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HomeMy WebLinkAboutWEL95-0017 - WEL Application, Design, Letter - 2/24/1995 MASON COUNTY Llll u FFB z 4 1995 DEPARTMENT OF HEALTH SERVICES Environmental Health Water Q Personal Health APPLICATION FOR WELL SITE INSPECTION \ 5 Receipt# Date a[0_ eceived By AN Tidemark#WEL9,5_- INSTRUCTIONS 1. Provide a location sketch and a detailed plot plan. The location sketch should be detailed sufficiently so that a field inspector can easily find the site. The&-failed plot plan shall show the precise location of the well,dimensions of the pr qxrty,the location of all cdsting septic systems within 100 R of the well,and the location of any structures on the 2. Clearly stake out or flag the well site. 3. Complete this application form and submit with the$75.00 fee to the Health Department. APPLICANT/PARCEL IDENTIFICATION WATER SYSTEM NAME w 1 - LID m R V OWNER NAME I)A\/t= J D W\NA ( _TELEPHONE APPLICANT NAME T)AV 1 4, tS�R�11 r IV G TELEPHONE 340 2;! S 3 lc SITENVATER SYSTEM ADDRESS Ir L 3 2.0 P I N C o Z 1q1� MAILING ADDRESS O C ? CITY STATE ZIP ASSESSOR'S PARCEL NUMBER z2 �3 t — 7 — 3 D SUBDIVISION (IFAPPLICABLE) DIV BLK L T DIRECTIONS FOR LOCATING SITE: VICINITY SKET 3@A kle Pinz (,mf WATER SOURCE IS:_NEW OR_EXISTI NG ; _WELL OR —SPRING NUMBER OF PROPOSED CONNECTIONS H:\WDATA\AACHIVE\WELLSITE.FM3 Update: 5,1994 Well Name Applicant Name Parcel# - HEALTH DEPARTMENT FINDINGS Tidemark WEL9_ YES NO N/A ❑ ❑ There is evidence of existing sources of contamination with the 100 foot radius of the well. Indicate distances on plot plan ❑ ❑ Roads within the 100 foot radius of the well are ditched or drained so that surface run-off is conducted away from the source. ❑ ❑ The ground slopes away from the source site.slow slope on site plan ❑ ❑ ` The sanitary seal on the well cap appears satisfactory. ❑ ❑ `Z There is a substantial concrete slab poured around the well casing. ❑ ❑ ` The well casing extends above ground level/concrete slab.circle one ❑ Ex❑ Variances will be necessary for well site approval. WELL SITE PASSE WELL SITE NOT PASSED ❑ HEALTH DEPARTMENT COMMENTS fl-)CIIc 9 MI�t�62 omc�-r�s.� 1L�; 7 i�i J Futdings and determinations of dsis review reflect observed conditions as they existed on the day the evaluation was performed. No claim is made by this office, either expressed or implied, concerning future success or failure of the system and site evaluated. Well site passage does not constitute water system approval Water system approval is dependant upon a two part process 1)passage of the weft site,2)Appoval of the water system design.Once the well site is passed water system Design maybe submitted for review. REVIEWER SIGNATURE DATE a REVIEWER PRINTED NAME H:\WDATA\ARCHIVE\WEL-SrrF.FM3 Update:December 5,1994 2-PARTY�MATER SYSTEM `yr,. fiMy4 DESIGN FORM WATER SYSTEM NAMEAV/ t L L) mA\.� t!.'y CHECK LIST Vicinity Sketch {{#q� l Layout Sketch f Well Site Inspection (WEL9..,—�--6 1 Z) Source Location & Protection Sketch a� Ili P Restrictive Covenant(s) (if Necessary) Water Well Report }9� _ Pump Test ( 1 hr. Stabilization) 3 /�w✓v� 6 O r: Total Coliform Te t (Other Tests if Required) Pump gurve/Table' .' Pressure Tank Specifications L..-, WFI Form Certificate of Ins action Fee 5 w �—Reciopt # Date - D` Recewed By �� MAY 3110 �s 41 aFAL H SERVICES X •h.t :, h 5q r. a hi*}9h�1 X.�' 7 ljv�j l� ,i .' • Y'iJ .' .a J Y{Vl .. y Model 18GS GO LDS PUMPS,IN , G METERS FEET LECI 320 ! _._ _ - - RPM 3500 -- - 300 1000 RECOMMENDED RANGE F -r 60 Hz - rsep rt k 6-28GPMuImp 280 odel 900 1 zo 4- 20 260 Y r t ► GS07 240 800 GPM 0 220 700 �. — but-orr a = 200 _, a—r -- - 180 - U 600 GS10 Z - - - --160 -- 0 500 ? Y _ ut-off I a 140 - + ._ 120 400 78 S2o� - - 30 3 80 ut-off P 60 200 oG � ts z I 40 _ - 520 t }; — - 100 20 » --- ut-off N 0 0 + 1g6 m •' ,�` 35 40 0 5 10 15 t 20 25 30 S30 3 0 1 2 3 4 5 6 7 (76 CAPACITY ut-off PS Y v ,„xrYSk�EtIS10 - 350 5 � �fMode Phase to Ot aches WetOht(Ihs) ; :� W. : Motor 7 Total t-off PSI GS354ITT ARM 40 b { OGS5041 $GS5002 pum . 4 t v � y 2-PARTY WATER°SYSTEM DESIGN FORM "`star Source Site Inspection # WEL9,Z Designer's Name m ly-� Name of System IPA`/ t G 11%441,S, Applicante Name k?) SystemAddress NE '3z Q nn mO0MailingAddress 22 ld 13 LFY+I?= Ld S50 R POOL-5 O 3]l7 (Well Site) Parcel #1,22,�JL7�-,74_ Phone Number ( � ) Owner's Name UA.VFs LOY \A�[ Parcel #22-2311 - -7L -1)0 33b Phone Number ( 60 ) 2 Owner's Name r"r DISTRIBUTION SYSTEM: - Services Pipe Information Peak flow Headloss Headlo s tvDe diameter - -length gpin 100 ft in fee 2 t'thE - Ig ... .,:.'ZOO 2 o 3Z1, Jg SOURCE PUMP: Pump rate �gpm. Complete booster pump and storage mcd=1pau dwn 10 gpm Required pump head: -, .Well Lift (00 ft System Elevation Difference f .'' 0 ft. Friction Headlosses ""�"'` "` 3 ft. Iy Residual (30Psi) ` °°'��• 0 ft'. - + ^. TOTAL 07 Pt. 5'LsI n' Pump selected: Auachpumpcurva/rab/a . '. Type/Brand name SvRitt'ki .A34c / {r� L Horsepower �� !Model Numbe ��CY x y Depth of PyW egtting 9 V ry p tv 9y3 _ 'WQ 2-party design continued. . .Page 2V§4 �ry Source Site Inspection # WEL9 Q Water System Name BOOSTER PUMP: Complete this section a$tong*m oir sectioat.if the capacity of the water supply is lass than 10 gpm(MID) Suction Lift ft. System Elevation' Differe a ft. Friction Headlossee ft. Residual (30 psi) '"'" ft. TOTAL £t. BOOSTER PUMP CONTINUED.. Pump selected: Atach p a Aabfe Type/Brand name / Horsepower el Number Depth of pump ft. STORAGE RESERVOIR: Must be wmplatad if a booster pump uind -' Attach manufacmtes'specifiations-T ¢g FDA approved MID - Production X 20 Storage X 20 PRESSURE TAM SIZING: - Working storage and pump protection -- Use the formula for bladdez tanks in the Group B Public Water System Approval.Appendicies. O� w a booster pump is requuxd,size the presam tads \ "boater puma.not the V ©mP��'\ I, C �\ ,. 1 I /1 tl Selected pressure Fangs t �O Bladder Tanks ._. 3 x r��---' DESIGNER SIGNATURE: - DATE HEALTH DEPARTMENT COMMENTS: � I e-wo 44 m 'T � RA YC� '45 n 1 ' N1 Ql/ REVIEWER SIGNATURE: DATE Minimum Pressure Tank Setting System elevation difference + Friction Loss + 70' X .433 ,.g 4 n"y Lt��1c✓i � ��IZoi2t i ;nr/ �jjLc7� H I rgc)vh Tu i Z..t. W� �L ► zZo ..ww -- /Di NF i II j i L i i f 1 i 6 2) WATER AND UTILITY AGREEMENT This agreement is entered into by and between Dou las L. Davies and Leslie A. Davies, husband and wife, here nafter referred to as "Davies" and David M. Lomax and Shannon A. Lomax, husband and wife, hereinafter referred to as "Lomax s" as follows : The DAVIES are the owners in possession of Tract 33 of Survey recorded June 8, 1978 under Auditor' s File Number AFFIDAVIT 345571, being a portion of the North half in Section 11, Nc: . - • - • - Township 23 North, Range 2 West, W.M. , in Mason County, WN.REAL ESTATE Washington. EXCISE TAX Fy FRflAT The LOMAX' S are the owners in possession of Tract 34 of MAY 2 41995 Survey recorded June 8, 1978 under Auditor' s File Number 345571, being a portion of the North half in Section 11, DORENE kAf Township 23 North, Range 2 West, W.M. , in Mason County, Treas.. Mason count>Washington. 1 . There is a drilled well believed to be located on the 779 . 02 ' established common boundary line between Tracts 33 and 34 . The DAVIES and LOMAX'S participated equally in the exp nse of drilling the well . Upon completion of the water system, t will consist of the following: A: A drilled well, a pump house, pump, pressure tanks, controls and other related equipment . B: Pump house to act as a utility station for phone power and water distribution. The drilled well, pump house, pump, pressure tanks, controls, other related equipment and utility station hereinafter referred to as the "Utility Station" 2 . The DAVIES and LOMAX' S hereby agree to share equ lly in the expense of construction, maintenance and operation of the utility station. Upon completion, the utility station as the purpose of providing a domestic water supply, phone and power for one single family residence on each of the two Tracts of land. 3 . The DAVIES and LOMAX'S hereby agree that the expenses to connect to the utility station is the responsiblity of the Tract owner. The DAVIES and LOMAX'S further agree to that th y will each be responsible for their phone useage and power constuaption, but, pay an equal share for electrical service to operate the well . The DAVIES and LOMAX' S shall have an undivided one-half interest in the utility station. Page 1 4 . The DAVIES and LOMAX' S hereby grant among themse ves an easement for the utility station. Said easement shall include all necessary rights of ingress and egress for the purposes of maintaining, repairing and replacing the phone, power and water lines and for the purpose of this agreement. 5. Within a 100 foot radius of the center of the e isting well, or its successor if the well must ever be redevelo ed, no present or future owners of Tracts 33 or 34 will conduct any activity which shall endanger sanitary use of the site or violate any applicable regulations regarding operation of the comm n well system. 6 . This agreement shall be bind the DAVIES and L MAX' S, their heirs, successors and assigns . DATED this day of 1995. 1 Douglas L Davies Dav"d' M. Lomax C Leslie A. Davies Shannon A Lomax l IIu ?' J tCOUNT;' T. 915 NAY 24 AN 11: 04 REQUEST OF: Clctren�..e Lr a_x In XW 1 �)CuI5b0)W^- Page 2 STATE OF WAS INGTON) COUNTY OF /I _ ) SS . On this day personnally appeared before me Douglas L. Davies and Leslie A. Davies, to me known to be the individuals de cribed in and who ex6uted the within and for, oing instrument, and acknowledged that they signed the same as their fr e and voluntary act and deed, for the uses and purposes therin mentioned. �'-� ,Z°Cj� ' ' �`CD DZTI GI/VEN _�lt-)TW*1,iHAND AND OFFICIAL SEAL THIS �day of NOTARY s J td E.NI! fT\1hN 'yam''., pUBLIG 'z % Nota/ty Public in and for he 20.91;_,O� State of washington, residing at 444 OF n"q5 =V STATE OF WS ING N) COUNTY OF �) SS . On this day personnally appeared before me David M. Lomax and Shannon A L max, to me known to be the individuals described in and who extuted the within and fo4oing instrument-, and acknowledged that they signed the same as their free and voluntary act and deed, for the uses and purposes therin mentioned. — -�7" It GIVE11 RS'MY'.HAND AND OFFICIAL SEAL THIS aa' , ay of 4,p ,. JU U `? 9 otary ublic in and for he . C;= S a e of WaRshington, residing at Page 3 Mrst Department and Ecology oriel WATER WELL REPORT DW UECard u , w 9 ARr os Department of Ecology tlemnd Copy—overseeCOPY STATE OF WASHINGTON Third COPY—Dr111aYa CODY Water iagM Permit No. ', OWNER: Name nav'i Pq— T rxnax Addaaa —Mas Woodward Way NW Enjilsho, WA 98170 �,aas.) LOCATION OF WELL: caysy Mason ._NF�j/4_U lµ sec ewrll T. 23BN,fl�wm- (2e) STREET ADDRESS OF WELL tor ms•soirees) (3) PROPOSED USE: M Domestic Industrial ❑ Municipal ❑ (10) WELL LOG or ABANDONMENT PROCEDI.RE DESCRIPTION 0 litigation ❑ DeWater Test Wei ❑ Down ❑ rramwMn:Describe by color.Mwradey site of material and SUM re,and show adduws of aquien 4 Ownafs rwmber of weti and to Wle� of 1M malarial b each straean pens with W Mast pw entry for each ( ) TYPE OF WORK: (it more than one) Abandoned❑ New wall R Method: Dug❑ awed❑ YATER" FROM 70 Deepened ❑ cable M Ddwno Brown conglomerate 0 3 Reconditioned❑ Rotary❑ Jetted❑ (5) DIMENSIONS: Diameterotwell 6 Inches. iardPan 3 170 Doled 196 feet Depth of completed well 196 R. (6) CONSTRUCTION DETAILS: emented sand & gravel W some wated 170 1 190 Casing Installed: . 6 Diam.from,_�h.to 1 ql it 31 Wei Diem.hod 2te R and & ravel w water 190 196 Llnar installed Threaded ❑ Dlem.hod R te R Perforations: Yes❑ No FKI Type of perforator used SIZE of perforations In.by M, perforations from tL 10 IL perforations from fL to a perforations from fL to fL Screens: Yes N No ❑ Manufacturer's Name Cook Type Stai s wire nles wrap Model Pie Diam. 5" stot sw 40 from 1 q1 R w 1 q6 fL ''we.✓ Diem.—Slot size Irom ate R Gravel packed: Yes❑ No a Size of gravel Gravel placed from k.to tL Surface seal: Yea ® No❑ To what depth? 19 fl. Material used In aeai Rentonitp Did my strata contain unusable water? Yes ❑ No Type of water? Depth of strata Method of sealing strata off (7) PUMP: Manufacturers Name_ Type: SU Klo (a) WATER LEVELS: above man W Mosul - b Work atened 2 _,19. CosWetad 3 95 tg static level 160 ft below top of well Dale Amestan Pressure aw.per wluare Inch Data WELL CONSTRUCTOR CERTIFICATION: Artesian water is wnooied by I oo ISMIC1ed and/of responsibility v accept rn well con for costa coon of tuer wag, and its compliance with all WashingWn well construction stab dards.Materiels used and (S) WELL TESTS: Drawdown Is amount water level Is lowered below ttetic level the Infwmadon reported above are true to my belt knc wledge and belief. Was a pump test made?Yee❑ No® If yes,by whom? NAME DaViS Drib YIeM: gal./min.With h.- drawdown low are, l wNrl Address ReooverYdala 114no taken aszero when pump turned of)(water level measured from well (skned) enseNo. 1884 top to water Time Water Level Time Water Level Time Water Level Contragw@'e NReogle��.�ISD 1100A Date tg 'ems Date of test (USE ADDITIONAL SHEETS IF NEC tSSARY) 6aiiar test_12 galJmim vith 7 it.drawdown altar 9 hm Auteel PUndt.whh stem set at_ a ler hm Ecology is an Equal Opportunity and Affirmative Ac tion employer.For spe. 'man flow g.p•m. Date Gal accommodation needs,contact the Water Resources Program at(206) Temperature of water_Was a Gwmical analysts made? Yes❑ No® 407-6600.The TDD number Is(206)407-6006. ECY OWI-2o(M)••t '41110^ } 2 Days Dfilzng I*. NE 340nvis army. } &lf G w& mea =s,», } \ s2za9Z5 \ : / Pump Test&r:Davies-Loma W.S. T Well rwi% Pump: 1 1/2 Erg. \ Static U ae } } L= Water Level Flow GPM \ ' o er o . swm !7 a m min. 160' 5 \ a min. 17 23 } \ 2 &* 17 23 } \ ! + !4 5 > 2 hrs. !U 23 \ . / gym_% _ ` Water Level . o !7 �ƒ ! &m !+ \ / �/ � \ \ � � \ : : \ . 9 .� \ � : \ � \ r « < \ . � CE.R'PIFICATION OF INSPECTION AND IISTALTATION OF PUBLIC WATER SYSTEM PROJECTS Within sixty days following the completion of and prior to the use of any project or portions thereof, for vhich plans and specificatio have received the approval of the Mason County Health Officer, a certification shall be made to the Health Officer signed by a professional engine or the installing contractor that the project cas inspected by him or his authorized agent and that it was constructed in accordance with the plans and specifications approved by the Health Officer in accordance sith WAC 248-54-330. Instructions: 1. If a project is being completed in stage construction, attach a map description of that portion of the project being certified. 2. As future portions of staged construction projects are coinpletede each must be certified prior to its use in the system. 3. Submit in triplicate. 4. Additional certification forms are available upon request rom the Mason County Department of General Services, EYwironmen Health Division. Pq i E7�3 — 1-0 yrR, W 5 and/or Name of water System Project Name o Pt Ne- CAnP RD Address City Zip Date: Certification: This project, for which pl cer approved by Mason County Health Officer, was completed on I hereby certify that the above identified project was inspected by me or my authorized agent and that it was installed in accordance with the plans and specifications approved by the Mason County Health Officer. c i ure sneer or Installing Contractor (Vbichever is applicable) Engineer's Seal (If signed by Engineer) . MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OF ICE BOX 1666 SHEL ON, WA 98584 ( 06) 427-9670 FAX 427-7798 June 15, 1995 Dave Lomax 22285 Woodward Way NW Poulsbo, WA 98370 RE: Davies/Lomax Water System Dear Mr. Lomax The plans for the above referenced water system have been rev' ewed. Approval of the water system is granted for 2 connections . The Water Facilities Inventory for has been sent to the Depa tment of Health (DOH) . DOH will enter this water system into their computer and assign a unique number to this water system. This number and the water system name should be put or all correspondence and water samples so that identification n be simplified and proper credit can be given to the water system. This water system will be required to monitor drinking water quality by the following schedule: O a bacteriological analysis for coliform annually; NOTE: This water system is intended for domestic consumpti n not to exceed 5, 000 gpd on any given day. Irrigation of more than �4 acre of landscaping will require a water right . If you have any questions, please call me at 427-9670 from 8 00 to 9 :30 Monday through Friday. Sincere Caro Jensen Enviro ental Health Specialist Cc: Mike Davis