HomeMy WebLinkAboutWEL2023-00057 - WEL Application, Design, Letter - 10/18/2023 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
J BELFAIR:360-275-4467.EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
IDDINGS FAMILY PROPERTIES LLC
PO BOX 2
MAPLE VALLEY, WA 98038
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2023-00057
617 NE Dewatto Beach Dr
323284300000
The 2-party water system, Iddings Well (323284300000/323284200040), 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,
if
David Anderson
Environmental Health Specialist
Mason County Environmental Health
in
z. MA . LOUNTY Dale Rec 1 Received . a
y ^ p' •i COMMUNITY SERVICES i A
lA,,.hrTa D AAA. I omm 5
415 N.ldh l (Bldg B)-SI .WA 9%584 f WEL Asa 13 0
Shelton 360-02Y640 n400 B II• 611275446 x400 Elmo:3604823269 x400 ��/��VV
��ZZ TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
LICANT
MAILING ADORERS
PEccreET.CITY, ATE ZI� To/i) '1 / / PHONE 39/ 2343
AO Pee 2 -P /(a,, /e IA //ey, G1// 9SO28"
SITE ADDRESS-STREET,CRY,STATE,ZIP ' /
o // - /VCrDCw /Q -o QeaJ 4'- - TLeya , W/9 qt -Fe
PRIMARY PARCEL NUMBER(WELL SITE)
SECONDARY PARCEL NUMBER(IF APPLICABLE(
*4-32328 - 4/2 - 0 oe> Vlo
WATER SOURCE SOURCE TYPE PARCEL I LOT SIZE PARCEL2 LOT SIZE
0 New xlstingWell ❑Sprang i6vi- ace CS '/ aces
PROPOSED WATER SYSTEM NAME(REQUIRED) / �/
Z�d( n 1//e�s
PROJECT DESCRIPTION
//y/rnc ve 'CD n re Iwo -paiIv /ori ✓afr Waite el
SV SfEi e. }ai` IIe Coif 19 uou5 ttarce/5 Ls abo✓e -
DIREc (DNS TO SUE'CONDITIONS
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septidsewer components and lines,easements.etc..)
See- a /T4cltieei/1/oT . • Wczi-er saAn(PIP O' We// /1 a r C OA -1-1. le ,
• 2 Fancy Infer S)15fe� /5 recorded W Auo/, ?Lot-
..
-There/ are " No " Se//7ie/sewer ccnt,caLf7S
'Ida'
Submittals Checklist: (these additional items will be required for approval)
4-r Satisfactory Bacteriological sample(this may be deferred if well is not yet drilled) - o/1 ..c; /B
Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)on -c,'k
Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document)..j ,e
`? Septic Records(additional locating requirements may apply if there is a lack of septic records on file) A/g
AI/is form may be scanned and available for public view on the Mason County Web site. Revisal: 10/ 3/2021
Page 1 of 2
....._.._.._._._..__...._......_.._.._.._._.___Staff Use Only.._.._._._.—._.._.—.__.__._.._�._.�.
Review Step 1: Well Site Inspection:
YES NO NA
❑ 1>tf ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
❑ Sj ❑ Are there roads within the 100 foot radius of the water source? If so, is road private, County or State.
---,,,rrr What is distance to ROW?
•DO ❑� ❑ Does the ground slope away from the water source site?(show slope on plot plan)
/I$dlJ` '�. E Is the well cap satisfactory'_ 3 ootJ of'� Lj 11..L_e(t cap MMnan%f,�(z�' '. s. I oce
pii ❑ ❑ Screened and vented? — (('/I GIN+" Yq/IL4otl'W47✓-
d
pi ❑ The well casing extends I6 level ground/concrete slab? (circle one)
X ° ❑ Is there evidence of a surface se I. —in Rfrn(1 Cat: 4Z c/y$�jii
,ZI ❑ Does the seal appear adequate? 4EVi4iy (_QnI -12).06YOye8
L��f :wet.
❑ (y ❑ Is a variance necessary for well site approva . T09; DIA (};
Comments —. MOV+I+ byItS fee tie/ ay & t loose ormrfssm)
lit
`/ g( S( IT Need to he jce4/eel
® Passim Fail Inspector Date I0/Z6/Zozj
ael" PVC
Review Step 2: Two-Party Review:
YES NO NA
❑ ❑ Water Well Report with adequate pump test on file? q ��/� n' ;r
If NO, date of Capacity Test 9/Z(Ito 70 Driller OM UVO Or"II i3 GPM 3p
❑ ❑ Received Satisfactory Bacteriological Analysis? Dale of test 9/(6/7Ot3
�-,�t 0 ❑ Received Signed, Notarized,and Recorded Notice? AEN Z 703509
/ ❑ ❑ m System appears adequate to
serve 2 single-family/ residences based
/onn information provided?
Comments /III 1 rp UL '
Ayy 1RF/�__. itl i eU Akre/ . II /6/7O73
I� Approved El Denied Reviewer ' Date 1t/7/(0Z j
(` Findings in this review reflect observed conditions as they existed on the day of the s site inspection_ No claim is vade. expresc
or implied of the future success or failure of this cyvtem. Well site approval does not constitute water sycten'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 mqr apply to all new wells drilled alter January 19",2018 per ESSB 6091_
This form may be scanned and available for public view an the Mason County Web site. Revised- l0/13/2021
Page 2 of 2
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2"2 360367-2631
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I COLIFORM BACTERIA ANALYSIS � (v�
Dale Semple elected l liras Sample County t111
Collected (n
9 I iT 1 23 10 cb < il tSD4 S r s S ZOZ t F°
Tune m water Syst - (peek only one box) (Fete Household RECEIVED
0 Group A ❑Group B ❑D:her I
Group A and u ua B Systems-PSystems-Rupert from Water Factlities Inventory(WFr)
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roystemNat ...rl ay
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T name
SAMPLE INFORMATION
Tampla collected by(name).Z-I9 e 1 5 { I .
Ivcalion or address where sanpie collected t ciel instructions Of ccmmerts
617 er Bd.,cct6 . hR µ'etc a0: BOA 1731
'(< , ,.ua 4g,S
Type of Sample(Muse checkonly one box of pi thto.tgh d-4 lsted below) 1
1 RIfoutine Distribution Sample 12.Repeat Sample(after unaat routine)
Chlorinated Yes No V I E Distrthution System
Chlorne Residual.Total__Flee_ chbrinaled.Yes No__.. I
3 Raw Water Source Sample Chlorine Pesldust Total Free—
❑E COP-GYM IF/PI
❑Ftal-ma:a evrl.smn wunravnl Unsatisfactory routine lab number
Roved ses No _ ._
❑Assessment Monitoring(AIP) unsatislaema routine collect date
❑Daher 1 -
5 , ,
B❑Sample Collected for Information Only
Inwesligative Construction/Repairs__- Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Cohiorm Present and TNansfactory
❑E°oh present 0E.w4 nbeent
No Coition&tooled
Replacement Sample Required:
❑Sample no old(>30 hours) ❑INTO ❑ -
e lehal DerssiSyResults'Total cpno /10Orrat E coh -100m.
Fecal Col! _ _it DDinl E eo toe ml.
r_lhoc Code ❑G. 9223B CISL 9222D I Dale nd rim Rmeved
❑sm9715B ❑Fnierolett I I3oo 'I• IS
DMA ail Time Ana,zed. I Dale eepmaCEp 197U23
S-ne:LMia paH number clus 40 I Lon Ilse My.
D B 0 D q (_ 0 \ 12-32otfs-a --j
oaTinerrsatt.-i19 r<.6W 01161 -'
2203509 MASON CO WA
10118/2023 12.32 PM NOTGE
LRURO R (DOINGS 1$191830 Roc Fa. $204 Be P>0et 2
11111111111111I111111111l111111III11111111111111111111IUI
Return To
Leta.- c /1 . -rd4, ;77 S
PO Ede x 2
Made ✓a/ ley, 4/I
9ro3F
Grant)S(a1'js y �OC,'7�e 5 .Li(Cr(2) Jac/r e
Grantee(s): (1)PUBLIC
Legal Description (1) SW S6 'E"X S
(Abbreviated form:i.e.lot, block,plat orsecbbbbn, township, range)
Assessor's Tax Parcel: (1) 3 2 3 2 5' - /�/-} - 0 0 0 0 O
don Tc2-9
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) .3 2 .9 2 5 - y-3 - O e o a V
Tax Parcel: (Connection 2)3 2 2 9' - 4/2 - O 0 O .9O
The system owner is responsible for keeping this system in compliance.e
The name of the water system is: —Z-�d r an c t,t/C///
This system is designed to provide for two service 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.
Dated on this /(T day of Oc bier , 20 07 9.
Signature oft Grantor(s):(1) / / ea/f-r . (2) il
ll y < 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 " day of (��-yr/ . 20 23
Unit A \( 1 t s-c 4s I,b)(f personally appeared,�.Y=fo,r- - -, who is known to be
signer of the above stmment, and cknowledged that h:(t'i(the signed it.
GIVEN under my hand and official seal the day and year last - .ov- ' en.
qr4 as vr`a`.a`Ielagrallb
Notary Publi 'in and for the State of Washington,
residing at 0..4rridera
My commission ex Tres: Qr3" .-/
NOTARY PUBUC
STATE OF WASHINGTON
JOYCE M BEYANS
MYCOMPAMMOw Daw
MARCH 14202/
COMMUNION 1CO
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