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Home My WebLink AboutWEL2023-00006 - WEL Application, Design, Letter - 2/28/2023 MASON COUNTY 415 N 6TH STREET, SHELTON, ,E 84 985 SHELTON:360 427-967XT 84 LFAIR:360-275-4467,EXT 400 BE ELMA:360-482-5269,EXT 400 • am, Public Health & Human Services FAX:360-427-7787 FORRESTER MESPHIN & JENNIFER PO BOX 1942 ALLYN, WA 98524 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2023-00006 30 E Benson Lake Dr 221035000032 The 2-party water system, 30 E Benson Lake 2-Party 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 Sincerely, David Anderson Mason County Environmental Health • MASON COUNTY Date Received 1(.8) a COMMUNITY SERVICES A aun e Receis.ed y ✓ / Building,Planning,Environmental Health,Community Health • ///�� 415 N.6ih Street,(Bldg 8)—Shelton,WA 98584 W E L p `��j .• o b co Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION a APPLICANT r PHO /vi,�;P14/-,J 4 -1-rol91Gpz. r Og2r -rek Sao �$� �`1 MAILING ADDRESS-STREET,CITY,STATE,ZIP 30 r -gr,J;DiJ 1_44;c f bEr 614,06.1.2.0 , vv'4 6I85 / SITE ADDRESS-STREET CITY,STATE,ZIP 30 i rt•J;diN) LAKE Rb, -b, C> APEd.�0J2 ti✓/ e5t2y PRIMARY PARCEL NUMBER)ALL SITE) .2 .3 - O -- C 0O327 SECONDARY PARCEL NUMBER(IF APPLICABLE) WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE ❑Nei\ Existing Vc Well ❑ Spring PROPOSED WATER SYSTEM NAME(REQUIRED) PROJECT DESCRIPTION -r TvJ PA-R►Y LJ ELL Fo c- 5 1"14 Gi- C'M 6A-RA 6r 00,,A1 s ,-1 o Irby DIRE TIONS TO SITE)CONDITIONS 4 ►�:r n 419y 3 Ai A-b f -rJai%) L 'r 1,-,4/E23-t D.4061 LAKE £0�4-D1 IA") i_c1T A-ri6 S I r lC 15 S-n2. } 6j1Y AA7tyt) 4 Site Plan: (may also be attached) (property boundaries.structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...) 1j) M [1 1' FEB 2 8 2023 b By Submittals�mi Checklist: (these additional items will be required for approval) L� 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) MNotice 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 Review Step 1: Well Site Inspection: ' 8# 1 Z a 1,.3 YES NO NA 20"rYUm I , ROCI& f I 1115Ve Ivel l (OMi)u't►1ol l". Ifalc GVnvrici t„i'KS r"S oe f .Sa a 1, Fr ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) ❑ ,Er ❑ Are there roads within the 100 foot radius of the water source? If so, is road private, County or State. What is distance to ROW? 6 ❑ Does the ground slope away from the water so�u/rce site? (show ope on plot plan) .V /W, OA ❑ Is the well cap satisfactory? Na 4 SC(e� - ` K��f/( C ❑ Screened and vented? Abe viva Z' y.1t'Le stifot 7e/'vi ra6� ❑ The well casing extends 7- • S above lev groun concrete slab? (circle/one) 0 al ❑ Is there evidence of a surface seal? X ❑ ❑ Does the seal appear adequate? ❑ ❑ Is a variance necessary for well site approval? Comments 0,II- 4.l4a p t$AC 311 4 2 3 L✓►�- ��s3�E �t'�i.l S�rar �/�sir Pass ❑ Fail Inspector Date J //(j7Z0 0-3 Review Step 2: Two-Party Review: ye, NO NA g1 ❑ Water Well Report with adequate pump test on file? If NO, date of Capacity Test 6si 13 t I I c1 14 Driller tV/6 t- Tome t D kA..t- GPM N 4 ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 'L( z 3 I i 0 Z 3 illy ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Z-1 l tl 7 i 7 VI❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments 6S0S C16[ -. Cr,VR - ` Li-1, 331 - iZ2 • cl 2_o ?-i-< Approved ❑ Denied Reviewer Date 5/4 /W Z3 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 'Ile Original and First Copy with \;rylic�Uun ::o. )epariment of Ecology WATER WELL REPORT - econd Copy-Owner's Copy bird Copy-Driller's Copy STATE OW WA8ffiNGTON Permit No .... . . .. (1) OWNER: Name_..J.......S..q.u.i.r.e............._...-......._._-..._..-_..__..._. AddreesS.t. Rt.._....]._...B.nx_...S.S........B.elfa.ir..__.._..___ _._ „I 2) LOCATION OF WELL: county.J1a.S.011 -_Hanso1L..L.13k8..................... /IL .S:` .t. sec_3....._ z.71..rr.. R.:31,._..w.u. L curing and distance from section or subdivision corner � 3) PROPOSED USE: Domestic !0 Industrial ❑ Municipal 0 (10) WELL LOG: Irrigation 0 Test Well 0 Other ❑ Formation:Describe by color,character size of material and stntctnre,and11 shoto thiekltass of apWfers and the kind and nature of fhe matariat ns each Si4) TYPE OF WORK: Uwner'a number of well 'r'°sn"'}afats+eted,tee{{tttht ai feast one entry Jon each change of Formation. elf more than one).... MATERIAL FROM TO -. New well t] Method: Dug 0 Ruled ❑ Cl) Deepened ❑ Cable pi} Driven 0 t Q p a[1 i -... -_.-.-_ a 3_ e.. Reconditioned 0 Rotary 0 Jetted Q r❑ngjnmtarate _ 3 40 ._ fine sand & n 1 ay 4❑ 45 _ 1) DIMENSIONS: Diameter of well ...__..9..._..._.-.. inches. O Drilled... .70.___._..._(t. Depth of completed well._.::7Q..__...._St. harms aC"C aV-21------------'--4-5-'-66 . C genes -------- 66 69__ ate.. 6) CONSTRUCTION DETAILS: grave1 &' Water.__ _ 69_ 20 __ CV E Casing installed: 6 - Dram. from J._..St.. ft.to.70 __ tt. _ --- __ _- _ ._ Threaded 0 " Diem. from .._.....__ ft.to _.�.•._. ft. • w Welded Dianna from ..:.. ... ._ tt to -.-_� !t - C - - Perforations: Yea 0 No a . d Type of perforator used.....-. ._ -- -.._'.....__.__. _.._ glat SIZE of perforations , L -..._.....-.-perforations from _...•.-.• ft. to -.-._.....».... ft. r Q ..___- perforations from _..._ _.L. tt. to __._.-_.... n. •- _.. - I perforatiots from _...» a__. tt. to .._...... ._.- !t. Sat Yes p No pl ate+ Manufacturer's Name.._....- _. .. . 0 Type_.._....._.. -_-. Model No.._...-_—_- Diem. . Slot size ....._.._:._from ..-......_.._ ft to.._..___... n. -. Dlam..._.--_-._.Spot size -.._..._.�from ._.-._--- tt.to..__---.- !t. , Gravel packed: Yes 0 No Q1 seas of gravel: __.__-. `- -_- — Gravel placed from tt.to._...._... .._-__ eV ? 1 _Surface seal: Yes f8 No❑ To what depth • _. •.... ft.• -._- ' al Material used In seal.a.8.il.t.Q.n.it.8�._............._..........._-._.._.._ Did any strata contain unusable water? Yes 0 Type of water?...-.----_-..._.__.....,_. Depth of strata-_----__:...__._..._ !-- — Method of sealing strata off .; . ' ., - ....._.....__.._.._.. .._. ..._, ------ --- 7) PUMP: -H.P -- g) WATER LEVELS. Iand•emean ea level.. ..._ • - above mean sea level:. .... tatic level ..........._.4.4 ft.below top of well Date..`-•3.�-J-4• _....... rtetlata prraaiire .....-. lb.. per square.inch' Date..r.:_:.:__.__........-. . . . . .. - . - Artesian water controlled by..........-,.-(Cap.vaP e.etc.)'._.....~• -- J- . —----C 9) WELL TESTS: owered below statict level r level is ----- Work start. e41t nn .7.7 A/ C ZZ ._..2_4_.19... _'t Completed...S.Egat.a.._d. o-7..._ 'fas a pump test made? Yes 0 Nor) It yes,by whom?.. .% DRILLER'S STATEMENT: cld: gal./min. with ft. drawdown alter . WELL This well was drilled under my jurisdiction and this report is .. - •• true to the best of my knowledgel and belief. tecovery data (time taken as zero w water when pump turned off) (water level T p.Q,..P.LJ.IRp..:.Z�..[ r.il.linq CO.. m measured from well top to ater level) NAME �(. `. Time Water Level (Person• fir . or corporation) (Type or print) Time water Level Time • Water Level Add: ...P.-..0......B.OLX-.3::... .Aliyn Date of test ..-.-...........................-.._.........»..... (Signed) (Wall Driller) deter test. .......1..4...gal./min•with-•-1-1..__ft. drawdown after_.._._l.....hrs. D n \rteLSn Sow.-- ................._......_._corn. Date ........__._..-...__.._.-... mac• , 19 Temperature of water--........wan a chemical analysis made?Yes 0 No g] License No Date IUSE ADDITIONAL SHEETS IF NECESSARY) 4335*3 s.F.No.?]SB-OS-(Rev.4-71). Return To 2194217 MASON CO WA 02/27/2023 01.36 PM NOTCE FORRESTER #184580 Rec Fee: $204 50 Pages 2 rji ESP 1? 5E-14 uE5ft72 111011111111 11111111111131111111111 30 T ' A L4 r P4t. 6 4P1�'�1,1 %,JA (i3S21/ Grantor(s): (1) , (2) -SE01-ri - f=4fa.6. Grantee(s): (1) PUBLIC Legal Description (1) 13 'S L`,J L -F 1 (Abbreviated form: i.e. lot, block, plat or section, township. range) Assessor's Tax Parcel: (1) ,2 „7 I D .7 - S 0 - 0 3 07 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) c2 i U - 5 D - 0 3 c Tax Parcel: (Connectilon 2) The system owner is responsible for keeping this system in compliance. The name of the water system is: TIZ�v A lC This system is design*d 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 day of Na- , 20 23 . Signature of Grantor(s): (1) w _ , (2) L� Page 1 of 2 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 1 day of \-- u-c1 v , 20 , N\. (L hk.:\ � �yti�, c (r'eS eCpersonallyappeared 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 a eat last above written. \ ��.0n�+1"sik N"►►ffff ublic in and for the State of Washington, '� 6 .• . Mr`• residing at ( — f '... toN Fk.., , ``;__ + %?s s My commission expires: C �-f f( Sic)-&Lf oNOTARYv... a s I 171724' _ ` \ PUBLIO •I: s'• I'.oa rt?6 a'��•�'� • Page 2 of 2 y /� BFNSO 'UNCOVER F)(ISTING 1000 [----- .7--///)-\ N�GAL 2- COMP. SEPTIC TANK k��R�VF AT TIME OF INSTALLATION AND INSTALL RISERS TO nl t SEE ALSO ATTACHED FINISHED GRADE. MAKE SURE 1 1 I I WAIVER APPLICATIC RISERS;AND LIDS ARE 1 I 1 ! WATERTIGHT ON BOTH I 1 lk SEPTIC AND PUMP TANKS. 11 I�‘ I p EXISTING t` I /0°i� I y`1 WELL \� ,/._1 _ li* \ 1125+ SQFT 5 BED r RESERVE AREA \ (20 X 57) 1 I 750+ SOFT 5 BED I 1 __---- PRIMARY AREA i II EXISTING GARAGE (20 X 38) I WI LEAN-TO I I FUTURE ADU 0-1 % SLOPE ;l • I _ I I gr. , PROPOSED TANI.5: - ��• NUWATER BNR600 �\ �1 POSSISkE SEWER 1500+ PUMP TANK 1 �/ LINE FROM FUTURE ADU c 1 ,0 j�p I ToIN�50FT TO WELL �s I a � /' EXISTING --\ p I � RUC � � ?Q?2 WELL ��O 1 ii: r� ,1,-,1,. , any couNrrc�iv,� 0, s;, I ONIiEIVTAL HEA';4�'C' �''. JB APPROX. EXISTING T/LINE 1 `` EXISTING TO BE REUSED s,o 0 ' WELL5E EXISTING SEPTIC& PUMP 1 �"Exra S ~�� TANK TO BE REUSED ��NEW PUMP &ALARM _.._ I EXISTING 3 BEDROOM HOME __ RECENTLY INSTALLED iJ 1 BENSON LAKE:11\..] - 1 APPROX. EDGE OF LAKE 1 DESIGN NOTES: INSTALLATION DESIGNER.SIGNOFF/ASBULT FEE WILL BE CHARGE TTIME OF INSTALLATION. ANY PROPOSED STRUCTURES Ali.: OTHER DEPA MENT REVIEWS,DESIGNER NOT RESPONSIVE LE FOR SETBACKS UNRE TED TO SEPTIC COMPONENTS. T CUSTOMER: JENIFFR FORRES ER. SCN.E 1:50 ' !1 SI PION DIGGING, C. PARCEL#:22103-50-00032 TEST HOLE L• TEST HOLE 2: TEST 0-18 OLD FILL 0-45 GLS 0-37 I ADDRESS: 30 E BENSON LAKE DR SEPTIC DESIGNS 18-44 GLS 45+H2O 37+I- 3083 E MASON BENSON RD. GRAPEVIEW,WA 98546 DESIGNER: ROBERT H.PAYSSE OFFICE-360-426-I803 FAX 360-427-2353 DESIGN PAGE: SITE PLAN Vanguard Laboratory 2635 Parkmont Lane SW a" 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: V230221-2 Sampling Address: Date Sampled: 2/21/23 11:40 30 F.Benson Lake Dr Date Received: 2/21/23 12:30 Grapeview,WA 98546 Date Reported: 2/23/2023 Sample ID: 30 E Benson Lake Dr Analysis Result SDRL MCL Units DF Date Analyzed Total Coliform&E.coli by SM 9223B(IDEXX) Batch ID:V23022I-2 Analyst:VJ Coliform,Total Negative I I MPN/I00 mL 1 2/21/23 16:55 E.coli Negative I 1 MPN/100 mL 1 2/21/23 16:55 Notes: MPN:Most Probable Number ppm:parts per million nd:non-detect Reviewed by Robert Smalling,Chemist on 02/23/2023 nia:not applicable SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 02/23/2023 DF:Dilution Factor f"I"- 17025s2017 MCL:Maximum Contaminant Level r► • ' REDID Page I of I : Id1444.113201f 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 testingLvanguardlaboratory.com www.vanguardlaboratory.com