HomeMy WebLinkAboutWEL - 11/9/2023 WA 98584
MASON COUNTY N6TH STREET,6"ELT96 .EXT400
! t• BELFAIR.360-2754467.EXT 400
Public Health & Human Services ELMA.360-482-5269.EXT400
FAX:360-427-7787
HALVERSON MICAH T
PO BOX 1519
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2023-00060
1591 E North Island Dr
221353092170
The 2-party water system, Halverson Water System(221353092170/221347590121), 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 360-427-9670 Ext.353 or email at
danderson@masoncountywa.gov
Since
David Anderson
Environmental Health Specialist
Mason County Environmental Health
net • sl MASON COUN NOV ale Received. • et
COMMUNITY S I � ✓Fn Avsit • R,MI
o,� v eudd .PH gtmxmmmulN®Ith<ommtn ryHeaM1M1 "��
415 N.6"SvutiBIdg 81 Shelton,WA 98 S84 WEL 2 >• coo Go
Shelton: 160-027-96n 8400 Berner 3 60-2 7 5 44 6 7 x400 Flint:360482-52') 54I10
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION'^
APPLIGLriT ,1 PNONE
36V - too —rJ3l-U t RA.-S T 4ls l ZIP �'1
MAKING RppRE5�5C`ECET,Cn1,SI STATE, sc ILn \NI q s3CI
SITE EAADDRESS-STREET,ORV,STAATTE,ZIP O
1ST A7 ar 1-t. I le...Z Dr.
PRIMARY NUMBER(WELL SITE)
ZZ13S - 3C -- 9Zi -10
SECONDARY PARCEL NUMBER(IF APPLICABLE)
1213'1 - 75 — SO IZ1l
WATER SOURCE SOURCE TYPE PARCEL I LOT SIZE PARCEL 2 LOT SIDE
❑ New �xisting 9[Wcll 0 Spring 1 a y 2-S
PROP SEO WATER SYSTEM NAME(REQUIRED)
lvcrse•-t 1r41-cr SvS1 -cfrn
PROJECT DESCRIPTION
(4r3JTc}- pro"( CI 2 l-e LF.CG,6,1 Weil opt Po(-c-e
DIRECTIONS TO SITE/CONDITIONS
J
C4(13W4 rS}154t Ts ZrtT1y_ }tins. /cc* (Mores ) +urn into
I S41 c\e:ocw•Sj catesS cram "kiOr .1 Re ( r..LcL !4(:cct_ C - c3e.l-e 4CC eSS
a 4o we II
Site Plan: (may also be attached)
(property boundaries.structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
SCL kkt i-r.NE.0 �LAbe. L3 -01
�Io1 S� pc5 2. 3
AFtL 2(S (cIzI
Submittals Checklist: (these additional items will be required for approval)
'-.Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled)
a Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
a Notice to Future Property Owners recording (record with MasomCo. Auditor, supply copy of recorded 91—Septic Records (additional locating requirements may apply if theree1 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:
slut( ..g a,
YES NO NA
'RI El ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
❑ IiiI ID Are there roads within the 100 foot radius of the water source? If so, is road private, County or State.
r What is distance to ROW?
iTI
�d ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
PI
❑ El Is the well cap satisfactory?
I/�I CI Screened and vented? ^t�
yyy/ccc,,,,,, ❑ The well casing extends I6 above level ground /concrete slab? (circle one)
tp El ❑ Is there evidence of a surface seal? Let y;•26 l0/6
LU^. ' 1100 60 5'
Kl El ❑ Does the seal appear adequate? Tu� A gQ�6
❑ jg ❑ Is a variance necessary for well site approval?
Comments old rfr(C (o et Scree et( Gnu( (lief!
4�I Pass ❑ Fail Inspector �//�1� Date I l 7$ / ZO
23
/Review Step 2: Two-Party Review: V 2 S Y�O ? t �n�
YES NO NA
X ❑ ❑ Water Well Report with adequate pump test on file?
)
If NO, date of Capacity Test �( I ZI(797 Driller f trees 'I PI, GPM 25
X- ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of tot 1115/)Z62I
all ❑ El Received Signed, Notarized, and Recorded Notice? AFN ZZOjr) 9
y ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments 7 7
/ Approved ❑ Denied Reviewer Date /V/ COO 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 welts drilled after January 191h, 2018 per ESSB 6091.
Revised: 1 011 3/2 02 1
This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2
Ire Me. >01�1
DDp CMOSYawd cl with WATER WELL REPORT UNIQUE WELIA.. A a Q 826
escos Ling—owefs area STATE OF WASHINOTON
TMN ccey—omen Capi Wan aawi PFwl Nc
(i) OWNER: Arne ( ,r V Lc dew
(2) LOCATION OFWELL: cane rnaSnn • 1N IMBs `-3 o1. N.a T
ran STREET ADDRESS CCWELLIanwaeavin�, _C N IS- }n rtr7e , qa Hnn 1o. . aSA
(3) PROPOSED USE: o r ar w M�
m O Municipal ❑ (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION
❑ Dowser Tan WO 0 Dew ❑ Pwndm:Cnab by onoay.and main r rran.re en..d..r..bass
r to w an eras at in mania in eat rrn pwena0 wet a r m wry for rm
Dv sna.ra.aa mwgnw bbn mbn.
(4) TYPE OF WORK: Ilww mm iimaa
10I6111Al FAOII A
Abandoned Nan wall A4 Mabee Dug Bowl
Newt O GMT om.nO aLeay nRai (... SOFT 3
namnllonedD AOWY0 MISS V J +rpA.M1 CoeS. i4 Rau.H / 7
(3) DIIENSIoNS: owns0.M Meet T.A`/�a /3RN A-te a-/ 3 R
Drawl GY a n,tr.d M own itT,.J4Gi4.)ci YeCa.w LoCCG cc
Weo Saa.J46.o..dei iat .. tiogv ‘0Cram(0) CONSTRUCTION DETAI ,) , e/ b-v� Nag,Nag, ye.l G...... �J 3
Cam Installed: Cr' O .tom rt lo Lit
Woaderiaa Own.lam kb ft.
TMsadsd O gan.Aan ..b ..
PWlgtlbn.: Yee ElNC IR 1
SIZEofp""'" in.by SIZE a. Wb'� `'1—Oilt(
n parlance*
pamawwsbom _ rt b M1 pMwatlws Mom M1 to ft.
SIL �1L) .0 \A •A invin 14.
padannvAan '" it to ft. ��� 444
EaMNb Ma.IY. No 0
MwMaear%Nam /VA 6 6 Xis
SS MSS No.r..- 7 VC-- 4
o.,s_iaw. /L . aam GS nib Cnt" t �_._ - '2)
171
Gan, Sol sin Ian IL to M1 RFCEIX
Oasts pealed: Yes❑ NO.Rr Sr at Qanl I1�aC��J '/���rLP�l�i\.I NTH
x •r'
E W E mat= tJ
•
Gravel Maud Man M1b It 'D" --
9unSs..w: Yang No Torldfpl.9 a rt 'O •T
Mann used a sal /3...:ro...l re 1 Ll P� Nl, ���ayAry..::YI G.
ob a.'We cowaumeeaa t Ya❑ Nag' JUN 02 1 "'-" "'z" l
Trw Swan Cast of @m
Mate@ Cl pang Ww oft
m PUMP: Mrrbn «.Nrn -IEALTH sCfVICES
T H.P.
(8) WATER LEVELS: .,isiV- a seismWaaenad PS may' It c .save Q-t' vY�r�v .ngn
arc its -.3 man lin "Saw
-o Mull Data.//S 41
17 WELL COIWLRUCTOR CERTwICA110N:
Moan panne bL Iw sum till Ow
A*ar tow w anrr W • I conaltuctled under ac<P lspnilllllY air a naa.mlm al Its S. and al
(Cap min am) mngYabP am al Wa1WgM Well mrtllcim landab.MOSS used and
(0) WELL TESTS: OraadaanY.waawerSi Ybwrad Cab.versel Si'inbred j marld tan re tin b my set .m w.
Ws apawrnWaitN No El iWa.bJMncan at NAME C_� ).
11a1d: ells. NM M1l. Miami
In.
I,pae.Na /3335..
bRaccivey y Me One Won vCMwpw9nnadoflhaalM coma iomsal ( � —
il
nw Wan Level Tao Wain Ural Tma War Ian Cal..ewora
Krrain /ogni7 oar S L3-47 IS
(USE ADORIONAL SHEETS IF NECESSARY)
Dear
Bs r..SIwimi.ay�.a.m / 2 a Raaswn era n"' �'E OY is an EQW Opponuiry and ARFinatln Anon employer.For 6PF
PrI _ I ! I bal.osDiald.Nn midi mnla nCI.Wa R Action a Pplpam al(ZOE)
OPl^. Ve 4074800.The TDD number M(200)/07.E000.
Ta Minis dwyFirl„d Wistonsi.d eakap D'N1•90 No❑
Vanguard Laboratory
2635 Iarkmont Lane SW, Suite A E !A a\
Olympia WA 98502 ,` , t
yq.006np 360-967-7010 A ;,1,AAh'1 A r es
COLIFORM BACTERIA ANALYSIS FORM
I Date Sample Collected T Tme Sample Carry
Cowed
pnu
I You
,m,m11 sej_Th .. h� o ,
Type of Tracer System(died(only one box 1^ ,. 1- c
❑Goup A ❑Group9 03-0lneri-', b '_�Y
Group A ard Group D Systems-Provide from Water Fac'Mee Inventory(W Fll
ton
tern Name
Contad Person. r c_ ,I 'IL`V l S`--,
Day Phone (,s(1)9(-L0 1 .• (^r' I Cell Phone ( )
�Emall I Eve.Phone.( )
SerbPs s ro Iwo lot name address,sod c octe nr e del
ric.s c_.NLo s1L L. � ),„ ` M'C t O._IC cr +1
SAMPLE INFORMATION
Sample collected by(name)
,Lr CC1- .-y[).Vc. �( i
Specific toason where sample Collected I
Speeds instructions or commerts
IJG1 }en 1l{__r,4O` i
;r r l ma LJ/L c'S fags( 1
—
Type of Sample(select only one type of sample from types 1 through 5 below)
1 itggoutlne Distribution Sample(NP) �l2 ❑ Repeat Sample(ATP)
Chlorinate] Yes—_ No -A. -so;em yftm snso r..re.
Mesatielaelorp roubne lab nyrrerr
Ch done Residuai Total __Free—.
3 Ground Water Rule Source Sample xsalisfactay muane celled date
S I 1
Nonrated Yes_ No --
❑Trggeled(API Chicane Residual.Total Fre _
❑Assessment i.%I
4 Surface or GWl Raw Source Water Sample)Er..,berate/tit IS 1
II-❑E ecal
5 &Lards e AIode)fr information Only ♦ clM<L
.AB US ONLY DRINKING WATER RESULTS LAB USE ONLY , . .(
O Unsatisfactory Totat dforn Present and I ffi Satisfactory
0 Ecolf present ❑E toli absent od_
Bacterial Density Results.total Cdifomi __.. Ipoml. E cal__. . i100mi
Fecal Colibrm - -- I10oml NRC 11 ml
Replacement Sample Required: ❑TNTC ❑Sample too old
❑ Sample'Jovme ❑Damaged Container ❑
�.— 11/3/2311i05 { __—
La = ,tan;C Mc' - SM9223B
I Ds :naxrea m CC H n/a
+-ah Sanea
285—
MASON COUNTY
t SEVERAL SERVICES DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
303 NORTH 4t8
SIBET •SNHELTON,WA BOW
PHONE E
RECORD OF FINAL INSPECTION OF YOUR SEWAGE DISPOSAL SYSTEM
OWNER toll
\1 l &&,vES A DRESS l^i�2 '�g -Roy 7 • �
1_—,.,r-'/-•
THIS RECORD IS NOT A GUARANTEE OF PERFORMANCE. LEG
ESARIPTION {�{L
rLG� y j�%'?��"' �r _
A SEPTIC SYSTEM IS NOT A MUNICIPAL SEWER. HOWEVER d •�Ir;ad ^ n S r Z 7 )
WITH PROPER MAINTENANCE AND CAREFUL USE OF w triad
mo G
WATER IT CAN GIVE MANY YEARS OF TROUBLE FREE SER-
VICE. MANY PROBLEMS WITH SEPTIC TANKS ARE CAUSED ONTMENTS I SOILaria.
BY FLUSHING EXCESSIVE AMOUNTS OF PAPER, CLOTH SIZE eyD X �3
AND PLASTIC MATERIALS DOWN THE DRAIN, OR BY SITE
FIELD LARGE AMOUNTS OF WATER FROM LEAKY FAUCETS OR O�EPTH TO �_ ONT�yETHR a1
FAULTY FIXTURES. WATER TABLE
THE SEPTIC TANK ITSELF SHOULD BE CLEANED EVERY INSTALItR.-+ ` �C..IMS
TWO OR THREE YEARS DEPENDING ON THE HABITS OF THE g
FAMILY, THE NUMBER OF FIXTURES IN THE HOUSE, AND •
THE AMOUNT THAT A GARBAGE DISPOSAL IS USED.CLEAN- SIZESEPTIC TANK (S) 1 ZOO 0 I CC/ 'e
ING AT THE RIGHT TIME WILL AVOID THE RISK OF INJUR- DRAINFIELD D 7 FEET
LNG OR DESTROYING THE DRAINFIELD DUE TO SOLIDS LENGTH a6/ SQ. FT
CARRYING OVER INTO THE DRAINFIELD. CALL THE TRENCH AREA
MASON COUNTY HEALTH DEPARTMENT FOR A LIST OF
LICENSED SEPTIC TANK CLEANERS IN YOUR AREA. THE ..��//
CLEANER CAN SERVE YOU BEST IF YOU SHOW HIM THIS DEPTH 1-2 / 000RRUGATED .W IGID ❑ CEMENT
RECORD WHEN HE COMES. .�„,,,,// BELOW DEPTH
HEAVY TRUCKS OR EQUIPMENT SHOULD NEVER BE CU. YDS. I! 7-S G FTOTAL
DRIVEN OVER THE TANK OR DRAINFIELD. CONSULT THIS SPACE RESERVED FOR Z� SQ. FT,
RECORD IN CASE Of ANY BUILDINGS, DRIVEWAYS, REPLACEMENT DISTRIBUTION FIELD;
SWIMMING POOLS, OR EXTENSIVE GRADING OR FILLING ���yyy
ARE LATER CONTEMPLATED. �p�����'�"'��IT�1." ;�" '
SHRUBS OR TREES SHOULD NOT BE PLANTED CLOSE TO i� ` i
THE SEPTIC TANK AS THEY WOULD INTERFERE WITH '���t,�■"�t 1"I'i�ii��'
CLEANING OF THE TANK. THEY CAN BE PLANTED IN THE �,",��■��'■„�ti'„�'.��
DRAINFIELD AREA PROVIDING WILLOWS ARE NOT USED. ' nIII01111111;i'Vr"L�!,R
THE YARD GRADE IN THE DISPOSAL AREA SHOULD BE
111011111
SUCH THAT SURFACE WATER IS NOT POCKETED ON THE "��I'■„` MK �V
DRAINFIELD. ANY SETTLING OF THE GROUND OVER THE . a1+11fetilS�..R A
TRENCCESSWHES
WATER THE FILLED
LAWN IN THE ITH SOIL.DRAI DELD AREA.NOT EX- ,:�[,•'•_N■w. 1:;,'-aten in�A______
WATER EVAPORATION FROM THE DRAINFIELD IS ABOUT •.•I f',r`La:..I,"„'„='.'+_ ,B
EQUAL TO ONE HALF INCH OF RAIN PER DAY. ■ : ��
FOOTING DRAINAGE DOWNSPOUTS AND WATER • L IB1!��.■ ■ -' ■■��111= R.AS_r�
SOFTENER
TO THE SEPTIC SYSTEM OR DISCHARGED BNTOE OTHE •igiiMR`�1�B.I1lA"1%Ianf 3•
DRAINFIELD AREA. ■ a. ____N
ARE
ALTHE TYPES OF BACTERIA WAYS FOUND IN SEWAGE.ETHERE IS NO ND IN A IEED TOC K ADD ■����■I�"��\�� �'„���
YEAST OR OTHER STARTERS TO A SYSTEM. THE USE OF RE- { . �� ��`_� ;l
H JUVENATORS E CHEMICALSVEN ETO CLEAN A SEPTICNDTANK "t"jii 'u '""'i■'i�S ,
HAVE NOT BEEN PROVEN TO 8E BENEFICIAL AND MAY BE
HARMFUL BY FLUSHING SOLIDS OUT OF THE TANK OR BY 1'� I� A
CHANGING THE CHARACTERISTICS Of THE SOIL. THE SO<}I
NORMAL USE OF BOWL CLEANERS OR CLEANING COM-
POUNDS WILL NOT KILL THE BACTERIAL ACTION OR SLOW y/'�; J /
DOWN THE OPERATION OF THE SEPTIC TANK. 7 !--ga- �J // i//
J / ^."3 • • BY
Printed Tht�I� IFpAD aCQ�unty Dr‘21"� , , , /is tr
D O$OTHER OFRONFD BY
e �P,ESSSEE a�ER�u -y i)M1PS DATE
4,� 961,4 WON CO WA Av4im6tzi Vol5J,-? 2J
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a °e_ y b 400 cg
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MERIDIAN- AS SHOWN