Loading...
HomeMy WebLinkAboutUntitled (2905) MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 BELFAIR:360-275-4467,EXT 400 �-+? Public Health & Human Services ELMA:360-482-5269, EXT 400 FAX:360-427-7787 KIPP ET AL MICHAEL G 171 SE Paulcyn Ln SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2024-00008 171 SE Paulcyn Ln 319027790032 The 2-party water system, Existing Private Well (319027790032/319027790032), 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 t MASON O!J:JI4 � Date Reeved COMM re „ VISE AnpStIl R2tel ,,. Building Planning Environmental Health n 415 N.6ih Street,(Bldg 8)—Shelton,WA 98584 W E L �d �� -- 0 la Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360.482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION �.. APPLICANT �,/� PHONE l�) AeI /0p Yfli4i2 Ori✓e c 'fib - Lioa-ok 7 Z MAILING ADDRESS-STREET,CITY,STATE ZIP 1 / $E P4(1144111 - ' --Sit- --Sitef�f-o n tiwi- '- Ci SITE ADDRESS-STREET,CITY,STATE,Z .SAICIe--* Y( CCiae PRIMARY PARCEL NUMBER(WELL SITE) 3 1 q 0 a77 9 o©3 7-- SECONDARY PARCEL NUMBER(IF APPLICABLE) a U Z 7.-7 ?OUR— WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE ❑New _Existing itWeII ❑ Spring zis Act 4 S PROPOSED WATER SYSTEM NAME(REQUIRED) '/l J fXSSTin) j( 4C__ (A/4-02._ PROJECT DESCRIPTION r (ins C►JD/L (Vvc/iv) /9-PL1 y4nd Cep /}'rl PIe-1 /')ale pe--7-•'1 /4 „Jefiraok-v)e --FJILS./i // 4 Z/ DIREC IONS TOIITEI CONDITIONS / Fyn /! z d 2 , /ems lb /7 / L I-7) ) // f jJL /9,3,.„L4/n Ae c,Ce- o.1 /e-41 Site Plan: (may also be attached) (property / r boundaries,'ri structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...) Ili 1: M T FE3 X ' 7024 ti \@.," _______ 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) G Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document) CJ"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 NA ❑ i' ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) CJ (p. ❑ 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? SO Ov r de-tve.cv44.7 0 ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) ❑ ❑ Is the well cap satisfactory? ('2 ❑ CI Screened and vented? 7L E The well casing extends r re above level ground/concrete slab? (circle one) ❑ ❑ Is there evidence of a surface seal? L.a1': 4 IS?867 ❑ ❑ Does the seal appear adequate? "1 Z3,0Z/(1t1l ❑ y ❑ Is a variance necessary for well site approval? I J,A VA 4a z 1k Comments yi Pass ❑ Fail Inspector Date Z f z 2CP( Review Step 2: Two-Party Review: YES NO NA ZYdO'af frig 1 , k ❑ ❑ Water Well Report with adequate pump test on file?If NO, date of Capacity Test IZ/Z?Yroa( Driller &C {t21 OPlit h' GPM I-0 4a.l ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test I(3 /Z Z`1 1X1 ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 7.--ZO7(1 V' ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments Xr Approved ❑ Denied Reviewer Date 57v?0. 4-1fr. 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 after January 19'h, 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 ---Zzov-t...cL4-vo-,--- cy..,...._ .."3,c4...ca Gt...c\-Ag,..„--4.--o OIWATER WELk, REPORT CURRENT URRE T Na' N 1 5 0 5 9 2 Notice inevrI,316"T Original&1st copy-Ecology,2nd copy-owner.3rd copy-driller AEA 9 8 7 Unique Ecology Well ID Tag No. Construction/Decommission("x"in circle) a ® Construction Water Right Permit No. 0 Decommission ORIGINAL CONSTRUCTION Notice O of Intent Number Property Owner Name Michael Kipp PROPOSED USE: ®Domestic ❑Industrial 0 Municipal Well Street Address 'it SE P a u I c y n Lane tL 0 DeWater ❑Irrigation ❑Test Well ❑other cityY Shelton Count Mason TYPE OF WORK: Owner's number of well(if more than one) EWM etude V! Lotion S W I/4 1/4 S W 1/4 Sec Twa 1 9- R3 N ij ®New Well El Reconditioned Method'0 Dug CI Bored El Driven on 0 Deepened E]Cable 0 Rotary 0 Jetted WWM C Lat/Long: Lat Deg Lat Min/Sec O DIMENSIONS: Diameter of well 6 inches,drilled 1 5 9 ft. (s,t,r still Depth of completed well 1 5 9 ft. REQUIRED) Long Deg Long Nfin/Sec O CONSTRUCTION DETAILS Tax Parcel No. 319027790032 CO Casdng [X]Welded 6 • Diam.From +1 . 5 ft to 1 5 6 ft CONSTRUCTION OR DECOMMISSION PROCEDURE E Installed: 0 Liner Diam.from ft.to ft, Formation:Describe by color,character,size of material and structure,and the O ❑ � kind and nature of the material in each stratum penetrated,with at least one la-, Threaded ' Diam.from ft to ft entry for each change of information.Indicate all water encountered. C Perforations: ❑Yes ®No (USE ADDITIONAL SHEETS IF NECESSARY.) O Type of perforator used MATERIAL FROM TO s• SIZE of petfs in.by_in.and no.of perfs from ft.to R Top soil 0 2 L Banters:10 yes ❑No ®K-Pert Location 1 5 1 ' Brown conglomerate 2 1 1 Manufacturer's Name_ Johnson Brown Hardpan 1 1 1 5 C Type s l o t t e d Model No. R Diam. 5 Slot Size .020 from 154 ftto 1 59 ft Loose brown tong I omerai a 15 23 13 Diem. . Slot Size from ft.to ft. L i to brown hardpan 23 46 CI Gravel/Filter packed: ❑yes ®No Brown sand , pea-gravel 4 6 ❑Size of gravel/sand 1L Materials placed from _ ft.to ft moist 49 Surface Seal: 3Yes ❑No To what depth? 2 1 ft Medium dark clay , sand 4 9 Zs Materials im in.scal B e n t o n i t e moist 57 Did an strata contain unusable water? C y :Yes ®No Medium dark gray clay 57 i Type of water? Depth of strata with gravel , sand 68 Method of sealing strata off M Gray clay dry, pieces 68 PUMP: Manufacturer's Name of wood 1 1 6 Type: H.P. I--- Gray gravel , clay 116 0 WATER LEVELS: Land-surface elevation above mean sea level R cemented dry 1 3 4 z Static level 1 3 5 fl.below top of well Date 1 2-2 7-9 1 N Artesian pressure lbs.per square inch Date Gray clay with gravel 1 3 4 W O Arusian water is controlled by and s e a p a g e 1 5 5 ccap,valve.etc.) Sand, Gravel & wafer 155 159 >' WELL TESTS: Drawdown is amount water level is lowered below static level. O Was a puttp test trade?❑Yes ❑No If yes,by whom? 15 Yield: gal/min.with It drawdown after his. �������D O Yield: gal/min.with ft.drawdown after hrs. W Yield: gal/min.with ft drawdown after hrs. O Recovery data(rime taken as zero when pump turned o )(water level measured from well top to water level) FFR n s ?002 cTime Water Level Time Water Level Time Water Level WachinQtnn Stale 'g — Department of Ecolo,v Date of test CO L Bailer test 1 p gal/min.with__R drawdown after 4 hrs. W Airiest , sal/aria with stern set at ft.for hrs. C) Artesian flow g.p.m. Date W Temperature of water Was a chemical analysis made? ❑Yes 0 No Stan Date 1 2-1 8-0 1 Completed Date 1 2-2 7-0 1 -C I— WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well construction standards.Materials used and the information reported above are true to my best knowledge and belief. t:J Driller CI Engineer ❑Trainee Name( Mark How el on Drilling Company Arcadia Drilling Inc . Driller/Engineer/Trainee Sign Address 1 70 SE W a I k e r Park Road Driller or Trainee License No. 1 9 9 2 City,State,Zip Shelton WA 9 8 5 8 4 Contractor's ARCADD I 0 9 8 K 1 If trainee,licensed driller's - Registration No Date 1 2-2 7-0 1 Signature and L.itmse no. —.---_-.—_-- Thurston County Environmental Health 412 Lilly Rd NE Olympia, WA 98506 —�' 360-867-2631 THURSTON COUNTY "" COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County Collected 1 / 30 i 020aY j� 0 Am 01�S 0 1Month Day 'lea• (-V 7 m Type of Water System(check only one box) V—Rrivate Household sr ❑Group A ❑Group B ❑Othesn%fe 7'An1 41.ree Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): I ID# System Name: Contact Person: {��Lc:hf e-( lei -pp Day Phone:(AO) (-,d _O 72__ Cell Phone:( 09d-0 2 E-mail:yyliC)pp5 ;j,c9/Il,4(le Ce m t Eve.Phone:( ) Send result to:(Rrint full name,address and zip code or email address) __chC l AE -1 WI pp chef r) , -W,� scigsey SAMPLE INFORMATION Sample collected by(name): Specific location or address where sample collected: Special instructions or comments: Ins 4 fAVCe-+ Type of Sample(must check only one box of#1 through#4 listed below) 1.t .Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes No ❑Distribution System Chlorine Residual:Total Free Chlorinated:Yes No 3.Raw Water Source Sample Chlorine Residual:Total Free ❑E.coli—GWR(A/P) ❑Fecal—Surface.GWI.springs(numeration) Unsatisfactory routine lab number: Filtered:Yes No ❑Assessment Monitoring(AIP) Unsatisfactory routine collect date: ❑Other / / S 1 4.0 Sample Collected for Information Only Investigative Construction/Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and Satisfactory ❑E.coli present ❑E.coli absent No liform detected Replacement Sample Required: ❑Sample too old(>30 hours) ❑TNTC ❑ Bacterial Density Results:Total Coliform /100m1. E.coli /100m1. Fecal Coliform 1100ml Enterococci /100 ml. Method Code:0 SM 9223B ❑SM 9222D al and eceived1KT ❑SM 9215E ❑Enterolert® �'Time RP il-0 Dale and Time Analyzed: \ '3 1'Z111 Date Report -I •z f_.-}<.' Sample Number(DOH number plus five digits) Lab Use Only: 0 8 0 - - T I DOIj Form I:331-319(revised 01/16) 2207488 MASON CO WA 02,12/2024 09 47 PM NOTCE MICHPEL KIPP #194977 Rec Fee: $304 50 Pages 2 IIIII IIIIII III IIII I'IDI IIIIII III IIII II II IIIII IIIIIII III IIIII IIIII IIII IIII Return To M idoe1 4po Piques 7 SF L=ct r► Lc e L+U-n c ca A 6 On ,beel/c5 Grantor(s): (1) 10,43 .t g p , Grantee(s): (1) PUBLIC n Legal Description (1) t:.� SFd`,S gt, SQ.L Z I cp Jq A) Q3 CA3 (Abbreviated form:i.e. lot, block, plat or sec ion, township, range) Assessor's Tax Parcel: (1) 3 1 v --7 7 - 5 0 0 3 2— 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) 1 CI d 2 7 7 - Q d 0 2- Tax Parcel: (Connection 2) J C? 0 2- 7 -7 "[ Q 3 The system owner is responsible for keeping this system in compliance. The name of the water system is: !` 1 I3 P D re V C S j/l) e, l 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. q+41 Dated on this day of . , 20t6r.1 4 Signature of Gr tor(s): Page 1 of 2 I State of Washington ) County of Mason ) I, the undersigned, a Nary Public in and for the above named County and State, do hereby certify that on this ' day of 9e,br -1 , 20 2-‘4 , J k`.0\c&\ \i-a pp, ).AVIA \Jay is 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. �� ..';on E;�:C..G %, Notary ublic in and for the St of Washington, �tiQ;�o„�5 20 �''610%0 residing at iJSO N) �(�}.11.h-`� ;_, o ao P ,1 =r. My commission expires: nco-AG a`1 4 S▪ w 1.c.. PPua o o �.1.--- 'se Numbec��o���\`` I Page 2 of 2 684 ,3-)c ,2 - 77- ,a0c,t, ift, 0 1 v. MNE 136.83 EIMED NOV 0 9 2001 3: HEALTH SERVICES 460 \ AGL e Z1-7 . , 72)VEt,(6_, ri it, C4 . _ itock 0 eve.e15. it // 9-o l *. ciok, 1 71 55 i IV pa -�," LA tea^ 0 �xw�. 17) rc-e._ L .EtIL k 31 Qoz:775w 32. • co ,,,,,,Ott . s - ?4 %D. ._ to:7 . . - sktp 3 i‘, , to d3 144P.' ' k j 110 • It 45. + • li ' '\ 100 .6, ., et : OP) � , Vi \ , . 4Ir wr r„. �rae ".. 4 2°1a 16 11110', mo 1 6 f, . :N\,\ ,__. . ; 7 --s--66k'll,, -3:_., 14 [ ` K� • is P -- Al i N 1 • p.L. soo' Cl 11. r i 1 1 .200 o WET J / ~ MIS Al 1 coiv`;x6 Eyisf)Nb 1. )401.4E ii a 51..oft Q� , i Co r 100 .a 1 0 • \5it, '''I al i I \.0 <AV \\ . 11 \ I\ . GoJ �10�0 'QQ / I oa 2c ' I , \ 1 i ----- q\ i3 W j Q HH \ w Bated From Mason County M printed from Mason County DIMS "i") S A�1