HomeMy WebLinkAboutWEL2023-00024 - WEL Application, Design, Letter - 5/24/2023 ' MASON COUNTY 415 N 6TH STREET, SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
4 • BELFAIR:360-275-4467,EXT 400
4 Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
Villenueve, Vince
4465 Golden West Ct
GIG HARBOR, WA 98335
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2023-00024
2610 E State Route 302
122162400040
The 2-party water system, Villeneuve Well, 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
d Date Receive :
• MASON COUNTY 5
("7 COMMUNITY SERVICES Amount Received. Recei y:
Binding.Planning,Environmental Health.Community Health sa.
4
415 N.6th Street,(Bldg 8)—Shelton,WA 98584 W E L b��3 - 0 0 62
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT PHONE
Vince Villeneuve 360.862.3055
MAILING ADDRESS—STREET,CITY,STATE,ZIP
4465 Golden West Ct Gig Harbor,WA 98335
SITE ADDRESS—STREET,CITY,STATE,ZIP
2610 East State Route#302, Belfair,WA 98528
PRIMARY PARCEL NUMBER(WELL SITE)
122162400040
SECONDARY PARCEL NUMBER(IF APPLICABLE)
iiZI6tiwootio
WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
❑ New In Fxisting ® Well ❑ Spring 0.75 Acres/32670 Sq.Ft.
PROPOSED WATER SYSTEM NAME(REQUIRED)
Villeneuve Well
PROJECT DESCRIPTION
Convert existing cabin to ADU and construction of new single family residence.
DIRECTIONS TO SITE/CONDITIONS
Travel along WA-3 N toward Allyn,continue straight onto E North Bay Rd and continue onto WA-302E until one reaches the destination on the right.
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
Attached.
1 IJr' IE U tJ r,
APR 2 4 2023 L
By
•
Submittals Checklist: (these additional items will be required for approval)
0 Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled)
l 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)
3616/
This form may be scanned and available for public view on the Mason County Web site. Revised: 1 Oi I i'?021
Page 1 of 2
------ Staff Use Only--- -----------------__ �� ___
Review Step 1: Well Site Inspection: '� �) ;vv.(
`�GSCc"is '10whth0W' -P't'fcc�lf t 'ilhihS
YES NO NA - Marm.e b ff ev - PcsilGedP�
f-fe(v Soap
❑ ❑ Evidence of existing sourcource of contaminate within 100 foot radius of water source? -,5)d,
(drainfields, tanks, buildings; indicate distance on plot plan)
X ❑ ❑ Are there roads within the 100 foot radius of the water source? If so, is road private, County or Stag
What is distance to ROW? "-f 9
V ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
$, (X ❑ Is the well cap satisfactory? La6.59 GICCCs f pl o y (bf ve)
❑ (x ❑ Screened and vented? 11
❑ The well casing extends 7 above level ground/tl oncrete slab (circle one)
p ❑ ❑ Is there evidence of a surface seal? tq t; LIP. ??7i ja
❑ aii ❑ Does the seal appear adequate? 6j y� cioi, / 1,41 1eoq' ton:- I Z Z . p 11-(66 ?,r
Q Awiior oar SPb+s.
❑ �] ❑ Is a variance necessary for well site approval? Wit, ' N
Comments /11a y C I'41S If e4 ipos'i on i, 4e it 01 5 i 0 i' tie 1 4e.lil.
A
X Pass ❑ Fail Inspector917--------
Date S!J/20 Z j
Review Step 2: Two-Party Review:
YES NO NA
❑ [ (] ❑ Water Well Report with adequate pump test on file? /�
If NO, date of Capacity Test t��l780,3 Driller Poo's Po•405 GPM IS.0
X ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test t//1 /lOZ3
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Z l f 630q
❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments ReceNed ao,f on s,'f/za lI or ( (1 stye-
weih al? 640116.0 if
Qnd 5 as fiawCreel c tm tc-a is / '4ovete
Approved ❑ Denied Reviewer1)////7--------- Date 5/0/1013
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.
Revised: 10/13/2021
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
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26276 Twelve II
Trees Ln NW II
Ste.0 SPECTRA Laboratories • Kitsap
Poulsbo,WA ...Where experience mauera
983700��, ` )779- •
COLIFORM BACTERIA ANALYSIS FORM
Z3^ +� (360)7 Date Sample Collected Time Sample County
j] 1/7 '�3 Collected
MOn `C //�' ❑6 PM
r • / � MOM Day Year � :�u[ 6-PM r r
�o4 0 Type of Water System(check only one box) •
IJL.LJ `lJ ❑Group A ❑Group O (.Cy-etherk.1
Group A and Group B Systems—Provide from Water Facil'ties Inventory(WFI):
IDq •
System Name: rj A„L 0 A 30 z
Contact Person: CC y/ek,..A L)LS
Day Phone: c,/361n,Q107 Cell Phone:
e Email: Eve.Phone:
Send results to:(Print fun name,address and Zip code or email ebov r el sop/of results)
�5 pimp a�. rAce-L ccAit\
SAMPLE INFORMATION
Sample collected by(name):
7720.1-1,36t
Specific location
where sample collected: Special instructions or comments:
•
Type of Sample(check only one box)
1.❑Routine Distribution Sample(A/P) 2.❑Repeat Sample(AIP)
Chlorinated•
Yes 0 No El (from distribution system after unsat.routine)
Unsatisfactory routine lab number.
Chlorine Residual:Total Free_
3.Ground Water Rule Source Sample ——— ——— —
l S I I I Unsatisfactory routine collect date:
Chlorinated:Yes No
❑Triggered (AIP)
Chlorine Residual:Total Free
❑Assessment(A/P)
4.Surface or GWI Raw Source Water Sample(Enumeration) I SI I I
❑ E.col/ ❑Fecal Filtered Yes No
- "1 ple Collected for Information Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Colitorm Present and tactory
❑E.coff present 0 E.coll absent !�\
IBacterial Density Results:Total Coliform mpr1100m1.E.colii mpnllDOml.
Fecal Coliform cfu/100m1. HPC cfu/1m1.
Replacement Sample Required: 0 TNTC ❑Sample too old
r �_�,____ ❑ Sample Volume ❑Damaged Container 0
t' ((D
kt[� DaW1
7imett erved: e,, Lab Reference,Number `O
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� Recept Temp C': Method�
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`!T/ !/ �' cL}Y/(� Incaraea redjerlier.wlbrced.rya nenreoo;W ai,reponh
ear,please lady as each MedileY Y 360-7794141 and
I31"— ��.- DOH Lab-Sample ri destroy dia ra1p. .
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^U Theo nab relate.*le tie Items WWI and remarg.(•)se
010. /_1 ,dredty two .Mb marl VW not be repreduo•d anal
in tA,what pea Mao dam word by Speeetebarel..
DOH Fono an31.31 p(attache 0611 7)
Spectra Labs - Kitsap, LLC (Poulsbo)
SPECTRA Laboratories -Kitsap 26276 Twelve Trees Ln NW Ste.C
...Where experience matters Poulsbo,WA 98370
Phone: (360) 779-5141
www.spectra-lab.com
Spectra Labs - Kitsap, LLC (Poulsbo) received samples for Davis Pumps on Tuesday, April 18, 2023 at
11:45 am. Unless otherwise noted, all samples were received in good condition and were tested in
accordance with the laboratory's quality control procedures. A summary of the samples received are
outlined below.
Sample No. Description Location Sampled
226037-01 2610 SRWA 302 Source 04/17/2023 12:46
This report package contains laboratory sample results and any attachments listed below. If you have any
questions please call (360)779-5141 or email us at www.spectra-lab.com.
1
This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other
than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at
360-443-7845 and destroy this report promptly.
These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced
except in full,without prior express written approval by Spectra Laboratories.
04/21/2023 Page 1 of 1
1
fade'Pumpa, Inc.
340 Alt'Davie'Farm lid
93eLfair,`Wa 98528
(360)801-6107
Project 2610 st rt 302 Belfair
Capacity Test TAG:NA
Date 4/17/2023
Pump 1/2 hp 115v
Well Depth +34 - unknown
Static Water Level 11.6
Draw Down Recovery
Time Water Level GPM Time Water Lever
0 min 11.6 0 0 32.7
5 min 31.2 15 1 min 21.9
10 min 32.7 15 2 17.8
15 min 32.7 15 3 15.5
30 min 32.7 15 4 13.8
1 hr 32.7 15 5 12.9
2 hr 32.7 15 10 11.6
3 hr 32.7 15 15
4 hr 32.7 15 20
Capacity Notes:
Well likely subject to tidal fluctuations. Depth measurement unable to be taken due to pump
obstructions. 81 gal tank on system waterlogged.
r
•
`• .
2196309 MASON CO WA
Return To 04/24/2023 02:21 P1 NOTCE
MASON COUNTY HEALTH #186213 Rec Fee: $204 50 Pages: 2
E f)DrisiA IIIIIIII!!'IIi II II'1IIIII IIIIIIII Et II
MAso� CaufTY R EA t:n4 Dot
•
Grantor(s): (1) v } v ,ENCti.VC , (2)
Grantee(s): (1) PUBLIC O F �lY
Legal Description (1) 7p L' o F Gorr- LOT
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) ! a a ► ga. coo- 0 40
Sec- (,0 1 ZZ K\
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:
( 1) l a /�- c2 4 _ o o tie s�/
Tax Parcel: Connection ---
Tax Parcel: (Connection 2) I a a / - 02'_ 0 0 0 '0 -
._ st9M E
The system owner is responsible for keeping this system in compliance.
The name of the water system is:
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 I g day of A 102 t t, , 20 Z 3.
•
Signature f Grantor(s : '
(1) A/vr-CtJ , (2) •
Page 1 of 2
•
Y,p
3
•
rb•
State of Washington )
County of Mason )
I, the undersigned, a Notary Publicnin and for the above named County and State, do hereby
certify that on this t.ZT day of RT1 , 20 z3 ,
\JT}JCeK]T vTv,� 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 'ear last above written.
Notary Public Notary Public in and for the State of Washington,
State of Washington residing at 5v9,1.' 1J C--270
ADARA BELLE PETERSEN My commission expires: S \—3()— 2025.,
LICENSE#22005087
MY COMMISSION EXPIRES
NOVEMBER 30,2025 •
Page 2 of 2