HomeMy WebLinkAboutWEL2023-00060 - WEL Application, Design, Letter - 11/9/2023 • 584
MASON COUNTY 415NfiSHEREET,$-427-970.EXT 400
SHEL AIR:360-42T4467,EXT 400
BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT 400
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
I�
•
/r . MASON COUN NOVate Removed 1�
, II COMMUNITY S IB A 1 m5 Ra""
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1111
m.,ttir •
/ Malang Planning Envlemmenfal Health Communay Health
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415N_63SreLt Bldg81-Shelton,WA98584 WEL a b I 00000
Shdtom 360427-9670 x4011 Hcltuir.360 2754467 x400 I Imv:3604N2-9h+1 a 10
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLIy`�q ,1 PHONE
YiGOON T Us ucNSOIn 3(,o- trio -E,36C
MAI NG ADDRESS-STREET,CRY,STATE,ZIP /�
� .0 4�111 IsSICi See_ tLod) ANIA . 48 SSC�
SITE ADDRESS-STREET DRY,STATE,ZIP -
iSSI G _Mot- 1-l. SSIr•..d.
PRIMARY PARCEL NUMBER(WELL SRE)
22rb5 - 30 - q io
SECONDARY PARCEL NUMBER(n APPLICABLE) I\La I '4 - 7S SC ' SOURCE TYPE PARCEL I LOT SIZE PARCEL 2 LOT WEWATERSWRCE S
0 New �xis[ing �Wcll 0 P riO
B 1 . y 7 2- S
PROTSEO WATER SYSTEM NAME(REQUIRED)
F ivcr-'cr.n 1+1/S l-cr- Sv 4-t red
PROJECT DESCRIPTION
k.nnr C - Part ? 4-e i=f.C1-,ac1 Well oot (ocrce (
DIRECTIONST TO SITE)CCONORINNS '� •
1 1 J (i 1 '1 1 {
ff Z°, PrCt Stwn L (S4�r(-` 15�frlN (�P *.%1`.1 /c@T Cklerik rn In
IS41 c\e:JCLJ'cy ciCYC ) creyn "INL1rtoit R4 ( takci ,t(ic..L Cril SCA i-C gr(c55
a -4e well
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius. driveways,roads,septic/sewer components and lines, easements,etc...)
Seer `'IN't ' l�LA Al0 Z3 -Ol
AsfL ZiR (0Izl
9
Submittals Checklist: (these additional items will be required for approval)
0-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)
S.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)
Thls form may be scanned and available for public view on the Mason Countyy'Web site. Revised: 10/13/2021
Page 1 of 2
4
Staff Use Only
Review Step 1: Well Site Inspection:
54p4 —gla„,
YES NO NA
131 ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields,tanks, buildings; indicate distance on plot plan)
El f IDAre there roads within the 100 foot radius of the water source? If so, is road private, County or State.
What is distance to ROW?
IT ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
I ❑ ❑ Is the well cap satisfactory?
IFI ❑ ❑ Screened and vented? t
yvT�e,,,., El The well casing extends to above level ground/concrete slab? (circle one)
T ❑ ❑ Is there evidence of a surface seal? tqf: 47.2610/6
Lan: - IZi.408385
❑ ❑ Does the seal appear adequate? Tq9: A Ba8�6
❑ 10 ❑ I/sJa variance necessary for well site approval?`,, / ' ,,,j,r_,,/
Comments aid r f(e tip hY S'ereo, tat On ieo* •
ikf Pass al Fail Inspector 4a, Date I i /jV / Zo J'
Review Step 2: Two-Party Review: `� Z 5 YGO 7 ? ° v n�
YES NO NA
❑ ❑ Water Well Report with adequate pump testst on file?
d!If NO, date of Capacity Test I it( T 7 Drillerfi�'yrcerr kal Bat, GPM 25-
it ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of tot I I /5f?G71'
cr ❑ ❑ Received Signed. Notarized, and Recorded Notice? AFN ZZOP; 9
y ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
CommentspiLS //lycr III
Approved ❑ Denied Reviewer `////(, Date IV( 28 v�
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 afler.7anuary I9'". 2018 per ESSB 609/.
Revised: 10/13/2021
This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2
pt Orldan and Art.yaryMW SM Cad lb. LO7 1 (n5
Deplaww G9atlp} WATER WELL REPORT UNIQUE WELL ID.a Ala c? 82<
owed opy;—Orel COPY STATE OF WASHINGTON
This cagy—cairn COPY ��O Ware Nplilpa,eN Na
'(1) OWNER:: Naar Y�l 11)A � IY y.�� .awly,K� (�Y�l� --6�^--JL{ILI
(Y) LOCATION OF WELL: carte fY (y1aL O Y N p ,.f ,w ss 5 rc�. n.R Qa4
RIO STREETAOOREB,OFWELL aaarewwl )S� 1 T_Slpr Df Q n t .0y $cL_`i
(9) PROPOSED USE: ol o . m.nc a s 0 Mabapd 0 (10) WELL LOG a ABANDONMENT PROCED
URE DESCRIPTION
❑ pwww Tat Wee ❑ Omar 0 Tanabe.Oaabs by lam J. S..sae al mobil ese dram W Yaw Mar Cl Nubia
and Ow Mb N rest a be mwwM b awn lame Y-aYL.MN P r an wary a ash
(4) TYPE OF WORK: ((iron numbnumberp well changed WanrO"((ironmn and VAMMLL Ma TO
. ..do New well ]4 Metd: Dug❑ Bored
Downed ❑ case ()TONIC] CT Lcly farts,..... SOFT 3
Wmidtla.d❑ Rotary bad c So...) 1-G PAW.1 (4 Cb Y;Apmti / Z
(5) OWFJEWNS: Obna.awl into. T. LL arena 14a et4 31
DINS 4 4 Na Pwmam,pl.a L T. b5-,I GR.,I<I Pee Lava Lae;.e SO
CONSTRUCTION DETu Mao Sa..Jf6R.ur., /acL' t ry ( 3
(6) d , , �s„I Rio yG..da,.. 63
Caring most G. - Man.wan d b <C G ft.
Vlwsed Mal.horn IL b.
Liei nilalacAr
w.n.lmm e.m It
pwMntfoin: Ye.❑ No.IG 1
Type Cl pedant,used /J /III
sae alpwawMS bay P. tOer•RP1-a6/Y
parbasMMfrenl - Lb a {Y� .�d, l ,1 yam\.,
pwbalbn from It.b a 1l 7�/1A \ L11Vb+Mf (4
prrbradcal from -" Lb R �„ ,T
SOWN: Ye GI No❑
Nrdaaar\Nwlw NA 6 n Xs
Tape Ts moos No. Car_"- "r 4
Olan.S_Ocala /L wan G 4 nm 6o '6"'n td 'a3
rn
Clam. EOM air Fran bb L RFCEI :- OS r;
Omar wawa: Yes IltutTh-
Sir al owed =.7 .r
O,ml pa fob Km A D II
F1/Ip/�1' 'RC 11�111 (��/ {
sad—: Yaan& No❑ lb Slat gob? (8 R 1� W ,+"' Mar
babb Mad In nY /3e.To.v, rr 11 .nliw fl i3S' D-. '
Old any strata obtain unusable~ set❑ Naar JUN 02 ; r vEc.,:. 'JL,9A"`
TYPO pwait? O.pm of wale �i11
Waal al=WM grataof
-
m PIMP: ,,,w„n ,,,Nome HEALTH SCRV{CES
Type: H.P
(S) WATER LEVELS: ..pland•wacaalr'nn1 vat burbl� Maly' ,a ca.ar I�Jt1 PMwyy v�3
Sob bat 33 w.lbab.ip of well orel)Uy/S ,Y7 WELL CONSTRUCTOR CERTIFICATION:
Mein pawn b.w.wan'nn ow
Mwbn alb*mwaa by IGPvwra.awl I con YWpr rapt,Mp,waWly be COFISI a aY way,MI O.
abnlpdann ray r woolinoon.a.ooewmNm raa.da.aaatlab wad and
(9) WELL TESTS: Oladewl i rwlr✓•r orb bane Slow wW seer melnromin/a�l,p�Pleyd�war.al.m my boa .e
Was a pipe modal Van No❑ w Yak by MMnI NAME et,.9 �/... ) /
Yob pa/Fran war LdrwAwnMW_ Na Address !�� 07eYi.9NA` V in Pcl
Y b3
er data(LLnaken ea taro anon pump tumid]cif)bar W. mood from ad
(Signed) ������� ';Yr�:I ���at..
p laws bob
Than Water Laval Tana Water sear In Wr La,..41 Co11VaNfr
Wiarlein /OrM7 peas 5`l3-47 ,s_
(USE ADOITIONAL SHEETS IF NECESSARY)
Dean Set
Ty {� Bailer tad�.�9aYmmnWas a®�� _n ewawn alp ��(C.t I W�Opportunity Mg ABrmmve Acbm employer.For ps-
1 t I 11 I 1 Y!U '—PM-MOOThe
UOS n numb. le(20 di.War R6FOIIIfass PN91BII1 it l•99)
Tenpr xe a*SCir $hwsi t7 No KM-MOO.ThPTDD nartrI(20E)a7a009.
n Vannuard Laboratory
2635 Parkmont Lane SW. Suite A
Ol.mpia WA 98502
v!r,49AS'a 360-967-7010 A; ,b VAt+'-, A .t a a
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample v� Cwny
n Caned
e .10 oM 1,I (e. ::cv \
Type MIA/Bier System(tlleck only one box Yr 'r"_.k-- i
❑Group A ❑Group s Qj-0Iber�-= —
Group A and Group B Systems-Provide from dater Facilities Inventory(Poch.
IDn
System Name
Contact Person ,1, � + I e 4t., . _..
Day Phone(jv_Ca)4 PO (t' I 1 Phone( )
Email 1 Eve Phone l ) ,
Se d: ills-are adcsss and z r aerr
c \J e...�. eyt L[_� CUi a
r • v ...,L .e• ry
SAMPLE INFORMATION
Sample collectedd (name) I1
Specific weapon where sample colkded It Specie,instructions or comments
IJ91 c. .,A.m"Vh .e,.,e \-12rl
Type of Sample(select only one type of sample',cm types 1 through 5 below)
1 $Boutine Distribution Sample(NP) 2 ❑ Repeat Sample(NP)
Callornated Yes No Y1/4.-
i sosaasfactory roulne b oornesii
Chlonre Residual Total f we
1-3 Ground Water Rule Source Sample UnsatStactory routine coleeldate
I S I i I
Oblonnated.Yes. No_
❑Trgge(ed la Dionne Residual Total rrce _
❑Assessment IAP) _
4 Surface or GWl Raw Source Water Sample;Enume,ehat) 1 S 1 I
❑E co., ❑Fens,
5 6y l »F3d for lnfommlen only : �I 6d - _
L~fi USE ONLY DRINKING WATER RESULTS LAB USE ONLY - . .
k
❑Unsatisfactory Tonal Coblerm Resent and I ffi(Satisfactory
r
0 E coo present ❑E coil absel
Bacterial Density Results TofaC Conform __ 'lJAm ,nor __.._n0onr
Fecal Confirm —_ _ _ 00ml 1-10C, J1 ml
Replacement Sample Required ❑TN'r ❑Sample too on
O Sample nude e 0 Damaged Contaler ❑ . . --
°ale a on es,,of .11/3/2311 05 ;,
SM92238
—I sae""I."d 1p DCi n/a
-ah San:-
1 285-
MASON COUNTY
1 GENERAL SERVICES DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
303 NORTH PHONE ETB)STREET
•SS �401 NBON,WA RPLEF
1
RECORD OF FINAL INSPECTION OF YOUR SEWAGE DISPOSAL SYSTEM �.'
OWNER -1 111 /. ._•�5 A DRESS E 1^1�'L'�8 o3G�EM'e E y
THIS RECORD IS NOT A GUARANTEE OF PERFORMANCE. LEGAL
?one/ ,3s•'lam'L ET (t
A SEPTIC SYSTEM IS NOT A NCE MUNICIPALN SEWER.ARFHOWEVER (w /sa� 1a S Ezra\
WITH PROPER MAINTENANCE AND CAREFUL USE OF I. ,�.ZE,� -71lOYgN J
WATER IT CAN GIVE MANY YEARS Of TROUBLE FREE SER- '• •�, ` Z
VICE. MANY PROBLEMS WITH SEPTIC TANKS ARE CAUSED SOIMMENTS ��� •L BY FLUSHING EXCESSIVE AMOUNTS OF PAPER, CLOTHFIELD
AND PLASTIC MATERIALS DOWN THE DRAIN, OR BY SITE FI 40 X �3
LARGE AMOUNTS OF WATER FROM LEAKY FAUCETS OR DEPTHO. TO MONTH ett
FAULTY FIXTURES. WATER TABLE '�� OF YEAR al
THE SEPTIC TANK ITSELF SHOULD BE CLEANED EVERY INSTALLF�� J L -goat5
TWO OR THREERS DEPENDING ON THE HABITS OF THE T.r
•
FAMILY, THEENUMBER OF FIXTURES IN THE HOUSE, AND SIZE 40'
THE AMOUNT THAT A GARBAGE DISPOSAL IS USED. CLEAN- SEPTIC TANK (S) ZOO ��
ING AT THE RIGHT TIME WILL AVOID THE RISK OF INJUR-
ING OR DESTROYING THE DRAINFIELD DUE TO SOLIDS LENGTH
CARRYING OVER INTO THE DRAINFIELD. CALL THE TRENCH AREA on/
MASON COUNTY HEALTH DEPARTMENT FOR A LIST OF
LICENSED SEPTIC TANK CLEANERS IN YOUR AREA. THE TILE F / CORRUGATED ,rf.RIGID ❑ CEMENT
CLEANER CAN SERVE YOU BEST IF YOU SHOW HIM THIS DEPTH • Z REPTH /TOTAL
RECORD WHEN HE COMES. ROCK ,,,/ a= DEPTH
HEAVY TRUCKS OR EQUIPMENT SHOULD NEVER BE CU. YDS. // EIS PIPE
DRIVEN OVER THE TANK OR DRAINFIELD. CONSULT THIS SPACE RESERVED FOR Z�[� SO, FT.
RECORD IN CASE OF ANY BUILDINGS, DRIVEWAYS, REPLACEMENT DISTRIBUTION FIELD:
SWIMMING POOLS, OR EXTENSIVE GRADING OR FILLING 4 • TH 4ARE LATER CONTEMPLATED.
SHRUBS OR TREES SHOULD NOT BE PLANTED CLOSE TO �- , '
THE SEPTIC TANK AS THEY WOULD INTERFERE WITH -
CLEANING OF THE TANK. THEY CAN BE PLANTED IN THE y
DRAINFIELD AREA PROVIDING WILLOWS ARE NOT USED.
THE YARD GRADE IN THE DISPOSAL AREA SHOULD BE i' �.I , ' ! I
SUCH THAT SURFACE WATER IS NOT POCKETED ON THE +. III
DRAINFIELD. ANY SETTLING OF THE GROUND OVER THE f ' I •T \ `
TRENCHES SHOULD BE FILLED IN WITH SOIL. DO NOT EX- Nt ' T. 1 6� �� P.
CESSIVELY WATER THE LAWN IN THE DRAINFIELD AREA-
EQUAL TO ONE HALF INCH OF RAIN PER DAY. r,k ,�oJ\ IIa. �O'���- _R
��
FOOTING DRAINAGE, DOWNSPOUTS AND WATER ; 1 SOFTENER RECHARGE WATER SHOULD NOT BE CON- i
NECFED TO THE SEPTIC SYSTEM OR DISCHARGED INTO THE - .!,
DRAINFIELD AREA.
THE TYPES OF BACTERIA NEEDED IN A SEPTIC TANK ARE '
ALWAYS FOUND IN SEWAGE. THERE IS NO NEED TO ADD - -
YEAST OR OTHER STARTERS TO A SYSTEM. THE USE OF RE- A 4
JUVENATORS OR CHEMICALS TO CLEAN A SEPTIC TANK
HAVE NOT BEEN PROVEN TO BE BENEFICIAL AND MAY BE ►�
HARMFUL BY FLUSHING SOLIDS OUT OF THE TANK OR BY T . .
CHANGING THE CHARACTERISTICS OF THE SOIL. THE I —r . IF+
NORMAL USE OF BOWL CLEANERS OR CLEANING COM- , -
POUNDS WILL NOT KILL THE BACTERIAL ACTION OR SLOW PI J /
DOWN THE OPERATION OF THE SEPTIC TANK. ? !iQ�
• , BY
Pr�intedTkdvaii0MDF ®unty DV ,�� , � ,_ 8t
ff.ET 9'i D OR OTHER / CERTIFIED BY
�(ME IIAt uur- UFRS w,h
2196121 MASON CO WA A\ z1(11 iiiiiitirifilitingL21 Vo1.57)Ty.2b
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