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Home My WebLink AboutWEL2023-00013 - WEL Application, Design, Letter - 3/23/2023 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670, EXT 400 BELFAIR:360-275-4467,EXT 400 P Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 MIKE DAVIS 340 DAVIS FARM RD BELFAIR, WA 98528 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2023-00013 261 E JOHNSON RIDGE DR 222137700030 The 2-party water system, EB 2, 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 or email at Danderson@masoncountywa.gov Sincerely, David Anderson Mason County Environmental Health , MASON COUNTY Date Received. �3 `/` t' COMMUNITY SERVICES Amount R • Y \'!,, %• Budding Plaruung.Environmental Health CommunityHealth 'his 415 N.6th Street,(Bldg 8)-Shelton,WA 98584 W E L )v a,2) -, otb i Shelton: 360-427-9670 x400 Belfair.360-275-4467 x400 Elms:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE k-� .)c>tfi I 30 e) NI/ 0(a(0 _ MAILING ADDRESS-STREET,CITY,STATE,ZIP 341C) AJ - - A.tf,S (.M '2)L0 'NH (37s SITE ADDRESS-STREET,CITY,STATE,OP 2I % .7c' NSCV\ 2ttlkGt l)r- PRIMARY PARCEL NUMBER(WELL SITE) 7-7_2 ( -- 7-7 0o`)30 SECONDARY PARCEL NUMBER Or APPLICABLE) 222-I 3 - 7 7 - 0 "/° WATER SOURCE SOURCE TYPE PARCEL I LOT SIZE PARCEL 2 LOT SIZE lS 0 New Existing C�Well 0 Spring - 0 S IC• 0 y PROPOSED WATER SYSTtE'M)NAME(REQUIRED) IF:- \7 -2- PROJECT DESCRPTION Z - 12atl' 'Ode( I DIRECTIONS%SITE/CONS ?f ' r.'2-- S5 r Q w - wte.\\ a in 1-e_- • -- Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...) d-"&12-j\ Ste- a 0 TCEOIVI7iii MAR 2 3 2023 11 By - r 1. Submittals Checklist: (these additional items will be required for approval) Satisfactory Bacteriological sample(this may be deferred if wen is not yet drilled) Well Log with pump test or 4-hour capacity test performed by drifter(this may be deferred if well is not yet drilled) Notice to Future Property Owners recording (record with Mason Co.Auditor,supply copy of recorded document) 6,7;- •,Septic Records (additional locating requirements may apply if there is a lack of septic records on file) This form may be scanned and available for public view on the Mason Cdunty Web site. Revised: 10113/202I Page 1 of a Staff Use Only- ------ ----------- ------ Review Step 1: Well Site Inspection: YES NO NA 0 ti'_ 0 Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields,tanks, buildings; indicate distance on plot plan) ti(0 0 Are there roads within the 100 foot radius of the water source? If o, is road private, County.or State. / What is distance to ROW? -2 vi i rr x.Wt.- 7 /ot�/c ( /e/ 0 0 Does the ground slope away from the water source site?(show slope on plot plan) 0 0 Is the well cap satisfactory? /" 0 ❑ Screened and vented? 2 / 0 The well casing extends d- > above level ground/concrete slab? (circle one) ❑ V 0 Is there evidence of a surface seal? El ❑ IZI Does the seal appear adequate? ❑ jEr ❑ Is a variance necessary for well site approval? Comments J 5 0 ( 5 r� ��/ / �- L[ 7, 3 ,=z 5 i. -7<( -(0 ^ ()z 2q-257,s [)--Pass 0 Fail Inspector Date " .21 -13 Review Step 2: Two-Party Review: YES NO NA A ❑ ❑ Water Well Report with adequate pump test on file? If NO,date of Capacity Test `I (2`1 (ic U 1 Driller ��Gi t' S Or'(11l( GPM CZ l ❑ El ❑ Received Satisfactory Bacteriological Analysis? Date of test Z/I? /It.Z3 El El El Received Signed, Notarized, and Recorded Notice? AFN -Li q1 cf 3?`f El ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments Approved ❑ Denied Reviewer �--\*-- Date 5 /2, / Z(23 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. Water System approval is a two-part process. 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 19`h, 2018 per ESSB 6091. .....E: - Revised: 10/13/2021 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 r _. t 1788SEIMkIS • Ur. SPECTRA Laboratories - Kitsap rat 96368 wA_. _' ...—e —.er-- _.. tlttxs ...WAere sapedwce wetr�rs 1 BACTERIA ANALYSIS FORM Date Sample Colected Time Sample County Collected , if Typed Water System(check only d1e box) 0 Group A ❑Group B -- — Group A and Group B Systems—Provide from Water Facitrties Inventory(WA): I IDa System Name: 5 /J, Contact Person: _ Pharr Day Ph ( ) -_ I Cell Phone:( ) ___-- Email: Send resits to:(Print to!name,address and zip code.Knit) — Ok:k_AsSC/—i_t .11/1 t_tryyTilil—illITISC61/301 SAMPLE 9e,'OR AtNN Sample collected by(name): Speck location where sans*collected: penal instructions or comments: ,m.VA ays 1 Type of Semple(select only one type of sample from types 1 through 5 below) • 1.0 Routine Distribution Sample(AN) 1 2.❑Repeat Sample(AJP) f Chlorinated:Yes No (fromdistr baton system alter(reat routine) • Unsatisfactory routine lab number. Chlorine Residual:Total Free 3.Ground Water Rule Source Sample —— —— S I I I Unsatisfactory mutine collect dole: • I l . • Chbrinated:Yes No ❑Triggered(AR) Chlorine Residual:Total Free ❑Assessment(AR) l �4. Surface or OWl Raw Source Water Semple(Enumeration) I S 1 I ❑E.col! 0 Fecal Filmed v.s-_No • 5 Sslrrpk Collected b Irrerrailon Only. LAB USE ONLY DRINKING WATER RESULTS LAB �. ONLY ❑Unsatisfactory Total Cotlforrn Present and - Satisfactory 0 E.coll present 0 E.ccli absent Bacterial Density Results:Total Coliform mm/1Dlkrd. E.004 mon 1100m1. Fecal Coliform du 11oonl. IPC !1 rot Replacement Sample Required: 0 TNTC 0 Sample too old 0 Sample Volume 0 Damaged Container 0• rertnietn kt4\ b e- 0(-0c eceipt Temp C•• hYenod Code SM9223B or SM9222D Date Reported le DOH ien Use ady - ..___ — .-.__.._ j Dort taasarnpiee 225- Li 0 1 OS I ocrr rvm m1a191+01+01/17)•ryannwe Ns[Waft.n el Trrinhe%.at al itansern froo'IT'all nq. nn.daewpolradaen.eWr7rnw.dallap 047.0e. L O CL WATER WELL REPORT CURRENT • ,, ,,. Original&1'copy-Ecology,2 copy-owner,rcopy-driller Notice of Intent No. w 115681 _ p E'c'o'i'ti'c'r Unique Ecology Well ID Tag No. }}�"r j(r� i Construction/Decom(nission ('x"in circle)ID Construction Construction . • Water Right Permit No. (n 0 Decommission ORIGINAL INSTALLATION Notice Property Owner Name Brad Johnson r / - of Intent Number ({ ( y Well Street Address Johnson Ridge = PROPOSED USE: jii Domestic 0 Industrial 0 Municipal O •❑ DcWater ❑ Irrigation 0 Test Well ❑ Other City Belfair County Mason C Location ND/4-l/4SW 1/4 Sec 1 3 Twn 72R 7W ErM circle Q TYPE OF WORK: Owner's number of well(if more than one) wP M one 7..r gi New well 0 Reconditioned Method:0 Dug 0 Bored ❑ Driven❑ Deepened XI Cable 0 Rotary ❑ Jetted Lat/Long(s,t,r Lat Deg Lat Min/,t ,ec DIMENSIONS: Diameter of well 6 inches,drilled 277 It. Still REQUIRED) Long Deg Long Min/&:e 0. Depth of completed well 277 ft. C• CONSTRUCTION DETAILs Tax Parcel No. 22213-77-00030 Casing - yzl Welded 6 " Diam.from 1-1 ft.to 277 ft.01 Ins ailed: ❑ Liner installed Dram.from__ __ .ft.to ft CONSTRUCTION OR DECOMMISSION PROCEDURE 4 r • 0 Threaded " Diem.from - ft.to ft >r Perforations: 0 Yes dd No • Formation Descnbe by color,character,r,:ze of material and structure.and the kind and • nature of the material in each stratum penetrated,with at least one entry for each change of Type of perforator used information (USE ADDITIONAL SHEETS IF NECESSARY_, SIZE of perfs in by - . in and no of perfs_from ft to ft. • MATERIAL• FROM TO - RI •Screens:- }Q Yes 0 No eit K-Pac Location 270 ctI Manufacturer's Name Cr ok Top soil fa_ 7 tQ Type -St 98 Model No. CIDiam. 5 from 272 ft.to 277 Diem. Slot size from ft.to___ ft. Brown sand & (g-avel 2 8 CI Gravel/Filter packed: ❑ Yes f2r No ❑ Size of gravet/sand 4-1 Materials placed from_ ft to ft. Gray till 8 3(] • ,� Surface Sul: a Yes ❑ No To what depth? 1 8 ft. .) Material used in seal - BPt'nni tP _ C'PIPPntPd Sand & gravel 30 80 * Did any strata contain.unusable water' ❑ Yes a No 5— tQ Type of water? — Depth of strata - Brown sand R .- 160 IMethod of sealing strata off ` O • PUMP: Manufacturer's Name Gray clay - 160 260 Type: H.P. • Z WATER LEVELS: Land-surface elevation above mean sea level ft. Fine brown sand & silts 7Fifl 270 , i!) Static level . 220 ft.below top of well Date d Artesian pressure lbs.per square inch' Date O --- ----- Sand & gravel with water 270 277 Artesian water is controlled by_ - (cap,valve,etc.) . 0) WELL TESTS: Drawdown is amount water level is lowered below static level O Was a pump test made? ❑ Yes I$No If yes,by whom? -- O Yield: gal./min.with ft lowdown after tors. C-/ Yield: __jal.imin.with ft dawdown after_ • hrs. — LLI Yield: - gat.imin with ft drawdown after hrs. 4 . ...Recovery.data(time taken as.zera when pump turned oft)(water level measured from well I _ _ _ — • .+ _ _. top to water level) C Time water Level Time Water Level Time Water Level L Date of test �U}t CO �? O. Bailer test 20 gal/min.with _24__ ft.lowdown after -__1__hrs. ` Airiest __gal/min.with stem set at ft.for his. 0 ` Zt`il;iPF,t M Cattt- Artesian flow g.p.m. Date II Dcparilncxit )T tc6-r-1 y Temperature of water Was a chemical analysis made? 0 Yes 0 No i— Start Date 3/15/01 . Completed Date 4/5/01 WELL CONSTRUCTION CERTIFICATION: 1 constructed and/or accept responsibility for construction of this well,and its comp)'ance with all • Washington well construction standards. Materials used and the information reported above are true to my best knowledge and belt.:f. g Driller 0 Engineer 0 Trainee Name t) Drilling Company Davis Dri 11 i ng Dnller/EngineerTfrainee Signature • Address 340 Mavis Farm). Rd_ Driller or trainee License No. 1 884 City,State,Zip Pei fa i r, WA (18528 It-TRAINEE, . Contractor's Driller's Licensed No. .. Registration No.FDA DI i 1 00A Date_ Apri1 01 • Driller's Signature J Ecology is an Equal 0 pon mitt,Employer. ECY 050-1-20(Rev 3/05) The Department of Ecology does NOT warranty the Data and/or Information on this Well Report. MASON COUNTY DEPARTMENT OF HEALTH SERVICES - �,,,�� 11 I / Environmental Health Water Quality 'erso • Health APPLICATION FOR WELL SITE INSPECTION 10P1 121 ,, 1Receipt# �'1 Date ` Lq(4I Received By (jJ Tidemark#WEL9Ct - CCO3 INSTRUCTIONS I. 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 detailed plot plan shall show the precise location of the well,dimensions of the property,the location of all existing septic systems within 100 ft.of the well,and the location of any structures on the property. 2. Clearly stake out or flag the well site. 3. Complete this application form and submit with the$77.00 fee to the Health Department, POB 1666 Shelton,WA 98584 APPLICANT/PARCEL IDENTIFICATION WATER SYSTEM NAME E OWNER NAME Otc V c ( TELEPHONEQS3 )'5Z_- ' ci 4 APPLICANT NAME "Ak)\5 �\LL \ (� �- TELEPHONE(3b0}.27'- 4 A-7 SITE/WATER SYSTEM ADDRESS /e 17 l D MAILING ADDRESS / �7�� 1 �� AI/ �� /� N to+ 9v s ITY STATE ZIP ASSESSOR'S PARCEL NUMBER.21 j - ��-- O i SUBDIVISION (IF APPLICABLE) DIV BLK LOT DIRECTIONS FOR LOCATING SITE: VICINITY SKETCH WATER SOURCE IS: NEW OR EXISTING; WELL OR SPRING NUMBER OF PROPOSED CONNECTIONS H:\WDATAWRCHIVE\WELLSITE.FM3 Updatc:January 7. 1996 Well Name G 0 Applicant Name Parcel# Tidemark# WEL9 HEALTH DEPARTMENT FINDINGS dui 3 — 77 — t M2a YES NO N/A ❑ ty1 0 There is evidence of existing sources of contamination with the 100 foot radius of the well. Indicate distances on plot plan 0 ❑ Roads within the 100 foot radius of the well are ditched or drained so that surface run-off is conducted away from the source. 'yO 0 0 The ground slopes away from the source site. Show slope on site plan ❑ 0 y The sanitary seal on the well cap appears satisfactory. ❑ ❑ i21 There is a substancial concrete slab poured around the well casing. ❑ 0 0 The well casing extends above ground level/concrete slab. Circle one ❑ 0 to Variances will be necessary for well site approval. WELL SITE PASSED WELL SITE NOT PASSED ❑ HEA TH DEPARTMENT COMMENTS (-) /eSs ' -2 ,/th ,..e_77----,,i,,- .....e...0-_— zf' -2-7-,..‹.--4.‘ --72-6:&-, °‘-.'41/1/.4..et-- LAW A?/ Co ' .e ie - ---,- ler [Findings and determinations of this review reflect observed conditions as they existed on the day the evaluation was erformed. 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 well site, 2)Appoval of(lie water system design. Once the well site is passed water system Design may be submitted for review. �' /94' REVIEWER SIGNATU else �-t: -�-e --� DATE 3 REVIEWER PRINTED NAME /4-47,-w A ere 1? H:\WDATA\ARCHIVE\WELLSITE.FM3 Update:January 7. 1996 Davis Drilling, Inc. NE 340 Davis Farm Rd. Belfair, WA 98528 275-5367 Test Pump For: EB2 Date: 4/24/01 Well Depth: 277' Static Level:220' Pump: 2 hp. Time Water Level How GPM 0 min. 220' 0 5 min. 223' 17 10 min. 223' 17 15 min. 223' 17 30 min. 223' 17 1 hr. 223' 17 2 hr. 223' 17 Recovery; Time Water Level 0 223' 1 min. 220.5' 2 min. 220' 3 min. 275' 4 min. 271' 5 min. 270' 10 min. 267' 2194339 MASON CO WA 03/01/2023 11.29 AM DECL EMILY DAVIS t$184672 Rec Fee. $207 50 Pages. 5 III II �II��I�I��IIIIIII IIIII III SDI I�I�IMII OIII I III II�M ID III Return to: Emily Davis 297 NE Kissin Tree Lane Tahuya, WA 98588 DECLARATION OF WATER USE AGREEMENT EB 2 Water System This declaration made and entered into by property owners: GRANTOR: TRU NORTH INVESTMENTS LLC With users: GRANTEE: TRU NORTH INVESTMENTS LLC TR C-3 OF OF LLS #95-0005 AF #624966 PTN OF NE SW SURVEY 21/9, Parcel# 22213-77-00030 TR C-4 OF OF LLS #95-0005 AF #624966 PTN OF NE SW SURVEY 21/9, Parcel# 22213-77-00040 Township 22 N, Section 13, R2W,NE 'A of the SW V4 The property owners hold title to certain properties situated in Mason County, Washington described as follows: TR C-3 OF OF LLS #95-0005 AF #624966 PTN OF NE SW SURVEY 21/9, Parcel# 22213-77-00030 TR C-4 OF OF LLS #95-0005 AF #624966 PTN OF NE SW SURVEY 21/9, Parcel# 22213-77-00040 Township 22 N, Section 13, R2W,NE '/a of the SW Vs The owner desires to provide a water system to supply water for the above parcels. The owner hereby dedicates an easement for a well,pump house and facilities which are necessary to produce and distribute water to said properties described as follows: Existing well is located at coordinates 47.39509. -122.87922 on Parcel# 22213-77-00030. A 100 foot radius around the well is reserved for a utility easement. LEGAL DESCRIPTION OF WATER SYSTEM An easement for Water System, Water Line and Utility purposes situated on that portion of TR C-3 OF OF LLS #95-0005 AF #624966 PTN OF NE SW SURVEY 21/9 particularly described as follows: Existing well is located at coordinates 47.39509, -122.87922 on Parcel#22213-77-00030 in Mason County, Washington. TOGETHER WITH and Subject to an easement for ingress, egress, and utilities a 100' radius around the well head. OWNERSHIP OF THE WELL AND WATERWORKS The water system is owned by Mike Davis, hereinafter known as "Owner". COST OF WATER SYSTEM MAINTENANCE The incurred cost of maintaining the water system shall be the responsibility of the Owner. The Owner shall establish a water rate solely at the owner's discretion sufficient to cover system operating expenses, regulatory costs, maintenance costs, establish a reserve fund for equipment repairs, replacement and a return on investment. MAINTENANCE AND REPAIR OF PIPELINES All pipelines in the water system shall be maintained so that there will be no leakage of seepage, or other defects which may cause contamination of the water, or injury, or damage to persons or property. Pipe material used in repairs shall meet approval of the Health Officer. Cost of repairing or maintaining common distribution pipelines shall be born by Owner. Each party in this agreement shall be responsible for the maintenance, repair and replacement of pipe supplying water from the common water distribution piping, commencing at the individual service meter, to their own particular dwelling and property. Water pipelines shall not be installed within 10 feet of a septic tank or within 10 feet of a sewage disposal drain field lines. PROHIBITED PRACTICES The parties herein, their heirs, successors and/or assigns, will not construct , maintain or suffer to be constructed or maintained upon the said land and within 100 feet of the well herein described, so long the same is operated to furnish water for the public consumption, any of the following: septic tanks and drain fields, sewer lines, underground storage tanks, state roads, railroad tracks, vehicles, structures, barns, feeding stations, grazing animals, enclosures for maintaining fowl or animal manure, liquid of dry chemical storage, herbicides, insecticides, hazardous waste or garbage of any kind. The parties will not cross connect any portion or segment of the water system with any other water source without prior written approval of the Mason County Department of Public Health and/or other appropriate governmental agency. NOTICE TO FUTURE PROPERTY OWNERS OF PUBLIC WATER SYSTEM This water system is designed to provide for 2 services. Additional planning and design approvals must be obtained from the department prior to expanding beyond this number of services. Design flow standards account for domestic use and watering of a typical lawn and garden space only. The design assumes that all residences will be equipped with ultra low flow plumbing fixtures and that all users will keep conservation in mind whenever the system is used. Additionally, a water right, obtained from the Department of Ecology, is required if the water system exceeds exemption standards. Public water systems are subject to on-going requirements. These include periodic water quality monitoring, system maintenance and various record keeping. Prior to purchasing this property, it is recommended that you contact the Department of Mason County Health to determine whether this system is in compliance with applicable regulations. Fees may be charged by the department for providing various services. The department maintains current information on this system to expedite retrieval of information for your use or lending institutions which require information on the system as part of their loan approval process. Each time information changes, such as a change in the number of homes connected to the system; a change in owner/operator name, address or phone number; etc., the owner of this system must submit an updated Water Facilities Inventory (W.F.I/)report form to the department. A financial plan was developed at the time of water system approval. The plan includes estimated average costs to properly operate and maintain the system in compliance with state and local drinking regulations when it is fully connected. Current information on costs available from the system owner. PROVISIONS FOR CONTINUATION OF WATER SERVICE The parties agree to maintain a continuous flow of water from the well and water system, herein described in accordance with public water supply requirements of the State of Washington and Mason County. In the event that the quality or the quantity of the water from the well becomes unsatisfactory as determined by the Health Officer,the parties shall develop a new source of water, the parties shall obtain written approval from the Mason County Department of Health. All fees and necessary equipment associated with the new source shall be born by owner. RESTRICTIONS ON FURNISHING WATER TO ADDITIONAL PARTIES It is further agreed by the parties hereto that they shall not furnish water from the well and water system herein above described to nay other persons, properties or dwelling without prior written approval from the Mason County Department of Health. HEIRS, SUCCESSORS AND ASSIGNS These covenants and agreements shall run with the land and shall be binding on all parties having or acquiring any right, title, or interest in this land described herein or any part hereof, and it shall pass to and be for the benefit of each owner thereof. ENFORCEMENT OF AGREEMENT ON NON-CONFORMING PARTIES AND PROPERTIES The owner reserves the right to make reasonable regulations for the operation of the system, such as the termination of service if bills are not paid within forty-five days of the due date, additional charges for disconnection, reconnection, etc. Parties not conforming with the provisions of this agreement shall be subject to interest charges of 18%per annum together with all collection fees. (Property Owner) State of Washington, County of ThLr 4 cY I, the undersigned, a Notary Public in and for the named above County and State, do hereby certify that on this 15► day of+ 3,-c , 20 , personally appeared before me ROL-I 'cc c X' to me known to be the individual described on and who executed the within instrument, and acknowledge that he(she) (they) signed and sealed the same as free and voluntary act and deed, for the users and purposes herein mentioned. GIVEN under my hand and official seal the day and year last above written. Notary Public in and for the State of Washington, residing at T Loa My commission expires: C(— 1- 90(91-1 NOTARY PUBLIC STATE OF WASHINGTON KIM TORRES Lic. No. 187552 My Appointment Expires SEPTEMBER 29, 2024 • (SI PSO�t MIER CO,) • iliallli , ►01-----Pi Fur s -. / N44. ; at `*+�� I\1 Gin s gos CaliM li# ,• ••mow J1 L. % Ong ••I. I . ' il 5?V qi 1 4r-y: ...,... .....t.L.,,, i ,. .., 6 4 pi • pi I I\ 0 ...,.. 1 �N r. 2S r<< tr.\-:'. 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