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
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
PO 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
c4rolommo
JUN 2 3 2023 I JUN Z7 2023
MASON COUNTY`''. _
COMMUNITY SERVICES By:
Received
euid Aa Plmnnq Environmental mMs Haahh.Conity Health : `-
415 N.6r'Stied,(Bldg 8)-Shclton,WA 98584 WE L D.-3- DC),0-51
Shelton: 360-427-9670 x400 Belfaic 360-275-4467 x400 Elms:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
iS T Vi Ct,1,r ' ,, s ,: su,1-rl 6 PH( )444.
IUNG ADDRESS-STREET,CRY, ATE,ZIP '7
nI 9- 4 zr, t(A i
arr aS-aT CRY,STATE, 1 ��
E, 1240)1 RE, AI 4 fi WA 4 3 2.623 -r-
2Z 1J4 NUMBERARCA- 6 7DI74 -
SECONDARY PARCEL NUMBER(IF APPLICABLE)
22114 —74 - 9oi 7/ Sy-- - _
WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SDs:
0 New Existing Well 0 Spring
PROJkOSED WATER SYSTEM)k5 VLP 2E(f gry WELL
REQUIRED)
�.�( 2"Wilt, 51,P ,J17Ar iilni'tz tl/A r1 a( 77 tie/ 77,c14
tern-
DIRE TO CONDITIONS
Rtr 14k y nee,r/ -a 1'd 'i 1. 4 iteil tivii- r k Lc AI kir
wsliJATi9,11 at ,far
Site Plan:(may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
Submittals Checklist: (these additional items will be required for approval)
(Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled)
iRr Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
[315lotice to Future Property Owners recording(record with Mason Co.Auditor,supply copy of recorded document)
0 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
---s-----Y-------- M-_--_-_.W Staff Use Only
Review Step 1: Well Site Inspection:
YES NO NA
❑ El ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainflelds,tanks, buildings; Indicate distance on plot plan)
❑ EXi ❑ 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?
Clij ❑ 0 Does the ground slope away from the water source site?(show slope on plot plan)
I] 0 0 is the well cap satisfactory?
V0 ❑ Screened and vented? % ,
0 The well casing extends Z y above level ground/concrete slab? (circle one)
❑ ❑ Is there evidence of a surface seal? `qf : 1iF,l9 7q3S
0 0 Does the seal appear adequate? too : _'2 z,5v3-33g
❑ El Is a variance necessary for well site approval? Tog ivi9 197.
Comments
Pass ❑ Fail Inspector el Date 7 /17/?° ,
Review Step 2: Two-Party Review:
E NO NA
❑ 0 Water Well Report with adequate/ /pumpttest on file? /
If NO, date of Capacity Test /l / 7/7v ZZ Driller Oav'5 Qr7 l�d.. GPM 2t�/
M 0 0 Received Satisfactory Bacteriological Analysis? Date of test (I 21" Q
❑ ❑ Received Signed, Notarized,and Recorded Notice? AFN Z.(q 1( 70-
❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments
Approved 0 Denied Reviewer Date 51! f /z -3
I
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.
Revised: 10/13/2021
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
WATER WELL REPORT Ise t'E"4;-4' ": NaiceofkdeaeNa Wet8780
ECOLOGY
TypasrT7dert: Usu.tetv�l.ntiegiie, 1lntgacEcdoiylYctllDTsYNo. 4A11?7
I Cementite Skc Well Wsme(if more than oac well):
C Deeca iuk t c-t) °signal iosutinieo N01 No WaMr Right PcrmtivCdxtl&i.,No
Tressed Um IS Dooaytc ❑IaYrsid C)Meeiapel ed•
hop ),Owner'.�ettr 10 Mime* :]Work* ❑T...t well E.)mho._
Well '�'Ooalarvgld
Well Street Addbellress Yifllf0ll WRY
IICa a TootAltruis 1 0 e hued Cable Tool City DraPeII W County MEM
J Dmeady ❑Can M Due 7 Alt. C Isset lerery MCI Pr.00l No,271147%10174
DrawNrt Liaaaerofbark3 s is.,N 140 R
Dept ofoseyismd wit 140 s. Was s mimes approved for this wad? CI Yes ff3 No
rbassrissam lbwas: Will If yes.wrest wu dos variance for?
Calif Liner Disarm. how To Tieick,w , Scot PYC Welded Deer
B I Cl 6 is e2 135 1M io, a i 0 J I U Location(gm imcnsedons on pogo 2): OS W Wy4 sr❑EWMI
0 t CI Ia. _ io• O
0 0 i C2 si-r.of the Se Y�Section 14 Tomul p 3 Z_Pi
mp 2W❑ 0 aid 6c7IJ I C
❑ l 0 is. in. ;.7 I 7 7 i 0 La kedc(Exertspie:47.12343)
hAanar w O Yes 31 No Type of ferfwenor took Longitude(Esampk-}�.i2xty
No.of se ism:kas Star ufperforeliens M.by le. Driller's Las/C.rnrraedsa or D.eoareYii.a Prouder
Parried tom R.t._L bedew round wine; Pa•IUtb4 Demote by come..eMct«,ale of oulterl sad itncttc arcs tis koil on
Scrum 11Y« pNo mute ofeset""e"tInens *m emo&wabakeiamastya,lebclmeof
Gl It-Packet t3 133 it Ina taatka Use addYi.rl dues if amcssay.
Materaelarn's Name May Medlin.Works
Magid\ia Mskrisl From To
mama 8 Me. Ska Ida 114 ie.from 1135 tit.140 R Top Son 0 �� 3
Maim k six,l„e to ram_n.se A. Hardpan 3 20
Soodlrtliw•pock 1 Yes 0 too sisa crack r.sbisl is. *own Gravel 2040
klmsrtali plaad Loto IL is L Blue Cloy Bay Gravel 40 8s
isms.Sat:•Ye l7 t o To what kW20 A.
- Orange.vim uuCaa)I 85 100
kk.etm}..d re Kr o+ala,tkr Brown Grace(&Sand 1 wails' 100 '- 140
Ors my stain costa tremble wove 0 Ya Y too
Type ofrose _ thpatufetnas",_
WWI.ftrslYis Aria.t f
reaps alawfasds Name etikMca , Type:atib
RP.j,_ Pomp beaks dtptb:_L orris ad*ow ism pro
Wa er Link:L.nd+ea4ct.ie.eiaa.be. mess so kwl I.
Stick-op armor moll carer tie above serer swam
Soak wwur kart 102 (L bolos top of welt mere Ilse
Artesia p eaty tb..overawe heir Due
Moir water le eo.s.Red by (esp.solve.dc.I �.
Mesa Tart
ohs.weft as psrbemee r No C.1 Ysg bridals'?
Yield ppe•wilt A.deawdown sM In.
Valid—pm wide`n.Mawdro aL. t.i.
Yield som old_it deeredowo after rn.
Sammy den(Was a main whey poop is tooled elf-err level neeee.rod from,.oil
Iq oo was IesM1
Tim. Weir lsa:l Tang Moat Leer Twee WaterLcvct
Dam ref psspiai tat _ �^ r
HAW ter:a p wtli3 L dnwdaenWWI la.
Air hot ipen ebb rem rot at A.fur_Irs. }-Oast 1103322
eee..ia.nee._pm J
Tropeem e s of voter ^F Wes a desen al analyst.ue.ds'1 0 Y.. •so Start Data Q9i05i22 Corspiaget
Usto 11�,A7P!?Y u
WILL CONSTRUCTION CERTIFICATION: I conckucled imdfor accept rapabohility fur coowoctlon of this will,sod iu compikace with R W ialeioiton well coratzuedoa r ardards.Mmefiais used sod the inftmossion reported above are tree to my bast losowledge sad belief.
Ia Driller❑Trainee 0 PE-PAW Natal Jade Grande Drillis&Coripeeey Davis Dienp
3i)Itudue f AAr . Address 340 NE Davis Farm Rd
License No. City,Snde,Zip 8i ilk.Wa.98528
IF TRAINEE:Sponsors LJdanse No.
Sponrdr's Siesture Resiatrstie. No.Dr1VISD11100A 0 into 1117/21
ECY050-I-20 Oleo Oi'191 Omit Hu,is*tsrtneaaN•.thiyesolarvvtelitntror.pl.ruc calf der0.ea.-b auareraProgrrwatJGIr-M7-66?2.
i Person with bcieet r kag ram raid(!7111fa•0 aekiatttva May Srn+kr. Prr.uw with a Dante taxability ey.e cull d77.RSJ-6341.
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atlap
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+Span farm
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Cillorkliat Y* yaw dm ara
UftwislaclorChlorite fbWait Twist_Rae_ Y ip+rrk lob maw
3.Or me*air Rae Somme iartepi -- - ,
Unatfactry roam°°reef dos:
D TipR.Q WP) Chb(igW.tk/M
AsOa.eQ.AI NV) Milne Rridua%Tool_Fr»
OE col 1:1 irasi
Irram*Cabal&barmen oar
usgOKY ONINIIIISWATUI=mug LAB USE ONLY
D timridiesiy Toles Caroni Neat.d
Q Ecolf part Eat,
neat.eal Omar lanes:T°m1 CoE°nm _
Foattrob °Ri rleh.r ■+d+pDOn�l Far.___. /100m1.
1 ItioM.■wR&mai Road p Mt CI too oil
Q Urfa Vans a Damegsd Caol4hierIA AMPAI
❑ _
11141.es Caw
W
oarRMo,�Ike W u.oar
Spectra Labs -Kitsap,LLC (Port Orchard)
` SPECTRA Laboratories-Kitsap 1786 SE Milo Hill Dr.
—When Qparbia Robes Port Orchard,WA 98366
Phone: (360)443-7845
JessicaD@spectra-lab.com
www.spectra-lab.com
Spectra Labs-Kitsap,LLC(Port Orchard)received samples for Davis Drilling on Thursday,November 3,
2022 at 1:12 pm.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. Desi h tion Location Sampled
135467-01 Bonnie Miller Wellhead I1/02/2022 15:00
135467-02 Wilson Way 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 relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced
except in Null,without prior express written approval by Spectra Laboratories,
11/06/2022 Page 1 of 1
r a
1MASON CO WA
Patton ro - I
' "nk t --[7t4.060. �o(knoll
Po tbAe k "
9 i. R III �'
1 MAR 13223 61
Grantor(.)(1) l n) a, r>O3 €.11 ,(2) Thefrges31416115 0199VIKAIN
Grantas(s):(1)PUBLIC
Legal Description(1) 1-bT' y A PS p D(R} i E - �7s
( bb�Ovlshd smut:La. asl ar Masi S/,�
Assessor's Tax Parcel:(1)4 a 1L !L-,z__. ..�ZL. .
NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWOPARTY WATER,SYSTEM
I(We)the undersigned grantor(s),certify that the water source located on the above-described
real estate under Leval 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 foaming
parcels situated In Mason County,State of Washington;herein described:
Tax Percy&(Connection 1) „LL .-.
Tax Parcel:(Connection 2)-t �„ _1..g...-.1„1z. 12- . 7 Lk-lift) 2' 1' Pin."
The system owner le responsible for keeping this system in compliance.
The name of the water system is: ( -rfr_QviEtD 111kl4f Way-vino aiesi WalL,,,
l7nls system is designed b provide for two service connections.Planning.and design approvals
must be obtained from the department prior to expanding beyond this number of services.
Additionally,swatter right,obtained from the Department of Ecology,le required if the water
system exceeds exemption standards.
This system(hard has not)been granted one or more waivers from spedgc provisions of the
regulation.
Dated on this t 741' day of ,20, ,.
Signature of Grantorts :
Pape 1 of 2
;Printed From Mason County CMS
Printed from Mason County DMS
• -
•
•
State of Washington
•
County of Mason
I,the undersigned.a Notary Public In and for t e above named County and Stab,do hereby
certify that on this !.3}'-day of tk..46.rl.r,
din Staa..,i'�SZ.0•44•1L► personally appeared before me,who is known to be
algner of the above Instrument,and acknowledged that he(she)(they)signed it.
GIVEN undw my hand and official seat the day and year last above written.
( ADAM J CAMILLO
sl4Mof ti�blo Notary Pubs and for the SUM otWash pta4
Commirslia Number DWI I:esklinG
MyCommission Eck* My commission expires: '3 O ZY
•
Page 2 of 2
anted From Mason County DMS
Printed from Mason County CMS
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its•5-- Q-11" SIL Tb %Lc%
.1-4-•O'22" Si L 4.R0 oT S, t-tZ. ' ® 500 Oallan Pre-Trash Tank .
i N 807.0M• 4 NuWater BNR-500 Pretreatment Tank
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. • 5 1,000Gallon Single Coaap.x .zit
.'; `+tt Pump Chamber/Clarifier Tanks
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