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Home My WebLink AboutWEL2023-00009 - WEL Application, Design, Letter - 3/10/2023 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 r BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 HARTMAN KELSEY ANNE 2111 SE WALKER PARK RD SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2023-00009 2111 SE Walker Park Rd 320215005003 The 2-party water system, Hartman Water System, 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 Sincer , David Anderson Mason County Environmental Health t err t,. `` t� Date Received .,s\, MASON COUNTY s 10. Z •11 I COMMUNITY SERVICES Amount Received: Received ey: -1- 6Z U4CG '',. rr �ti� Building,Planning Envvonmental Health,Community Health \\ / 415 N.6°'Street,(Bldg 8)—Shelton,WA 98584 W E L 'COZY ` 0000 q Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 , TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE L1- _ ' T _3*- ,(.c 7 r( MAILING ADDRESS-STREET,CITY,STATE,ZIP �1- J � _ SITE ADDRESS-STR ET,CITY,STATE,ZIP 2iiI i � ( P�.,k 0. 4H1- AA9r- PRIMARY PARCEL NUMBER(WELL SITE) .32 oz( 50 -- 03 003 6 SECONDARY PARCEL NUMBER(IF APPLICABLE) 32.n-2-( - St -- Okeb WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE 0 New 'Existing 521.Well 0 Spring /5 / ACPCS ,,`{l/ fel PROPOSED WATER SYSTEM NAME(REQUIRED) , ` PROJECT DESCRIPTION ;°t1, LAI I l Ll;(e DIRECTIONS TO SITE/CONDITIONS / / _ A� Site Plan: (may also be attached) (property boundaries.structures.well site w/100'radius,driveways.roads,septic/sewer components and lines,easements,etc...) ---\A 14 /60t1 A, . . ,„. _ Submittals Checklist: (these additional items will be required for approval) ❑ Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled) ❑ Well Log with pump test or 4-hour capacity test performed by driller(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) ❑ 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 County Web site. Revised: 10/13/2021 Page 1 of 2 Staff Use Only e Review Step 1: Well Site Inspection: tvl 161 lc c` : lx 0X(5.'7c17 e' y 11 , .I x new hcsne, d� Sty"c'/b1';id t► ,11 I rti 1.-i ► v t1 YES NO NA Set 5. lr t) al ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) 1 pkc ❑ ❑ Are there roads within the 100 foot radius of the water source? If so, is roa• ', County or State. What is distance to ROW? ,i- X ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) ig ❑ ❑ Is the well cap satisfactory? 0 , it#5 04 9 f f y/zoi ❑ Screened and vented? Z�� t PR ❑ The well casing extends above level ground/concrete slab? (circle one) BJ ❑ ❑ Is there evidence of a surface seal? ❑ ❑ Does the seal appear adequate? ❑ IX El Is a variance necessary for well site approval? Comments Did '0-1 0,65C'Vi Q Ve-f Uel -t4 ue11 c1. 0r►e o -I& f fvr WI cop ► ou y bo Its CI blot mSf'7//ed bv1 <Qf 0 f ie Cii5 17 LE .le - Pass ❑ Fail InspectorAP Date _?/2.,3/z0 Z3 Review Step 2: Two-Party Review: YES NO NA ❑ X ❑ Water Well Report with adequate pump test on file? If NO, date of Capacity Test 1//l/IC;e? Driller /1G1%,01 Lvti/Tif'l',t S' GPM 1?a, C,fP7 X ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test (//E Z C'Z.S' ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Mil ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments Approved ❑ Denied Reviewer 7S Date y / 1 i f 0 3 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'i'ells drilled after January 19', 2018 per ESSB 6091. _.,�.r - Revised: 10/13/2021 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 • Lit Teo H.4.w4 HAWKI N S WELL INSPECTIONS Water System Flow Test Flow test Date: January 12, 2023 Site Location: 2111 SE Walker Park Road, Shelton, WA 98584 Prepared By: Marshall Hawkins Hawkins well inspections was onsite at the above address to conduct a 4-hour flow test of a domestic well with drawdown. During the flow test we were able to withdraw 12- gallons per minute for the duration of 4-hour with no loss of flow or pressure @47-PSI. During the flow test approximately 2880 gallons of water were withdrawn from the well. Drawdown and recovery reading are below. Drawdown 10:00am Starting 26.5' Gallons per Recovery Water level minute time 10:01am 26.5' Below 26.5' 12-GPM 18 minutes. Well pump the top of (a�47-PSI turns on casing. 10:05am 27' 12-GPM 10:10am 27.5' 12-GPM 10:15am 28.5' 12-GPM 10:20am 28.8' 12-GPM 10:25am 29' 12-GPM 10:30am 29.2' 12-GPM 10:40am 29.5' 12-GPM 10:50am 29.8' 12-GPM 11:00am 30.0' 12-GPM 11:10am 30.4' 12-GPM 11:20am 30.9 12-GPM 1130am 31.0' 12-GPM 11:40am 31.2' 12-GPM 11:50am 31.3' 12-GPM 12:00pm 31.5' 12-GPM 12:15pm 31.7' 12-GPM 12:30pm 31.9' 12-GPM 12:45pm 32.3' 12-GPM 1:00pm 32.3' 12-GPM 1121 W Harvard Ave. Shelton. WA 98584 • (360) 401-5353 • 1:15pm 32.3' 12-GPM 1:30pm 32.3' 12-GPM 1:45pm 32.3' 12-GPM 2:00pm 32.3' 12-GPM 1121 W Harvard Ave. Shelton, WA 98584 • (360)401-5353 • Vanguard Laboratory 2635 Parkmont Lane SW ° Olympia,WA 98502 360.967.7010 VANGUARD Report of Laboratory Analysis LABORATORY Collected by: Hawkins Well Inspections Matrix Drinking Water 360-401-5353 Laboratory ID: V230112-4 Sampling Address: Date Sampled: 1/12/23 13:00 2111 SE Walker Park Rd Date Received: 1/12/23 16:25 Shelton,WA 98584 Date Reported: 1/16/2023 Sample ID: 2111 SE Walker Park Rd Analysis Result SDRL MCL Units DF Date Analyzed Total Coliform&E.coli by SM 9223B(IDEXX) Batch ID:V230112-4 Analyst:VJ Coliform,Total Negative 1 1 MPN/100 mL 1 1/12/23 17:00 E.coli Negative 1 1 MPN/100 mL 1 1/12/23 17:00 Nitrate by EPA Method 353.2 Batch ID:V230112-4 Analyst:RS Nitrate(as N) ND 0.50 10.00 mg/L 1 1/14/23 10:00 Notes: MPN:Most Probable Number ppm:parts per million nd:non-detect Reviewed by Robert Smalling,Chemist on 01/16/2023 n/a:not applicable SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 01/16/2023 DF:Dilution Factor 17s25:?A17 t r .ccicnrrra MCL:Maximum Contaminant Level !.;�! �� Page t of 1 Samples were recieved in acceptable condition.The result(s)in this report relate only to the portion of the sample(s)tested.All analyses were performed consistent with the Quality Assurance program of Vanguard Laboratory.Please contact the laboratory if you should have any questions about the results. 2635 Parkmont Ln SW,Suite A,Olympia WA 98502 I Office:360.967.7010 I testing@Jvanguardlaboratory.com www.vanguardlaboratory.com a w . __ , Z O -I u q F. ro RI I U a NJ O. i I N ; j ! ! it 1 ,... __41 m 0 1 2? 9 liPq i r x t 11 a N 411'�. �' 1 `Ss `1 .t,11, ---o I V1 1 i ItVi N............................... t:1 "4 1 • 2194753 MASON CO WA 03/10/2023 03,46 PM NOTCE Return To ROHR e184997 Rec Fee. $206.50 Pages: 3 CbrOCi f iIIIIIIIIIIIIIIIIIIII11IIIIIIIIIIII1IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII .2127LUMNar ask Q�I U- cleSTaLl ,/ D Grantors : (1) Kel 5 /4"Rrtii'iart , (2) Cf �` 40(4,-- Grantee(s): (1) PUBLIC r n e1 p Legal Description (1) y,M(I_�P AIi 1 t-3 CI O eY (Abbreviated form: i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) ) 0 1 .- 3 U - ® d 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) 3 2- 0 2 I - S e) - C) c e D 3 Tax Parcel: (Connection 2) 3 2 2 I - 6 - 0 , d The system owner is responsible for keeping this system in compliance. The name of the water system is: at±(t&Q A /A/A ter5'S °+'4 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 2 v day of janDoxi) , 20 2 3 . Signature of Grantor(s): (1) , (2) Ktinke.14-mcal Page 1 of 2 i • .., Y • 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 GIB'' day of /46VVh , 20,93 , ,,Vad I.y T Z014 r 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 seal the day and year last above written. •,Ts lv nmm rn•.. _ ,�• 1 1 CHANELL FOCHT�' (ir1(i rOC�+ 1I' •ivA •?tOT Y PUBLIC 022020183 a 's STATE OF WASHINGTON 3 Notary Public in and for the State of Washington, `s COMMISSION EXPIRES residing at Lea(A) 5- (O u v y w)c MARCH 23, 2026 j My commission expires: /f,arC1i Q 3, 20Z6 ISee Attached Acknowledgement p , 1 I . , . I \\ac.\ Page 2 of 2 • fiainillOWNONSINMEMINalabk I CALIFORNIA ACKNOWLEDGMENT CERTIFICATE A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document, to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State Of: C li.fornia County Of: Alameda Il , OnU(k 1 , 2023 before me, Rita Renee Rucker,Notary Public,personally appeared VQL Q *()vli1Q/ Aa\---VM an who proved to me on the basis of satisfactory evidence to be the persorl(41 whose Aw ees4is/are subscribed to the wit ' instrument and acknowledged to me that riat he/they executed the same ' e1 his/their authorized capacity ,i , and that by lahis/their sign a re on the instrument the person or the entity upon behalf of, ch the persor�k'' acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS m hand and official seal. RfTA RENEE Rw UCICER =z�"?^{= cra rr2413003 M; mil., +: w. - NOTARY PUBLIC •GAUFORHIA , 7", ALA.MEDA COUNTY „, Comm bon Expves AUGUST 15,2028 Sign tur . it Renee Rucker Title of Document: \\\ al C —clA X'2) r)S o ec o-F rr-N a 42d .ku60-Ta 1 u ct..VU- %s-VCxn Total Number of Pages including Attachment: -77 Notary Commission Expiration Date: Aug. 15, 2026 Notary Commission Number: 2413003