HomeMy WebLinkAboutWEL2023-00048 - WEL Application, Design, Letter - 9/14/2023 en, , MASON COUNTY 415"6TH STREET, SH27-967 EXT
- T HELTON.360 427-96 ,V EXT 400
, BELFAIR. 360-275-4467,EXT 400
,� � Public Health & Human Services ELnna_3soa825266o EXT
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FAX BOSLEY GARY S & CAROL A
2205 CRYSTAL SPRINGS RD W
UNIVERSITY PLACE, WA 98466
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2023-00048
8159 NE Belfair Tahuya Rd
322027600500
The 2-party water system, Bosley Water(322027600500/322027600600), 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
MASON COUNTY °"°R" q ,�_ /j
ai
COMMUNITY SERVICES a" �_ RemNi
. � W�iNn Manning.E .ry Health, "O rrYX.
415 N ( Sired Ode S)-Sham].N\ A985R4 WEB lo al3 — W 0443
Shawl. 360-27-9117u x400 &Llhir.369 V5Ji6 400 hl w.3604N2-52b9 saao
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT PRONE
S\Wlec l&bSeml 2S3 - no- 3133S
MAILING ADDRESS-STREET.CRY,STATE,ZIP
27bs U9S1aV Se`o, Ro w , uri.vcfsly Osur I A0(NaG
SITE ADDRESS-STREET.CITY,STATE, IP
girl WC ettPt;r 1`11•14. /d‘ Rd, "fvt•ya wa, q SSTS
PRIMARY PARCEL NUMBER(WELL SITE)
�VI Ca.
1 (o00SOO
Rs2Tp `ECONDARY PARCEL / MBCOOPP0c O
WATER SOURCE SOURCE TYPE PARCEL I LOT WE PARCEL]LOT SIZE
ICvJew 0 Lxisting pr Well 0 Spring ,5'. 31( Abt}' _-. 09 RCRes
PROPOSED WATER SYSTEM NAME(REQUIREOI
50C4{1: W wire r
PROJECT DESCRIP
.g:E(e.A"Mik C3/4- Cornetc.`gl
DIRECTIONS TO SITE CONDITIONS
c OIA bet-car- kit \IA 300112:d1n4r Oh NE be\SN:Lc 4c4 Q.®, advilZ
X kuvv. ax5,14-.
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
•
1 4 202.R
Submittals Checklist: (these additional items will be required for approval)
W 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:
YES NO�T NA
❑ 7`" ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan) /`
cg ❑ ❑ Are there roads within the 100 foot radius of the water source? If so, is road pt arG , County or State.
What is distance to ROW? YR L/
❑ ❑ Does the ground slope away from pthe water source site? (show slope on plot plan)
WAw - 'LI Is the well cap satisfactory? PO/ 'f 3 tvt-p'C 4 Moon i bow loos(
i�)y5 ❑ ❑ Screened antl vented? tr
` ❑ The well casing extends I S above level ground/concrete slab? (circle one)
? t I! Ot fl Is there evidence of a surface seal? [pi ' W7, 4l47/7
q t%kT" 40❑ Does the seal appear adequate? ion ' —I Zd.016 zuS.
❑ ❑ Is a variance necessary for well site approval? Tc, : R l N 197
comments fU{ iCg cell kq5 Slfimped. l0 60011 Gro(rn4 IeGe / of eg e a-
s� I 0 F uf7tOr: 0
�J Pass ❑ Fail Inspector l / —) Date 77770OV
Review Step 2: Two-Party Review:
AS NO NA
/Vo ❑ ❑ Water Well Report with adequate pump test on file? / J AIf NO, date of Capacity Test 6C [ 7/zoZZ Driller QY(it t r�Vd U yy,,�' GPM 19
O ❑ Received Satisfactory Bacteriological Analysis? Date of test 9/t 3/70
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 170037
❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments 7'
16 Approved ❑ Denied Reviewer Date /0//// 4/13
Findings in this t'tier'reflect observed conditions as the,evicted on the day of the site inspection. No claim is made express
or implied of the Iieture,vmcecs or failure of this n:stem. Well site approval dory not constitute water.evstem approval. (Voter
System approval is a two-part process.
All proposed connections to new wells are vuhject to hater adequacy requirements at time of building permit per MCC 6_68.
Water usage restrictions and additional fges may apply to all new wells drilled altter.Januagy 19th. 3018 per ESSB 6091.
Revised: I0/131202I
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
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WATER WELL REPORT R DEPARTMENT Of Notice of lnlml No.WE49093
ECOLOGY UtSuc Ecology Well ID Tag No BLN197
Type bast Slav of washington[R comrneo Sim Well Name(if mom dim.one wdff
❑ Dnvememao R+giol SONNY=NUI No. .__ Wald Right Pami4T:exlitiva No.
tnpnad Ur ■Dcwwww ❑Imes& :I MnkRel PfolvatY Owns Naar S�1 Ei DOLE' _ .. _.
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If y .what was the variance for
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17 Driller 8 Maim O PE-Print Name MAIN TROTTER Dales Company COOLWATER DRILLING.INC.
9 sir r-- Address 10921 NW HOLLY RD
Iikms No.33W City.Sae,Zip BRE ERTON WA 90312
I TRAINEE:Spersoes Ikmeo Coun t:to's
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360-407-6872 Pasoms wiS4 having lass Cam calf 7l1 for Washingrw Relay Sender. Penou with a speech dfability cad
877R13-6341.
2203037 MASON CO WA
10/05/2023 01.41 PM NOTCE
Return To BOSLEY Y191471 Rec Fee. $204.50 Pages 2
All 1111111111111111111111
Gar- os
oS cr W OC
J
G12 r i kU'k64 1 1073
RFCefreo
Grantor(s): (1) &flt'/ S(')SVL , (2) Car° k
Grantee(s): (1)PUBLIC J Set_ pi,-Z Tl,v`P 22 p,it
5 0f 3
Legal Description (1)T$ .1),A,scA 26/gl Yerl\e t DP(,#2"1S R�Arzzobq''to
(Abbreviated foie i.e. lot, block,plat section, township, range)
Assessors Tax Parcel: (1) ` , 7 2 n Z- 7 6 - o 6 so C)
NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM
I (We)the undersigned grantor(s), certify that the water source located on the above-described
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 of water to the following
parcels situated in Mason County, State of Washington; herein described:
Tax Parcel: (Connection 1) S 2 2 f7 Z - 7 6 - 0 0 S 0 0
Tax Parcel: (Connection 2) % _2- 9 0 2 .- 7 6 - 0 0 6 0 O
The system owner is responsible for keeping this system in compliance.
The name of the water system is: �os\ S �\\
This system is designed to provide for two se ce connections. Planning and design approvals
must be obtained from the department prior to expanding beyond this number of services.
Additionally, a water right, obtained from the Department of Ecology, is required if the water
system exceeds exemption standards.
This system (has/ has not) been granted one or more waivers from specific provisions of the
regulations. r7 /�
Dated on this Ci day of 2"t , 20..
Signatur f Grantor(s): /'7
(1 /< 41•
7 Page 1 of 2
State of Washington
County of Mason
I, the undersigned, a Notary Public/�in and for the above named County and State, do hereby
certify that on this a day of CfM(IttP! , 20e73
Cir]l tB0Th1r,-1 t CarokBolei personally appeared before who is known to be
signer of the above instrument, and acknowledged that he (she) igned it.
GIVEN under my hand and official seal the day and year last above written.
....N�111 p1j
LYNN 111
v ex yo i e re y Notary Public in and for tRe State of Washington,
?:/ .ous,. *p 0 5esiding at �Gt c c>w o .J C A
2p41343 "% 'Vy commission expires: 11 ' IC7 ' 26,
C. n
- o _
NA rrr, 1 1516` U
1/11 i 1011W AS�,s
Page 2 of 2
ADDRESS:
8159 NE BELFAIR TAHUVA RD. TAHUYA WAY,98588
PARCEL it
322027600500
330.0'
Private Easement Road 60'
330.0'
Drive Way
0 °es♦
100 O'Well Radius •
\ Dram ieid
/ \
' cr-Weil
Electrical Vault-0 25
\
\ parkin
ory \ a II ao aas -1 100
70 EV— Residential House
Septic Tanks
\\ Gommencel/
Emergency Turn Around
For Complete Building Access p0
N P W
r
N-
p
N-
435
,
a
yo
Y
330.0'
Parcel: 322027600600 & 322027600500
Have been combined