HomeMy WebLinkAboutUntitled (2940) MASON COUNTY 415 N 6TH STREET, SHELTON,WA 98584
SHELTON: 360-427-9670,EXT 400
• ,`+ryy" BELFAIR:360-275-4467,EXT 400
r Public Health & Human Services ELMA:360-482-5269, EXT 400
FAX:360-427-7787
OGDEN ET AL JESSE DAVID & KAYLA KIANA
480 W Elson Rd
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2024-00012
480 W Elson Rd
419034400030
The 2-party water system, Ogden (419034400030/419034400030), 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.
I
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
•••••. A-7
1210 MASON COUNTY Date Received: 1 2
.I'. COMMUNITY SERVICES Amou cew d: 5_ Received(
/ Building,Planninry Emironmcnlal Health,Community Health
415 N.6th Street,(Bldg 8)—Shelton,WA 98584
WEL fr;,C4)Z* - Q Cc (,
Shelton: 360-427-9670 x400 Bclf'air:360-275-4467 x400 Elm:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT PHONE
e s� o
MAILING ADDRESS—STREET,CIT TATE,ZIP
LESo w EISvv1
SITE ADDRESS-STREET,CITY,STATE,ZIP
Lf,90 v/ L IS o vl RcA Fte71/1
PRIMARY PARCEL NUMBER(WELL SITE) 1 CI D —
S
CO
SECONDARY PARCEL NUMBER(IF APPLICABLE) 33 U A`/qr/V/`75o
WATER SOURCE
�S'OURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LO SIZE
❑New Existing Well ❑ Spring - i- tc. ,s N
PROPOSED WATER SYSTEM NAME(REQUIRED)
PROJECT DESCRIPTION
DIRECTIONS TO SITE/a$1-- c-CONDITIONS ����� ovN Yl jI 11 & E (S'o vk
p t tow r�so-k ,! t etg fr 4 - L-c so i s o t R13 0-
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
Ct
- 1
FEB 2E
Submittals Checklist: (these additional items will be required for approval)
Ig Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled)
Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
tr Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document)
Septic Records (additional locating requirements may apply if there is a lack of septic records on file)
This form may be scanned and available for public view on the Mason County Web site. Revised: 10/13/2021
Page 1 of 2
-------------- ------ Staff Use Only —
Review -----
Review Step 1: Well Site Inspection:
YES NO NA
❑ 11, ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
❑ El Are there roads within the 100 foot radius of the water source? If so, is road private, County or State.
What is distance to ROW?
❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
❑ ❑ ❑ Is the well cap satisfactory?
❑ ri
❑ Screened and vented?
❑ The well casing extends abov level groun I concrete slab? (circle one)
❑ ❑ -Fd, Is there evidence of a surface seal?
❑ ❑ 4-- Does the seal appear adequate?
❑ cki El Is a variance necessary for well site ap royal? 0-rit
Comments `V0 V elo--/ cL t\
(rf,S5L/2 j-cr,/
?$‘Pass El Fail Inspector - ( JUG- - Date ''CD —21
Review Step 2: Two-Party Review:
YES NO NA ISirm k 1414,A1,3,(100a
[X ❑ El Water Well Report with adequate pump test on file?
If NO, date of Capacity Test Y/171 2a0 Driller tikfifil kki L1 f1MM:i GPM ISi—
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test C�(Z�/J 707-
L 1 El ❑ Received Signed, Notarized, and Recorded Notice? AFN 2..140.1101
Ft ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments
XApproved ❑ Denied Reviewer Date .1/8 LO2--(.
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', 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
WATER WELL REPORT CURRENT
Notice of Intent No. W i 11 t-IW
E. Original& 1st copy-Ecology.2nd copy-owner,3rd copy-driller Q 1 '-
Unique Ecology Well ID Tag No.! '' "j
Ctruction/Decommission("x-in circle)
Constriction Water Right Permit No.
0 Decommission ORIGINAL CONSTRUCT7ON Notice fy �
of Intent Number Property Owner Name 14
PROPOSED USE: Domestic IDIndustrial 0 Municipal Well Street Address 6195,Q ll.0. Sk2How L
❑DeWater ❑Irrigation ❑Test Well ❑Ocher w^'a c
TYPE OF WORK: Owner's number of well(if more than one) City�l.��-E Oh CtY 1• �� �r�,�-,�
��{{ Loca601 1/4-1/4 .t/4 Seca- TwnJ_ �EWM cirri
dyNew Well ❑Reconditioned Method:�Dug 0 Bored ❑Driven r`y
❑Deepened DiCablc ❑Rotary 0 Jetted song. �t W
Lat Deg Lai Min/Sec
DIMENSIONS: Diameter of well _inche drilled ' - _f. (s,t,r still
Depth of completed well ft. REQUIRED) Long Deg Long Min/Sec
CONSTRUCTION DETAILS Tax Parcel No. - 19_h2=L1U
Casing relded !b - Dian.from -� 1 ft.to6 1 ft CONSTRUCTION OR DECOMMISSION PROCEDURE
Installed: O Goer instilled - Diarn.from ft to ft. Formation:Describe by color,character,size of material and structure,and the
Threaded land and nature of the material in each stratum penetrated.with at least ooe
❑
Diam.from ft kind
for each change of information.Indicate all water encountered.
Perforations: ❑Yes g No (USE ADDmONAL SHEETS 1F NECESSARY.)
Type of perforator used MATERIAL FROM TO
SIZE of perfs_in.by in.and no.of perfs from , fL to _ ft. 7 0 � j 1/
I /O
Screens:�Yes ❑No K-Pac L.ocationT3 f 5S �1 �i �/
14/
Manufa s Name call 4 s 1{��7 7 ��
T 11 Model No. /f J
Dian. Slot Size_A 0I from_- ___ft.to >'S ft. - y l `j 148
Dian. Slot Size from ft,to ft. 4414., [,�t j�B i 6.0
Gravel/Filter packed: ❑Yes No 0 Size of gravelsand_ a -.),\ / -`� , a�1
Materials placed from ft.to ft- ,t i't,_ 6. i1,')J
Surface Seal: al Yes'No To what depth? � ft _
Materials used in seal ,1'1Z?.-lr#---
Did any strata contain unusable water? CI Yes kij No
Type of water? Depth of strata
Method of scaling strata off _,.,gyp
PUMP Manufactures erne P . U/cam- 11�1
Typ 1?�1lS4b H.P. f 1"' 4
WATER LEVELS1 Land-surface elevation above mean se l vel �0 ft
Static level ft.below top of well Date /9--OZ _
Artesian pressure lbs.per square inch Date
Artesian water is controlled by
(ap.valvc.etc.)
WELL TESTS: Drawdowo is amount water level is lowered� below static level.
Was a p/er test made?EYes 0 No If yes,by whom?f2 77JL .-
Yield: / gallmin.with ! ft.drawdown after -1 hrs. ,
Yield: iral/min.with / ft.drawdown after hrs.
Yield: aallmin.with R.drawdown after hrs.
Recovery data(time taken as zero when pump turned o f(waser level measured from `
well top to water level)
Time Water Level Time Water Level Time Water Level
Date of tes ..4•- -O '
Bailer test '&'f gal/min.with 1(5rft.drawdown after�_hrs. ,
Airtest gal/min.with stem set at ft.for hrs.
Artesian(low g.p.m. Date 5 Z.. I-7—�-
Temperature of water Was a chemical analysis made? ❑Yes 14 No Start Date �7�� Completed Date
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 kelief.
klDriller ❑Engineer ❑Trainee Name 'n E ' Drilling Cornpan ^ //�✓ 1 5r al c.`.-i -
Driller/Enginecrlfrainee SignatI1 A/- .1.— E ---.-.- Adder t1ol 42 LAnp '-
Driller or Trainee License No. 16 City,State,ZiRS-kaftinn C
4 s l6i9y
Contractor's �
If trainee,licensed driller's Registration NI1*2) C Dale 05—r 02—
Signature and License no.
Ecology is an Equal Opportunity Employer. ECY 050-1-20(Rev 4/01)
Printed From o County DMS
rii"(i:(,d irom Mason County OILR'
ut I\
Thurston County Environmental Health
412 Lilly Rd NE t Olympia,WA 98506
= 360 867-2631
T URRam\COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected
Monti Day Year jL .:0-
- i "' 1 `?�>�.•
Type of Water System(check only one box) rivate Household
0 Group A 0 Group B 0 other _-
Group A and Group B Systems-Provide from Water Fadities Inventory(WFI):
ID#
System Name:
Contact Person: vG L � i.62✓�
Day Phone:(q )A:�; •d�"1- Ceti Phone:( )
E-mail: 1Ci,,16 c,1 QNt p!,✓rrca; Eve.Phone:( )
Send results b:(Pont full name,address nd zip code or email address)
.Y'
SAMPLE INFORMATION
Sample collected by(name):
Specific location or address where sample collected: Special instructions or comments:
;f ° r/Yi G+S(e^ 2c
Type of Sample(must check only one box of#1 through#4 listed below)
1.I aRoutine 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.coil-GWR(A/P) — —
❑Fecal-Surface.awl sags Inumera•;cn) Unsatisfactory routine lab number
Filtered:Yes_ No
❑Assessment Monitoring(A/P) Unsatisfactory routine collect date:—
001her /
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 Saa�tisfactory
❑E.coli present ❑E.00li absent No Coliform detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑ _---
Bacterial Density Results:Total Coliform_ /100ml. E.coll /100m1.
Fecal Coifomt-- /100m1 Enlerococci _/100 nd.
Method Code:Ea SM 9223B ❑SM 9222D Date and Ire Received:i t' tG
❑SM 9215B ❑Enterolert®
Dale and Time Analyzed: ,' Date Reported:^ ►?) ',
Servile Numbs-poi number pus te ,
Lab Use orgy. ' .
0 8 0
DOH Faro#331a19(revised 11123)
C k • I114 '/S
2207901 MASON CO WA
02/26/2024 09 19 RM NOTCE
JESSE OGDEN #195294 Rec Fee $304 50 Pages 2
IIIIIII IIIII!I MI I III II IIII 1111 II II!IIII II IIIII!III IIII IIII
Return To
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Grantor(s): (1) J , (2)
Grantee(s): (1) PUBLIC Legal Description (1) C I4 S E ' 'it/ SCC 3 TN N R LI vJ
(Abbreviated form: i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) ( 3 () .- Y - v 0 0 3 0
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;uherein described:
Tax Parcel: (Connection 1) L( I ci o 3- =f I - 0 0 D 3 0
Tax Parcel: (Connection 2)
The system owner is responsible for keeping this sys in mpli ce.
The name of the water system is: P �
This system is designed to provide for two service c cti6s. 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. r'/
Dated on this day of / , 20 Ll
Sig ture of or(s):
(1 , (2)
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 ofT--e'lru,,_af , 2O?
3d ') persoRlly 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 y ast.�bove written.
Zr
N is in and for the State of Washington,
residing at ge
My commission expires: (``1.(/1f3 / 7 0 2
......... ........... ...1. ...
vz\ssoN
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104 NOTARY ,$);
= 171724
s N . PUBLtC
'-,, OF WAS'rV:,
Page 2 of 2
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