevard SE,Lacey,Washington Invoice Date 5/26/2026 98503 United States Completed Date 5/26/2026 (360)491-1470 Customer PO _ Payment Term Due Upon Receipt l L6 Due Date 5/26/2026 PLUMBING & PUMPS Job Address Billing Address Scott Dinkleman Dinkelman Scott 3061 East Pickering Road 3061 East Pickering Road Shelton,WA 98584 USA Shelton,WA 98584 USA Description of Work Arrived to perform one hour flow test on submersible well pump system. Flaw test was ran at 8 gpm for a total of 100 minutes providing 800 gallons of water with no signs of running dry. Static water level upon arrival was 10 feet and well depth was 50 feet indicating pump is submerged roughly 40 feet in water. During draw down static water level reached 30 feet and maintained level indicating a recovery rate equal to or greater then 8 gpm at this time.Upon completion of flow test well recovered to static level in approximately 4.5 minutes. overall well system is showing no signs of running dry in near future and is functioning as expected at this time. ® PMPQNP j tap score CLIENT INFORMATION Kitting,Logistics,and Support provided by:SimpleLab.Inc. Questions?For fastest assistance: Client:Scott Dinkelman ppo �pScore. su rt m com Requested On:Sep 13,2025 Do not contact facility technicians directly.Phone: Email:sdinkelman@gmail.com TESTING PERFORMED SAMPLE INFORMATION Testing Requested: Essential Home Water Test Collection Date:Dec 7,2025 Matrix:Drinking Water Collected By:Scott Dinkelman Testing I Report ID:PMPQNP Received Date:Dec 10,2025 Testing Facility: Infinite Chemical Analysis Labs Reported On:Dec 17,2025 Facility Location: 8312 Miramar Mall Sample Location:Kitchen Sink San Diego,California 92121 Sample Address:3061 East Pickering Road,Shelton,WA 98586,United States TESTING NOTES FROM TAP SCORE There were no problems with analytical events associated with this report unless noted.Quality control data is within laboratory defined or method specified acceptance limits except where noted.If you have any questions regarding these test results,please contact suppod©mytapscore.com SUMMARY ANALYSIS ANALYTE UNIT RESULT METHOD EVALUATION pH pH 6.82 EPA 150.1 OK Total Dissolved Solids PPM 148.9 SM 2510 B No benchmark available Turbidity NTU 1.34 SM 2130 B No benchmark available Conductivity umhoslcm 281.8 SM 2510 B No benchmark available Hardness PPM 0.72 SM 2340 B No benchmark available Expanded Hardness PPM 0.937 Calculation No benchmark available Grains per gallon Grains 0.0425 Calculation No benchmark available Alkalinity(as CaCO3) PPM 88.03 SM 2320 B No benchmark available Langeller Saturation Index -3.8 Calculation No benchmark available Sodium Adsorption Ratio 1.04 Calculation No benchmark available TEST RESULTS ANALYTE UNIT RESULT MDL RI METHOD EVAWATKIN Aluminum PPM NOT DETECTED 0.008]4 0.02922 EPA 200.7 No evelua4on possible Antimony PPM NOT DETECTED 0.00014 0.00042 EPA 2009 No evaluation possible Arseek PPM 5.OE5 0.00016 EPA 200.8 ve `Barium PPM PPM NOT DETECTED 9.0E-5 0.0002] EPA 200.7 No evaluation possible Beryllium PPM NOT DETECTED i.OE-5 5.OE5 EPA 200.8 No evaluation possible use dram iaport•anonNe•done m M1m,with no weramvnraamn,.Tap smre trexhx•The rgl,rm•nam this and by aCPXpg this report you egr••m ffikh by wsrosq PMPQNP I Page 1 of 3 Bicarbonate PPM 107 calculation No benchmark available Baron PPM NOT DETECTED 000348 0.01043 EPA 200.7 No evaluation possible Cadmium PPM 1.OE-S 0 1.0E-5 EPA 200.0 <HGL e Calcium PPM 0.11 0.00319 000856 EPA 200.7 No benchmark availablCarbonateon Carbonate PPM 0.032] Calculation No benchmark available Chloride PPM 2.33 0.00] 02 EPA 300.1 No benchmark available Chloride-toSu0ale Mass Ratio 0.407 Calculation No benchmark available Chromium(Total) PPM NOT DETECTED 0.00019 0.00056 EPA 200.8 No evaluation passible Cobalt PPM 5OE5 0 50E-5 EPA 200.8 <HGL Copper PPM 007197 0.00022 0.00005 EPA 200.8 <HGL E.mli PIA NOT DETECTED SM 92230 No evaluation possible Fluoride PPM 0.2 0.004 0.2 EPA 300.1 <HGL Iron PPM 000 0.00072 0.00215 EPA200.7 <HGL Lead PPM NOT DETECTED 2DEd Ii EPA 200.8 No evalu0tion possibl Lithium PPM NOT DETECTED 0.00017 0.0005 EPA 200.7 No evaluation possible Magnesium PPM 0.11 0.00037 0.0011 EPA 200.7 No benchmark available Manganese PPM NOT DETECTED 7.0E-5 0.00021 EPA 200.7 No evalua4on possible Mercury PPM NOT DETECTED 1.0E-5 4.0E-5 EPA 200.8 No evaluation possible Molybdenum PPM 0.00034 1OE5 5.0E5 EPA 200.8 <HGL Nickel PPM 0.00042 0.0001 0.00031 EPA 200.8 <HGL Nitrate(as N) PPM NOT DETECTED 0.006 0.2 EPA 300.1 No evaluation possible Nlbib(as N) PPM 02 0.006 0.2 EPA 300.1 <HGL Phosphorus PPM 020 0.00587 0.01762 EPA 200.7 No benchmark available Potassium PPM 6423 0.00060 0.00204 EPA 200.7 No benchmark available Selenium PPM NOT DETECTED 0.00041 0.00122 EPA 200.6 No evaluation possible Silica PPM 20.6 000618 0.01655 EPA 200.7 No benchmark available Sider PPM NOT DETECTED 1.OE5 2.0E5 EPA 200.8 No evaluation possible Sodium PPM 205 0.00017 0.0005 EPA200] Na benchmark available Strontium PPM NOT DETECTED 4.OE5 0.00011 EPA 200.7 No evaluation possible SUOate PPM 4.70 0.009 02 EPA 300.1 <HGL Thallium PPM NOT DETECTED 0 1.OE5 EPA 200.8 No evaluation possible Tin PPM NOT DETECTED 00034 0.01019 EPA 200.7 No evaluation possible Titanium PPM NOT DETECTED 0.00026 0.00084 EPA 200.7 No evaluation possible Total COIOorm p/A NOT DETECTED SM 92238 No evaluation possible Uranium PPM NOT DETECTED 3.OE5 0.0E-5 EPA 2008 No evaluation possible Vanadium PPM NOT DETECTED 0.00017 0.0005 EPA 200.8 No evaluation possible zinc PPM OAJ 0.00064 0.00132 EPA 200.] <HGL Now To Read Your Tap Spare POP Report Your results are being evaluated against Me Health Guidance Level. This is a health protective,nonemispos le drinking water benchmark.HGL is based on the most protective human health benchmark used among public health agendas for a contaminant Drinking water at or near Me HGL over the course of your lifetime is thought to be safe. MDL:The Method Detection Limit is the lowest concentration which Me analysis teem and instrumentation is configured to measure. RL:The Method Reporting Limit is the lowest level at which The laboratory can confidently and accurately quantify the concentration. Use of this mpmf pan onpbe dons h fi,,with no attemWna oradbmpns.Tap Score mainraina me rghr to enforce this said bye cMpl g his rMd you prey to abide by this policy. PMPQNP I Page 2 of 3 Tao Score ID tap score Did you know? This Tap Score report is easier to understand when viewed online. Access in-depth information about every detection, including health risks and treatment solutions. app.mytapscore.com/signin use of @e report can only be hna In MI.wIM no atle24srs oraetlRuna.Tap Sore malnfeins the ri9M1f to enforce this and by erssplln9 this rewtl you agree fa abide by this poly PMPQNPI Paga3o/3 re., fn,a 2246232 MASON CO WA gewrn Ta � G i��l��i l /Ii1�Y� 'l i`I 21�t A+ SEP 2 y ?�p6 �i..r�r.e.alSFk, 1fa�A �S1� �'fCpIVED Grantor(s):(1) Scott Dinkelman (2) Merry Dinkelman Grantee(s):(1)PUBLIC Legal Description(t)TR 7 OF E112 NN1E &TAX 1192-A S 351102 226 -`Y I-f([glbtbbot,block,plot orsection,township,range Assessor's Tas Parcel:(I! �(J(J f U sog - `s zo - R 2- 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,stare o: 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) 22004-11-00070 Tax Parcel: (Connection 2) 22004-11-00070 The system owner is responsible for keeping this system in compliance. The name of the water system is: 3061 Water System 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 lithe water system exceeds exemption standards. This system( has not) en granted one or more waivers from specific provisions of the regulations. Dated on this Z' day of cYie,. ir20 7-Co Signalute�-s-c-�\ Page 1 of 2 gate of W ashineton -_ounty of Mason I.the undcrsiuncd.a Notary Public in and for the above named County and State.do ncrcor cs-` that on this a ) _day of .,2L�(•,a. SCtIW 4- ctevYu. LM Ivnn.s personally appeared before me.who is known to be signer of the above instrtunent,and acknowledged that he(she)(they)signed it GIVEN under my hand and official seal the day and year last above written. , . 1 p mu, 11�LA4x'�t`—L %-1. W J ,u°NNE M h;cw•,- Notary Pu%lic in and for the State of Washingto . �tt,..�. e'=Or o°�' ejq`�ls°: residing at ��" @ .,,c NOTARY °x" My commission expims: bi 0 2bZ _ E 21009497 i N ; PURUO r=/ "''�9A•Q��HN�O Pave 2 0': 'q 4 if It Mi r ,k x" T; i > E. � it) WELL- iqE e L- S x z Scott and Merry Dinkelman 3061 E Pickering Road Deparenent of Eoobpr' Shelton, WA NI 26 27-6 Water Resourees Program AFTER THE FACT RECORD DRAWING, pg 1 MASON COUNTY PUBLIC HEALTH PARCEL IDENTIFICATION Owner Name Michelle Oe a.n Assessor Parcel# 2WD04- II- 0M0lD Mailing Address5ill5 cm kit S. UIWt *3D5 O/M Specialist Name City, State, Zip 4Amonds WA ASO21D Installer Name Site Address 30to I E Ptcct(nc - S IFL6Hsigner Name Please complete this checklist to the best of your knowledge. If items are unknown leave blank. INSTALLATION CHECKLIST System Type Pretreatment Type Drainfield Ln. Ft. Drainfield Sq. Ft. Drainfield depth >5 ft.from foundation? - -- ---- - -------- ----- - ------ ❑NIA W YES NO ,5oft.from wells? -_ _ __ _ _ _ __ __ ____ _ _ __ ___ _ _ _ _-- ❑ ® ❑ >50ft.from surface water? - - - - -- - - - - --- - - - - -- - - - -- ❑ ❑ Cleanout between building and tank? ---------- ----- ----- ❑ V Tank baffles present? -- - - - - - - - - - - - --- - - -- -- - - --- ❑ ® ❑ 24"access risers over each compartment?- - ---- -- - - - - - - -- ❑ ❑ a rW Effluent filter installed?- - - - - --- - - --- -- - - - -- -- - - - ❑ ❑ -- Septic tank size kobO gal Manufacturer C D-box water level and speed levelers used? --- - - - ---- - ---- ❑ NIA m YES ❑ NO J OLL ry ManifokllD-box accessible from surface?- - ---- - - - - -- - - - -- ❑ ❑ II mz Check valves installed? - - - -- - - - - --- - - - - - - - - ------ ❑ ❑ 04 Li f Transport Line Size Schedule/Class Bedrooms installed (if known) ❑2 ❑3 ❑4 ❑5 ❑6 ❑CommerciatimOther >10ft.from foundation?- ---- - --- - - - - ----- - -- - - - -- ❑ N/A w YES NO >100 ft.from wells?----------------- ------- ------ ❑ t l O W >100 ft.from surface water? - - -- - - - -- --- - - - -- -- -- --- ❑ m ❑ LL >10ft.from potable water lines?-- - - -- -- - - - - -- - -- --- -- ❑ IjI ❑ QZ >5ft. frompropertylinesandeasements?-- - - - - - --- ------ ❑ ❑ >30 ft.from downgradient curtain/foundation drains?-- - -- - - - - - Observation ports present? - - - --- - -- - - - - - ❑ ❑ ❑ Graveless chambers or 1p Clean gravel used? (check one) Proper cover installed overdrainfield?------------- ------- ❑ ❑ Pump tank setbacksconsistant with septic tank? ------ ----- - - I- NIA DYES O N Y Pump tank size gal Manufacturer Q24-access riser(s)and accessible from surface?----------- - - O ❑ ❑ dAlarm or Control Panel Installed? - - - - - - ----- - - - - - ----- ❑ ❑ ❑ 7 Control Panel equipped with Timer/ETM I Counter---- - -- - - - - ❑ ❑ ❑ a- Pump installed in ❑ Bucket or ❑ On Block or ❑ Other 0. Pump Make/Model ❑ Floats or ❑ Transducer E a Tank draw down in/min Pump capacity gpm Squirt Height ft Pump on time Pump off time Daily flow set at gpd Updn 42)29/2016 AFTER THE FACT RECORD DRAWING, pg 2 Assessor Parcel# RECORD DRAWING ❑ Drainfield&manifold orientation&layout wldimensions for relocation. ❑ Trench/bed dimensions and critical distances within layout ❑ Septidpumptank S-e-e- aC Location wldimen- slope for re-location fly WJ 1 h,�l v t ❑ Location of buildings existing/proposed ❑ Observation ports, dean-Out locafons, &manifddsld-boxes ❑ Location of wells, surface water,roads, &waterlines. ❑ Reserve area(s) ❑ North Arrow If needed drawing may be attached on a separate page No. Pages Attached CERTIFICATION OF INSTALLATION DESIGNER!APPROVED O/M SPECIALIST I certify that the information contained in this document is accurate to my knowledge. The drawing and information has bee road I common locating practices. Z Signal of Designer or pproved O/M Specialist Date MASON COUNTY PUBLIC HEALTH This is an after the fact record drawing, which may or may not include a county inspection. This information is to only document an existing OSS location and components. Signature of Environmental Health Specialist Date THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE Updaed vzsnOis _— — -- 3O 6I j i 2ZDo 1 ll 00070 SD'3' Uj Q7 60D &, I c ;e, Q Cc; Sepik I ,i4 O' � ek �aVSP_ 0- Qox - C0�� - 3Z, laeL&\S d �oto�ej51�� -l_ 2 So loo` Iso In : 0 lol' 5 I 1 / 1 I H s xg s I ' \ ' I \ I �@i I 9 / ` r I \ I I I I I I I e \ I otl m I 9 I JIg� F— \ o y I \ I / .s IIH I � y o I a p I 1 I I I j I ii/ -d I Cj 4 I J, I • � R� I 1