HomeMy WebLinkAboutWEL2023-00061 - WEL Application, Design, Letter - 11/14/2023 415
584
MASON COUNTY "6THELTON. SREL'967 ,EXT 400
SH STREET,
,SHEL-ON,VEXT400
BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
PAYSSE ROBERT H & PATRICIA
3083 E MASON BENSON RD
GRAPEVIEW, WA 98546
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2023-00061
1940 E Mason Lake Dr E
221041290101
The 2-party water system, Paysse1940 (221041290101/221041290101), 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
Sincerely,
David Anderson
Environmental Health Specialist
Mason County Environmental Health
ratMASON COUNTY Date ReCeIPn4 / t1 C]a
) COMMUNITY SERVICES AMC R, d ReewedBY
�\ / Building,Pdmnng,Environmental Health.Communty Health /Q- S
415N_6'"Street,(Bldg 8 -Shelton,WA 98584 WEL aoa . - �oo� i
Shelton 360-427-9670 x400 B)lain 3 60-27 5-446 7 x400 Elam 36fH822-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
A�PPPPLIICAANT4X\ P Y PHONE
MPAILIHGODORE33-STREET.C•TY,eTPSE EIP 360- 4)26 - Igoy
3083E t'045e0 8ey-c.y_(ZeQ 6e.iev .c+.Q Y We.... A3i^16
SITE ADDRESS-STREET,CITY,STATE,ZIP
114o tna4 ea. Lake Or. E. •. 1 .
PRIMARY PARCEL NUMBER(WELL SITE)
aatD4 - la — 9v b
SECONDARY PARCEL NUMBER IIF APPLICABLE)
WATER SOURCE 0 1 A SOURCE TYPE � PARCEL 1 LOT SIZE PARCEL 2 LOT SZE
0 New ®E sting liYW ell ❑ Spring ,.51 A+Gle5 pal{9
PROPOSED WATER SYSTEM NAME(REQUIRED)
c2E‘/..43 e 1940
PROJECT DESCRIPTION
24 Aril v-1 o-., A D U
DIRECTIONS TO SITE/CONDITIONS
ran.- _ch.( I rot`. tin- L , e VV-- Ft,PJ..3 R.r.-'y t^risvT— 'RJ'e.yivr - .QYr), Go 3.1
VI"i)t$ a- -J 3'Jft4AD:c 2-rA>amP519 .. Loup Le,Cr A--k CrPP-err" y
Site Plan: (may also be attached)
(property boundaries,structures.well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
St"C wnecieJ
Submittals Checklist: (these additional items will be required for approval)
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)
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)
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: Age/ �l, Z0
YES NO NA (HQ' ^ 5S
CK1 ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields,tanks, buildings, indicate distance on plot plan)
❑ X ❑ 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?
❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
❑ ❑ Is the well cap satisfactory?
N ❑ ❑ Screened and vented? ` It
❑ The well casing extends l above level ground I concrete slab? (circle one)
jaf ❑ ❑ Is there evidence of a surface seal? La} ' 4i3tIf 02L3
r ❑ ❑ Does the seal appear adequate? L0fl -ill.4J9JS60
❑ f-lr ❑ Is a variance necessary for well site approval? 145 ; kAl
Comments
I21 Pass ❑ Fail Inspector `2j Date 11 / ZI / 70/3.
Review Step 2: Two-Party Review:
watWs/y,vef ((/30/7CV3
}Y�ES Nq- lyu� it-how (o tnit te 20fa1/ws1,
14 - ❑ Water Well Report with adequate pump� test
on file? Well 10, ha, n / y (ZS{ /
If NO, date of Capacity Test 6/ //I7f Driller 1 (o0v'q LcIll4p, GPM 20
-i- ❑ Received Satisfactory Bacteriological Analysis? Date of test I r /I /ic??
-% ft❑ Received Signed. Notarized, and Recorded Notice? AFN 2704f(7/
W ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments Crx�o "? vglvof k red. i)730(at73 .
?Approved ❑ Denied Reviewer ,mil jam+ Date / 74f3
Findings in this review reflect observed conditions as they existed on the day of the site inspection. So 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 YICY'6.68.
Water usage restrictions and additional fees may apple to all new wells drilled after Janump 19'2 2018 per ES.SB 6091.
Revised: 10/I3'202I
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
I rre vveii Log uata ana image are 'He Is' with NU Warranty. Well Log I r .•,r ,_,�,_,7..a„_
MOTER WELL R 6 : r . i W06•726
ll
STATE Cr WAS'FINGT CN e[u 3_ .t
L
O rWNEi
... Name .... ----- Atldiesb i I960 90901r LAKE ORIVR SRELTON. WA d5d.-
a - .... . ..Count. ' - . `---.-`..........-- 12/ N-
Q1 STRERT f..J C1 xr:L 1. County MASON - VI :/I M ,/6 ..at 4 r 21N N.. F ]W /1.
1' vei Grit car nJL'.aesr, eF NL:c. mr n esr Haar.ssl I LNO 0 . Lm DRIVE, ..[Cron
ID} 3 PN IOSFS LSE DOMESTIC 1 I1)1 WELL LOG ry
III IYIF of RORK. s [Lumber o well II Describe b v(
tO Ittt I a and show :M' fit
L NM MOLL Method mote
^ and n of the f rr v''.
y naturetrues r f C.
_ ,.. __ - at least one entry [c[ na.:n change !n fc'niarare
C• b OTMENLIC/11 Dasiretered well 6 inches - '----
C ll.,i 91,9 L. 6:p( t - . 1:c N ed well 97.9 IL. MATERIAL — 1 I .v
C _ IL...-._ / ___ ..... ....,,...... GRAVEL COURSE VIL 'MP CLAY BINDER 0 t
O CC9...v LfIJK LP 1.-.AILS CRAWL
LOAM
OU SEAL L :0
"OaC WIELDED
i-r_CASING 6 ! • - to 97.4 :: HARDRR COURSE SE SA ELM CLAY SIRING 110 00
E R'HDLD CASING a fro, rr fa- HARD PAN COURSE SALII MRRR BEARING 160 i
A ..
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as 5 is what depth 20 ...
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6.
C DIE en➢sr n_ta,., unusable v e NO
Type
of i a oftSept.]. o[ 6[ ft. IW L.
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c, PJMP. Manuf,J Lure's Nine -'
Type 'Po
O ,x, WArEP LKKVGL:: La:I.-garfa.evor I
Z .a,. n level fa
it.♦ I Jelow -up sr v 1. nate 06/07/95
d . . Lila per re inch La.e I
0 •a0 v. r,L roll led 1-Y _
a Work am el 06/07/96 ,.•,.,,.I!,i 06/0I/96
L cranna roe. reedlercer.ON
O red it ev. .m ' . . a eel I d n
0
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rn�- v mr Rater L..e Time Water Level NAME AResoxa DRILLING I
la
• E ADDRESS SE 1D
1700 AJu SEA PAPS �/J y{nJ'
A n ftd-aveo.r aafterI' 'sL;rveul /t_ 'A.,. 192e
0, ll/ r ,. w, Stem Ter .t 77 ft. for I hr.
y m Date 1 E - !r'
O Tempe n.u- of ware. smarm analysis vde, x0 I ReslstratI N CAD 90K1 bu ,
___ _ __ _ _ e
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Department of Ecology Well Log Image System
Thurston County Environmental Health
2000 La keridge Dr.SW e Olympia,WA 98502
i e=_-- 360 867-2631
Ilk RS1ON cCLn 11
COLIFORM BACTERIA ANALYSIS
Date Sample Co!lecied Tme Sample County
Gorenee
I 0 AO
ahr. Ors
Type of Water System!oheok only one box) ❑ Foveae Household
0 GroupA ❑Gmu3E 0 Other
Gimp A and Gmup B Syslems—Provide Mem Mier Fasines inventory liNFll'.
IDA
System Name
Contact Person
Day Plane:i 1 i Cel Phone:I I.
m 1. l Eve.Phone:( )
see msysic rnlnnare oddee eadzr rabeo'era zh:ress.
SAMPLE INFORMATION
SameN col xted by frame) - -
Specie location or address mere sample collected Spe:al lnstmotons or comments.
Type of Simple must;heck only one hex ofel lnrounh 4!:stet be owl
- - -'-R a mp.
1.❑Routine Distribution Sample ].Repeat
Sample Aker unsat.routine)
Chlorinaed.Yes_ No I 0 Dlstmollon System
Chlorine Residua' Total Free I Chlorinate: nes No —
3.Raw Water Source Sample I Chlorine Residua'Petal Free _
❑E roe—GWR(A'P'
❑Fecal—-R, art ,. ... .i,a,.-9 1 Unsatisfactory reline oh numoar
rn. no Nr _
❑Assessment for tor:ny fk?Pr [unsass'aaory routine collect dare
Oahe(
5 l I
4.El Sample Collected for Information Only
I In vestigeave Consticior Repairs Omer
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Cal'orm Present and ❑Satisfactory
❑E co'present ❑E conabsent No Colman da@Cleo
Replacement Sample Required'.
❑Sample too ohd iv30 hours) ❑-NTC 0
9aaeria1 Dens'4 Res.is Taal Coihforrrn 1100111 E cci —IlOUml
Fecal Colilevn -100m. Entemwaa npp ml
Metncn Code:0 SM9223B ❑SMp2220 I Dane an T re Rne red
0SY52155 ❑Emaroert
Dap alb Tn'9 A'ay=e_ I Dais Fancied.'_ ,
' toe use 01e
0 8 0
EXISI ING 3 BEDROOM k'
PRIMARY & RESERVE '? B
(SWG99-0172) �J ' F�VS"9s0
I
j
yi,EXISTING SEPTIC TANK il BI
I I
I /\fl
EXISTING 3 BEDROOM HOME �° II
/
\ EXISTING WEL
\v ,-.. (2-PARTY) j I
I r 1 I
I \ i
i
i
n \ / 1 ...,
1 I
IAN /W ERLINF li
AV PROPOSED SEPTIC TANK —\
I
I PROPOSED 2 BEDROOM I
I PRIMARY & RESERVE
I Olt
11
220'
= I —`
iN
it iia I. PROPOSED 1 I lei
L 1" 2 BEDROOM API/ u,
I B o. 4S>4-. In
H. - - -- - - - - - - - - - JI
30'ACCESS/UTILITY EASEMENT 11
AN ASBUILT/INSTALL SIGNOFF FEE WILL
BE CHARGED AT TIME OF INSTALLATION.
C UV JI t 2zlu�lzeolo RJRllll 1 PATS E TF�/1.I 14FI TIEI .L ILI 1T Tllil i
PIONEGIZ DIGGING,, INC. Rc n r,z FU.JIS 11.101,
SEI'I-IC DESIGN:, ADDRms xyv MAS.FN RI N Ov R)
l06]I I INIII N>iN RIJ R V'IAELW,lcvotiMa DESI6AIR'. RCN[*T II_PAl*4
MO 126-h01 EP it% 221-5I SIILI I_ >IIF PIAN CMI 1'=50 . .m . - .oawoa..._�.a
/ ,
�• S MASON COUNTY
,orli COMMUNITY SERVICES
=,%p1 in
.+ Building,Pbnning,Environmental Health,Community Health
415 N 6'h Street, Bldg 8. Shelton WA 98584,
Shelton'. (360)427-9670 ext 400 4. Belfair. (360)275-4467 ext 400 4• Elma: (360)462-5269 ext 400
FAX (360)427-7787
Application for Waiver/Appeal
Amount Paid:
Receipt Number.
Instructions
1. Complete Parts 1 and 2. No determination can be made until these pads are fully completed.
2. Fees may be billed for waivers and appeals, based on the Environmental Health Fee Schedule.
3. Submit completed application with attachments to Mason County Public Health for review.
PART 1. Applicant/Parcel Identification
Name of Applicant ROBERT H.PAYSSE Telephone 360-426-1803
Mailing Address of Applicant 3083 E MASON BENSON RD
City GRAPEVIEW State WA Zip 98546
12-digit Tax Parcel No. c 2 1 0 ° -- _
a - 9 e 1 0 _
Site Address XXX E MASON BENSON RD-GRAPEVIEW
Subdivision Name and Lot
PART 2: Nature of Waiver/Appeal
0 Contractor Certification Requirements
❑ Class B Reduction in Vertical (Installer, Pumper, O&M Specialists)
❑ Separation 0 Food Sanitation Requirements
❑ Building Permit Review Policies ❑ Group B Water System Regulations
❑ Location, WAC 246-272A-0210 0 Water Adequacy Requirements
❑ Holding Tank WAC 246-272A-0240 0 Enforcement Timelines
❑ Mason County Onsite Standards 0 Departmental Determinations
❑ Other
Description of Waiver/Appeal (include justification, additional material may be attached.):
2-PARTY REQUIREMENTS Ali /Co Ogc40,, ,/At y,^4-P- . ,
Applicant Signatures ., h-Q�'°� Date:
vhi-1 Forms',Waiver-Appeal Mason County Local Revised 1120/2017
Page I oft
PART 3: Public Health Evaluation (Staff Use Only)
1. Type of Determination Required: Type of Onsite Waiver(if applicable)
- Appeal Waiver l None required Class A Class B n Class C
2. Identification of Specific Code/Standard/ Determination (include date of determination or latest Code/
Standard revision)
3. Nature of Appeal / O o `
,may T G R I Lao�y ,
4. Hearing Official:
❑ Board of Health ❑ Health Officer
❑ Pollution Control hearing Board 0 Public Health Director
❑ Certified Contractor Review Board 0 Environmental Health Manager
5. Mi I a ing Factors. / / `
C tne.e. .�lr /K c• nisedt Lri[e `,r u10,of M4yy4 sr
4 /t"e"-e r{r:I /c/v. 6 '/' (✓ R J'�l`a/L b't!_T/• a
•
4 are
vitt- �4 r4 T4..Pb� .4.7 W. 5C Lau/N "-et PA Mert
aw r pre( Per rrr, eiT-
6. I have received this✓waiver/appeal request. It is complete and mitigation required by the state and
local policy has been submitted.
kV°.
Staff Signature: Date: VI-772__f
PART 4: Determination of the Hearing Official
❑ The hearing official has determined that approval of this request will not adversely affect public health and
is hereby granted. This decision is based on the following fin i9gs and cond i ns �7
ma,u._ C.s. �r c..n-rcrs / ;„ 1 p/•t<!J u}/p
C l./a .� i. Gr ry4'3t Cppr P. re-lw // a. MI% st/,1.ti O!a
3J 0'q( ' 4Q.r t, 4/c4., /UP ,.rye LYA4/ died riot
❑ The hearing official has determined that approval of this request could potentially adversely effect public
health and is hereby denied. This decision is based on the following findings and conditions:
Hearing Official Signature: Date:(!C�"'� Date: /7! 54/
LfH Forms%Waiver-Appeal Mason County Local Revised I/2(172017
Page 2 of 2