HomeMy WebLinkAboutWEL2023-00031 - WEL Application, Design, Letter - 6/27/2023 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
aik BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
COOPER DEAN G & KATHLEEN T
P 0 BOX 1066
PORT ORCHARD, WA 98366
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2023-00031
670 E Wilson Way
221147690174
The 2-party water system, Oosterveld 2-Party 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
Sincere)
David Anderson
Mason County Environmental Health
. pl [ETOWIF i. ::,Liii a....)
itm 2 7 2023
0 JUN 232023
MASON CO 1iiiiiimi
COMMUNITY SERVICES Received By. i
Building,Planning.Environmental Nrlth Community Heath - I. __
415 N.6th Street,(Bldg 8)—Shelton,WA 98584 W E L �-L-(�) 3- C)0 0 3
Shelton: 360-427-9670 x400 Belfair.360-275-4467 x400 Elma:360-482-5269 x400 \
1
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
( �� VI (L PHONE_ O
LINK ADDRESS-STREET Elf?, ATE,ZIP (,l� n.a :. f � II(Jnfl jam//! !C/✓f✓ 41-._ it:J i7 �i \,1 ;1rSIT ,•- STR ,CITY,STA
•5t) E, k iLsoili 4 fi ) WA 9 )54 Jk � a PRIMARY PARC NUMBER(WE Eire) 41 —'
22IJ4- LL 76 - 9D174. .
SECONDARY PARCEL NUMBER(IF APPLICABLE)22114 -76 - 9o/7/ By _
WATER SOURCE SOURCE TYPE PARCEL I LOT SIZE PARCEL!LOT S�
0 New XExisting Well 0 Spring
PROAOSED WATER SYSTEM NAME(REQUIRED)
�£04p 2-P4 ry WELL
PR ECT DESCRIPTION
f�{F. 2 W 5iy fn b Waite tliiU &tn a ct Ty A-k m-71 .
e
DMREC T CONDITIONS
, 9i .i iiit'R/ tyi r4eApkittaw1#'4,-itzed feher'Air L OII 1tf t4;
'Drft'Ia4ii&/ t9t1 £l‘rr
Site Plan:(may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septiclsewer components and lines,easements.etc...)
1110440/
Submittals Checklist: (these additional items will be required for approval)
'Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled)
IEr Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
125ilotice to Future Property Owners recording(record with Mason Co. Auditor,supply copy of recorded document)
L� 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 i of 2
i
-------------�*---- - --------- Staff Use Only
Review Step 1: Well Site Inspection:
YES NO NA
❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
. (drainfields,tanks, buildings; indicate distance on plot plan)
❑ tX1 0 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?
❑ 0 Does the ground slope away from the water source site? (show slope on plot plan)
I] 0 0 is the well cap satisfactory?
t ❑ ❑ Screened and vented? ,
0 The well casing extends 2 above level ground/concrete slab? (circle one)
\Zi ❑ Cl Is there evidence of a surface seal? `qd : L��, yg 7 35
❑ 0 Does the seal appear adequate? 1 g
c� : -izz-d6S33
❑ yi
❑ Is a variance necessary for well site approval?
Tcli eye frt.
Comments
if-
Pass El Fail Inspector 4 Date 7/I Y/7° -
Review Step 2: Two-Party Review:
y NO NA
0 0 Water Well Report with adequate/pump test on file? /� /
if NO, date of Capacity Test 1I! 7/Z07Z Driller Oa(rt On(�r`7 GPM 26
1§ 0 0 Received Satisfactory Bacteriological Analysis? Date of test ((f210
❑ 0 Received Signed, Notarized,and Recorded Notice? AFN 2.(Q if ?F$S
yi0 ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments
Approved ❑ Denied Reviewer Date -/17 /zz-3
t 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 19th, 2018 per ESSB 6091.
This form may be scanned and available for pubik view oil the Mason County Web site Revised: 10/13/2021
Page 2 of 2
WATER WELL REPORT e.. vLoA;-M't": Notice ann mNo.WE4711
Type rWart: ECOLOGY Unique EcologyWctlID AN Tag No.
7 Ceantiteke State tit tl Mint ion
Site Well Name if more than are wen):
t C Deoamaigbo b Orltkal hhstauaiien)110T No Water Right ficraiivCctllticrtt No.
M Wee 11 Dwt7ta CI Indwatial 0 4soietool
CI Ll►tratwiq !..1 krfat+lra ❑T..i ia'u4 U(there_ Palpen Owner Name Jan Oar odd
Custromlin MaiitediWell Sued/Wdreas W84011 Way
R T 0 Alas D Drina ^-letkd 1i Cable Tool City 0•.PevinK C
C Depdna C Oen 0 Dun Al- C mid-Meaty —
Dt.arlewi Diaoreaonetime 8 ha,in14D Tux Paecd No,?2114T8p0174
Dept antxrplassd siaR 140 t. Woe a variance approved for this welt) ❑Yes II@ No
s>•aenetetlw = verb If yes.what sat tic variance for!
Campy Thar Mame fiver To Tllceknma Stti !tit Wended bread —
XI Q E in .2 135 1M m j ; i ? I i.] ImtionWe instructions on mac 2k HIWWlidor0EW�1
0 1 O ----in. in. 0 1 3 J 1 J fi'/.tKthe Vs:Salim 14 Township 21 N Foy,: 2W
0 1 El is. — ia. :3 I -J - 1 7 Letitsdc(Example:47.12345)
Pur4+riVw O Ys 7 No Type of perforator wed Longitude(Eaelgtk-1YD.12343)
NO.ofpiwaoons_ Spas of perforators is by in. Dreler'sLR/GaaeeseketsrDaortaws O0Promkr-
htfrMed tatty Lis L beiw pound weeny Forertb,c Abater by cola.eboseiw,epee enticed and alrecnaa ar Vat l,d ad
Boseaes YAK 17 No 4 Y ha.4r. t 59 'awe s De we em area byer pcaeostod.*Shoe lag one ran,fie mte term of
aleramke tales Nave AUDY Msdtime Works
moot h1 k3onratila Use ad811aar Prone iFrmnrty.
�r limb.. From To
moats.. Urerial
okasw 8 pie SINsla 14 in.polo 1b P. a 140 L Top 8op 0 3
Moamar_.�I. Sic due In.ties�-�n is L Hardpan, 3 20
SaadlFMtw patio:1 YesU No Sibs erred;nomad la Sr
Oar/Gravel 20 40
Ikerkk plated 9wt L 1s L Btuu(lay SSW Gravel 40
els
(Army ten:r Yw 0 coo To why dyne!20 a. nape a 86 100
sartrw heel i d fdalprtlla Brown Om*8 Sand I we* 100�'— 140�
Did saw web ewaae penult(wan' El Yet 31 No
Tr*ofwow? _ Drab am.
MaElod afsealYy am off
Prep hlnirfte4nfe Wee tltundkS Tyr.:sob -
H.P.a_ polo karts depth:__L asp od Pow raw: pm ~ _
c
Walker Leak:Isa eatane eirvalion agave moss sea level I 1.---,1.---,.w�
Stick etp Om of teed caafit, L about(roan((nice
Sark Wear ktvt 102 a wow tap°f aesp aash% Dew
Arec is Fawaie lbe per.aiae,e inch Dar
Agleam waver I.aorniaibtd b7 I op.tMvc aft.) ` ,
Wi a Tows
Was apropos asp padatssd!C'No n Ye. ca by tom? `
_
L i
Yield wet wen aaakww slew _kn. .
Yield Rea vridt et el abeirea dirt lob
Yield Poi with L iawdewe earn l ,
Mowery eau rimy a cow etas pry(I tined err-wMer bird meowed Qum wNt
e9se�land
Tines Wear Level Tot Wets.I an Tate Wort Level i
Date dpaMkf rM _s
Warm 10 opeo MO& L drindwrn afar' hn.1
Air na. Wealth etaalaM 111 Air ha } Dane 11/0Eir22 .--.
menden Ilea gat
Imamate Onager_"F Was a.finn alarlyd.cowrie 7 Y. ■so Stan DMe09/Q5f 2 Corapktnd Otto 442. —.{—T—.
WELL CONSTRUCTION CERTIFICATION: 1 coassueled andror accept eespuosibikty for cemuoctioit of this milk and i s evmpiMoee with II 11 uhkelon well
construction standards.Mase+iais used and Ow let fom ation reported above are true to my ban tnowlodpe end Isrikf
lr Driller 0 Trainee O YE-Plias Nana Judi Grande Do Ring Company Davis Drilling
Signature DAh�t�1n Address 340 NE Davin Farm Rd
License L1et,
City,Stale,Zip BNfale.Wa,88528
IF TRAINEE:Sponsor's IJowese No. Contractor's
Sponsors Slimature Regiairstion No.DAMN 1100A r do 11/7/12
ECY 050-1-20(Rev am)fJ%un nevi!raw(loewalrn/14 on ulieenewJirrso,.pleas.:cult der MM.,Rrnsor.s Program W 3044474472.Pasoan trills Wank?fats roe call/7111wr ttirakisph.n Rrkr.Venire. Pera,.yr wNh r yrreck dicoM4n•cry cult t77d33-6341.
M EMq
Pod ors,wra _ 1k Sr
oow - -�PL+LT E tori Kitsap
Colocid Timm say*
Cony
a / 2. /2
440-69
Typo ofwayr8lpytr,(chock ory ono
borr)
c A ❑Group 8 OM..r G i
G A.rd Group g S s..Pro Nai
vide Pan r FadQyK Irwin '
*kw Norm
c Perm - _ • . w •
Day+ , CefPhorkr( ) i-
Shod wimp:glAkl WI wpm.maw ow bp oado
4.4:11iSctd. --r • ---t:—
am*afficiod tom*
33ft:Nc Nolifon We*serglk sitz
w211
PAN it *Wt.*w*IIPOOlwRif fams tout free III 5 MP*
crto sit Yae Posillibilootoolor dlatost min.)
%Who iEIN Toff_ amew labenbar.
3.Growl tMdar Rob Soma game •__
LE Li y rouliro mtad daM
Naomi WP, rawd:l'a No
❑Aw.aae prbrk»Nordin':NIL_fret;4.Swim or MAI lbw Sane%Wiwi tit )
E col O foal fano
siCoWarde,tr„r„yaa„r
U8�CtALY niwaLJNATet MIBILT3 Lae WE OILY
Q TablCafi..Nowt MI
CI Ecolitas td ❑Eaoh6unt `
��lAawltr;TaW
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Q 3arffo voluaa to Donegal Centime ❑..__
maw cw.
8' 38 or 31417170
0811/OWN be Loh We OW
aa+t.eawp.r •
225-
Spectra Labs -Kitsap,LLC (Port Orchard)
` SPECTRA Laboratories-Kitsap 1786 S13 Mile Hill Dr.
-.tom=whoa matte Port Orchard,WA 98366
Phone:(360)443-7845
JessicaD@spectra-lab.com
www.cpectra-lab.com
Spectra Labs-Kitsap,LW(Port Orchard)received samples for Davis Drilling on Thursday,November 3,
2022 at 1:12 pm. Unless otherwise noted,all samples were received in
accordance with the laboratory's quality control procedures.A sumni goodcondition and were tested in
outlined below. ary of the
he samples received are
Sample No. Description Location Sampled
135467-01 Bonnie Miller Wellhead
135467-02 Wilson WayI]/p1J2022 15:00
Wellhead 11/02/2022 10:00
This report package contains laboratory sample results and any attachments listed below.If you have any
questions please call(360)443-7845 or email us at JessicaD@spectra-lab.com.
•
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:elate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced
except in toll,without prior express written approval by Spectra Laboratories.
11/06/2022 Page 1 of 1
21 • . : MASON CO WA
,,. ,
Return To *UAW 2
Pa &"` 4o'S .r( NEVI
13 2023
•
Grantor(.):(1)Zit a?• C541, €.Lb .(2) t 11.lip1k, R eNtait_.b
Grantee(s):(1)PUBLIC
Legal Descdpdon(1) 1 ; y M r S p �6R� � fir ti .7a .
(Abbreviated kxm:Lib,lm. PON ar N to .s s hinge)Sit
Assessor's Tax Parcel:(1) LT-.
NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TW •PARTY WATER.5YVTEM
I(W )the undersigned(Fantails),certify that the water source iodated on are isbpveilescribed
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 ofwater to the following
parcels situated in Mason County,State of Washington:herein deserted:
Tax Parch(Connection •+ 7 /"
Tax Parcel:(Connection 2) ,_2 _,� �- �'1� Z.t .� (m e A,m,'
The system owner le responsible for keeping this system in compliance.
The name of the water system is: O 1lGkthELD Lei 6.4,/ Way Ti WE
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 srvloes.
Additionally,a water right,obtained from the Department of Ecology,le required W the water
(Western exceeds eommplion standards.
This system(ham/has not)been granted one or more waivers from specs*provisions of the
negotabons.
Dated on this 13-IL day of ,202%1
Signature of Grantor(e :
Page 1 of 2
Printed From Mason County DMS
Printed from Mason County DMS
I
y w
•
•
a ft at Waahington
County of Mason
I,the undersigned,a Notary Public in and for the above named County and State,do hereby
certify that on this 1.3+4 day of �, „� .2024.
ill` }i srec�.Cyre5,14TuAl., personalty appeared before me,who is known to be
ataer of the above instrument,and acknowledged that he(she)(they)signed it.
OtWN under my hand and official seat the day and year last above written.
l MM J CAINIM'
a dlool Pablo Homey P and far the Stalin of
Comagss# Number 04a9p residing at 4ati §►.ice 'W 3�i-
* t ea My commission'vireo: �,o 240
011/2020211
•
Page 2of2
i
} anted From Mason County DMS
Printed from Mason Co
unty OMS
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its'5:- Q-22`' Si .. Tb HZ,o. ® 50o Gallon Pre-Trash Tank
- -4-0-2.2" 51�. 4.2oo�t S, t-tz o ' .
1N '65ttOM• 4 NuWater ENR-500 Pretreatment Tank
S'w"p-li"Slt- TO t12,O -.
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>, :,/ Pump Chamber/Clarifier Tank
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PAULA JOY JOHNSON 1 .