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HomeMy WebLinkAboutUntitled (2842) MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670, EXT 400 !�h BELFAIR:360-275-4467,EXT 400 ' Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 KENNEDY SADIE 51 NE Lynnwood Beach Rd BELFAIR, WA 98528 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2023-00063 51 NE Lynnwood Beach Rd 222012300140 The 2-party water system, Kennedy Water (222012300140/222012300140), 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 ti2a0 7 .' Date Received --�w.— - § frn` MASON COUN DEC 1 5 2023 //�[���V//� COMMUNITYS RV • Amount Received: �� Received D Building,Planning,Environmental Health Community H- -..�_ S ZS i ---- --- 415 N.6th Street(Bldg 8)-Shelton.WA 98584 W E L 10 Z3 — Q00 61 Shelton: 360427-9670 x400 Be11air:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT _ PHONE 5d;z_ kenned 319 O . \� 4 3)4 0 MAILING ADDRESS-STREET,CITY,STATE.ZIP SITE ADDRESSREEL- r STATE, Po o ct 93 e �� k- "Ld�� lA)�-' q V J v // PRIMARY PARCEL NUMBER(WELL SITE) &.a. r -6 t s: o 014 0 SECONDARY PARCEL NUMBER(IF APPLICABLE) z2Z_O (71 o0f40 WATER SOURCE SOURCE TYPE PARCEL I LOT SIZE PARCEL 2 LOT SIZE 0 New Existing ptWell 0 Spring x 5- U 0 PROPOSED WATER SYSTEM NAME(REQUIRED) Vcn n tiv r PROJECT DESCRIPTION Lyle v ean-4 t Ovv A) 1D U . New h o►noz__ -e(A) bui l+ bra Exhic-h Ia1IP L ►nk --u e l�IS- ir We DIRECTIONS TO SITE:CONDIT NS Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius, driveways,roads,septic/sewer components and lines, easements,etc...) Submittals Checklist: (these additional items will be required for approval) l Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled) a1 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 — -- -- ------------ Staff use Only---------------------------------- Review Step 1: Well Site Inspection: C '`i q 15 ( 8(01 Ir�'lte... cl Mold awo y) i`` thin ►,,e A - 14WSi D YES NO NA - 6X07 ' dt'f '50 gul ❑ ❑ Evidence of existing sources of contaminat�� iU"rfwithin1 00 foot radius of water source? (drainfields, tanks, buildings: indicate distance on plot plan) [A ❑ ❑ Are there roads within the 100 foot radius of the water source? If so, is road private, oun or State. What is distance to ROW? ""40 ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) ❑ ❑ Is the well cap satisfactory? ❑ 6-(1 ❑ Screened and vented? 0,- 5I71,t Al QL 4P ' < ❑ The well casing extends /7 above level ground /concrete slab? (circle one) KI ❑ ❑ Is there evidence of a surface seal? co 1'; y . 4110I$6 ❑ ❑ Does the seal appear adequate? Lem - (7,2. . 8g 4SI7Z ❑ ❑ Is a variance necessary for well site approval? T4!) ' WI' Comments 1=k(Sl t� decelfreld te5. 'thei 7S ‘e- ?Yni iXtN l 5 p at/t ic- e 50 PraNl Lail�l Pass Fail Inspector 112 Date 1 / 10/ Zo Review Step 2: Two-Party Review: YES NO NA ❑ [I ❑ Water Well Report with adequate pumptest on file? If NO, date of Capacity Test II /(5/Zv L) Driller at1015011 DON, GPM l f 2• r (CE ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test II l Z S/ZOU 121 ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN ZZOSSZR' [I ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments Wh'ZC)Z L( COO 1 °p�r9Ve 3 /�/Zoh1. ® Approved ❑ Denied Reviewer Date 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 ACC 6.68. Water usage restrictions and additional fees may apply to all new wells drilled after January 19th, 2018 per ESSB 6091. Revised: 10/13/2021 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 NICHOLSON DRILLING INC. PUMP TEST NAME: KENNEDY,SADIE DATE I November 15,2023 SITE: 51 NE LYNWOOD BEACH RD TIME 9:00 AM BELFAIR WA,98528 WELL DEPTH UNKWN Feet WELL DIAMETER 6" inches PUMP MAKE UNKNOWN PUMP MODEL UNKNOWN TANK MAKE TANK MODEL Time Depth Draw Rate Time Depth Draw Rate Time Depth Draw Rate 11cw1,1 To Down gpm to Down gpm to Down gpm Water Water Water Static 23.6 0.0 40 72.8 49.2 660 0.0 1 31.3 7.7 45 72.8 49.2 _ 720 0.0 2 38.0 14.4 50 72.8 49.2 780 0.0 3 43.3 19.7 60 72.8 49.2 12.5 840 0.0 4 48.1 24.5 70 72.9 49.3 900 0.0 5 51.8 28.2 14.0 80 72.9 49.3 960~ 0.0 6 55.2 31.6 90 72.9 49.3 1020 0.0 7 58.0 34.4 100 72.9 49.3 1080 0.0 8 60.5 36.9 120 73.0 49.4 12.5 1140 0.0 9 62.6 39.0 150 73.0 49.4 1200 0.0 10 64.5 40.9 14.0 180 73.1 49.5 1260 0.0 11 66.0 42.4 210 73.1 49.5 1320 0.0 12 62.1 38.5 240 73.1 49.5 12.5 1380 0.0 13 68.2 44.6 270 0.0 1440 0.0 14 69.1 45.5 300 0.0 1500 0.0 15 69.6 46.0 360 0.0 1560 0.0 20 71.6, 48.0 12.5 420 0.0 1620 0.0 25 72. 48.7 48D 0.0 a 1680 0.0 30 72.5 48.9 540 0.0 1740 0.0 35 72.6 49.0 600 0.0 1800 0.0 RECOVERY�� Time Draw Time Depth Draw Time Depth Draw to Down to Down to Down Water Water Water 1 64.4 40.8 11 0.0 45 0.0 2 58.3 34.7 12 a 0.0 50 0.0 3 52.6 29.0 13 0.0 60 0.0 4 48.0 24.4 14 0.0, 70 0.0 5 43.9 20.3 15 0.0 80 0.0 6 40.4 16.8 20 0.0 90 0.0 7 37.4 13.8 25 0.0 100 0.0 8 35.0 11.4 30 0.0 120 0.0 9 32.8 9.2 35 0.0 150 0.0 10, 31.0 7.4 40 0.0 180 0,0 (1 SIGNED BY: "- --' 6.-- \ CHRISTOPHER CHILTON:PUMP SUPERVISOR ____k •SPECTRA Laboratories-Kitsap ...Wkax asperraace amrrera COLIFORM BACTERIA ANALYSIS FORM Date Semple Collected Time Sample County it f27102y. : IL:ISiP H5on Munn Dar yew Type of Wake System(check only one boot) ©Group A ❑Group B Q Other Group A and Group 8 Systems—Provide Gan Water FacAitles Inventory(WF* ID# �+ System Name: cilnF.j" Contact Person:Nicholson Drilling? Day Poona:(380)876-4421 Cell Phone: Ema( Ere Phone: Send mitt to:(Pad rW cam,Wawa rd sb coda a ameaEwa for arecuaMc copy of moth) Nicholson DAfng PO BOX 123 Pori Orchard,WA 9 366 Off ce.r thn sondrifl)ng@gmap,com i SAMPLE INFORMATION Sample confided by(name): A,/!ei SpedGc rotation where sample colected Special instructions orconvments: B; Type of Sample(check only one box) 1.❑Routine Distribution Sample(AlP) 2.❑ Repeat Sample(AlP) Chalnated:Yes ID No (front c45wruronsystemellerrruatpavane) Chlorine ReiM,wr T Unsats(actay routine lab number: Total Free 3.Ground Water Rule Source Sample l 1 I Unags ry Stact�l rou6ne collect date: S ChIrrinated:Yes No ©Triggered(A/P) Chlorine Residual:Total Free ❑Assessment(AlP) 4.Surface or GWI Raw Source Water Sample(Enumeration) IS I 0 E.cot 0 Fetal Moroi Yea__No__ 5 UCI Sample Colecled for Information Only: LAB USE ONLY DRINICING.WATER RESULTS LAB USE ORLY ❑Unsatisfactory Total CoGfwm Present and %factory ❑Ecoff present ❑E.coa absent Bacterial Density Results:Total Coblor m_pcd10Dml.Eco6 men/1011ml. Fecal Calibre chill DDmL Replacement Sample Required: 0 TNTC ❑Semple too old © Sample Volume 0 Damaged Container p y� e�1 j Dale/Tyre Lf 12- 1, I l Dt7 t l rh,Rotekat T C*: 1JeQadCode , ""� T•cotNi1Sl. �a Reported NOV 2 is 2023 `� .. ad rs.waa.rr+•rscaraa lo.r,.aaieara„are Mr!.�Ir.r>16Ja7aKrr Doll Lab-Sm ipp)ee l # ra,a^ JLY /j 01- irsw.�lrriYsMaldOwrw drdboed61- V rL• "I D�� i4yws 1► 2205528 MASON CO WA 12/14/2023 03:19 PM NOTICE IIII IIlll1I ll\I I\IlllI IIIII IIII\\IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIPages. 2 Return To �/ Jv 1 , Grantor(s): (1) S j keel wl , (2) Grantee(s): (1) PUBLIC !�( iQ��' 14 2 3 L1 _�, i Legal Description (1) 5 i/a IL iated form: lot, block, plat or section, township, range) (Abbreviated Assessor's Tax Parcel: (1) 0 I - 3- O 0 7 V 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: /l Tax Parcel: (Connection 1) �- U I 3 I Li_. 0 Tax Parcel: (Connection 2) . { - _ 6 0 r 4 0 The system owner is responsible for keeping this system in compliance. The name of the water system is: Ve,A A e d (k)Cc-(-- This system is designed to provide for two service connections. Planning and design approvals must be obtained from theprior obta ned fromth Departmeno g beyond of Ecology,sise r of services. Additionally, a water right, 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 ti day of c , 203 Signature of Grantor(s): (1) , (2) Page 1 of 2 State of Washington ) County of Mason ) I, the undersigned, a Notary Pub in and for the above named County and State, do hereby certify that on this ) '-, day of ert1'1"1._.✓ , 20 ? , 50'V,4 )'nIARAL personally appeared before me, who is known to be signer of the above instrument, and acknowledged that he (she) (they) signed it. GIVEN under my hand and official seal the day and year last above written. „N M"oN wF "° Notary Public in and for the State of Wash'ngton, /o'NoTARY �F`• _ residing at 1� V N 21009497 = My commission expires: b I I )ZbZS PUBLIC .07/3012O CSC•• .-FvVASN�,,`°, ''''.,4„<<,ic''''' 4 4 4 4 4 Page 2 of 2 �.' ,05 • • / \ ( • �\ % O i lJ -re��.f \ / ..5 / / -�� `'���,-'e11 Radius `\\ ii- 1 rD �/ c� �/// \l 1 / l I Q 1 N / I 1 E. 1 (1 / 1 4 — 1 ) l � ,\ 10 I / 1 \\ I. 3 b i r \ / 1-• (1 / \\ •\\ '! 1 Q'/ / \ c I i / \\ I to 4 I i - , \` 1 1 NJ 1 \\ p 73 1 - 1.xj • >� i • - / .` 1 0 i' \`. \ 7 '� 5` \ �i i .. \ t -� Z JP -' 0 . \` ---_i'I-- D 7 \ N \ NJ fr,N \ 7(1 (D ' 1 .II I 73 -- . 1 o� -. . ��, , rrD i .. .--;I_ _____ AT ,Oi i ----.—t-- W E 10S Lyinwood Dr s � f r in � � ov, n Ni al a r, o---.1a fit r O w i ttt et,1_, L fl � - r G= RI c>Os‘tttN O77 n w w D o �_ �J. •41t cr NJO Co O 2 x o a 3 7-1r' 0 Z 0 o r A5I3u '1 ' 51 NE Ly'i w'000 8euch -pr' zz20 ( z30O (o THURSTON-MASON HEALTH DISTRICT Division of Sanitation No. V\ • Court House Anne 5th and Birch Olympia, Washington Shelton, Washington Phone: 352-4851 Phone: 426-4407 SITE INSPECTION NO. APPLICATION TO CONSTRUCT OR ALTER AN INDIVIDUAL SEWAGE DISPOSAL SYS 3 (Application required for each installation) t Property Owner ihR&/4 D , 11,4 X41 A Address 22 e 2 - Sou /H A/L(4ES 7,4c Al 14/4s'H Builder Address 9 �yo 9 Address of Site Location of Property, including: L-ot _ Block' # Other Detailed directions to'site: SCE. / -'7 4/ L 2- ' R 2 X %2- A'A41 /4/ v i 4. 1) i .:cRT Cate ; , y Property: -- Commercial ,. ` Size?) !?residence , . No. of Bedrooms,/ 12J3asement Type 'I' ' 1' erg Water Supply . - Well . Spring Other - . Is water supply or body of water within 50 feet of sewage system? iv•• • Septic Tank 250 ..gals. Drainage System length ft. Trench wid•h_ (Refer to Table 1 of Aulletin) ft. And / or system other than above (Refer to Table 2 of.Bulletin J Check for installation of: Automatic Laundry (?) Automatic Dishwasher ) Garbage Grinder (' ) Is contractor installing septic tank? X Drainfield? X N C Name of Sewage Contractor -r(..-A-114171)✓ 91,1Y4c-0 GZ6 Sewage contractor must be licensed by Thurston-Mason Health District THE UNDERSIGNED hereby applies for a permit to construct a new ()rand I or alter ( ) a sewage system on above property in accordance with the Bulletin. Applicant's Signature.* , ,. - }Z- Address 2 2 b � .`- - 7--a-urn,1/4-)1/oo/ - 9 e `/o,y Bulletin: Washington State Department of Health Bulletin E.S. #1 en- _titled "A Septic Tank System for Yor Home" for minimum requirements. (Not to be filled in by Applicant/ �o Permit # 3 "7 1!Q Fee -to- a c) Date Issued 1- J- By •")"7, Area Sanitarian Dates Inspected IREMARKS: r • Prin}ed ,,,p,i a, 1°l�l,r..d. p �v by� (Sanitarian) Printed from Mason County i7f s r . a, • • • ".C._2 .Its ii i:..14. :tU:.. ''f-rI.Y' FijiiT . :::.1..• , ��: J 7,..,.i W ji y It'vJ''t7•:7'. ~y,'7L•!.''.1.:J b� iiy'r'r b•:E•f•i+r' _ Ott f:t.L•!'.Ju': 2;ii •'3T1e l;',t--3.:; :,Tc;.' �l SST �t ,/ ,`• *-. t r(� :. .. ..?... l+ 1C. . 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