HomeMy WebLinkAboutUntitled (2943) MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
riMt: BELFAIR:360-275-4467,EXT 400
� Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
Juan Rivera
PO Box 1326
BELFAIR, WA 98528
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2024-00007
1950 E Rasor Rd
122077500510
The 2-party water system, Rivera Water System (122077500510/122077500510), 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 Date Received:
COMMUNITY SERVICES Amount e�iv 2 _0 y;
Building,Planning,Environmental Health,Community Health � �l�
415 N.6"'Street,(Bldg 8)—Shelton,WA 98584 ��Y E L a_O �� - ��`0��`1110 c,cy
Shelton: 360-427-9670 x400 Bolfair:360-275-4467 x400 Elma:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT PHONE
JUAN RIVERA 360-689-6327 ,0
MAILING ADDRESS—STREET,COY,STATE,ZIP f
PO BOX 1326 BELFAIR, WA 98528
SITE ADDRESS—STREET,CITY,STATE,ZIP
1950 RASOR ROAD, BELFAIR, WA. 98528 061n
PRIMARY PARCEL NUMBER(WELL SITE)
12207-75-00510 RFcF/VFW 2
SECONDARY PARCEL NUMBER(IF APPLICABLE)
12207-75-00510
WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
❑New EXExisting [ Well El Spring
PROPOSED WATER SYSTEM NAME(REQUIRED)
RIVERA WATER SYSTEM
PROJECT DESCRIPTION
TWO PARTY WATER SYSTEM
DIRECTIONS TO SITE/CONDITIONS
GO TO STATE ROUTE 106, TURN UP ALDERWOOD RD, TURN RIGHT ONTO RASOR RD,
GO TO ADDRESS ON THE R1GH I SIDE 01- I HE-<OAD
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
4-7 .1 % (az ti. ., .7., ,
F.' ,--- 11- 1 0 0 LE r
t " ell ( FEB 06 2024 L
(4) _
Submittals Checklist: (these additional items will be required for approval)
gSatisfactory 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
-----_---w-_____W Staff Use Only---------------
Review Step 1: Well Site Inspection:
YES NO NA
❑ ] ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan) ,—.
4 E E Are there roads within the 100 fo t radius of the water source? If so, Is roa(privat , County or State.
What is distance to ROW? 6 O
❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) 'L 4+
❑ 0 Is the well cap satisfactory? Old"re, n,Q °W m I" SCr .
❑ ❑ Screened and vented? / /1
0 The well casing extends / O above level ground I concrete slab? (circle one)
❑ ❑ 9' Is there evidence of a surface seal? L,q 1- - yf•LiC56(Z
❑ ❑ [ Does the seal appear adequate? L OY): _1 L7.yg Z ?7(
❑ [A E] Is a variance necessary for well site approval? 1 Ui• M/t
Comments 4/J A.v 1- 5 c''c c '/ ,ApLe,eA
6-pass ❑ Fail Inspector Date 767?O I
•
Review Step 2: Two-Party Review:
YES NO NA
0 [1:1 ❑ Water Well Report with adequate pump test on file? (2,oio,? fa1(1) )
If NO, date of Capacity Test /!(&/2OJ?L/ Driller RaUff Oifi lib'
! GPM l 7
❑ 0 Received Satisfactory Bacteriological Analysis? Date of test I/(B/'7c?fl
0 0 Received Signed, Notarized, and Recorded Notice? AFN ZZo 7 ZG-7.
cZ! ❑ ❑ System appears adequate to serve 2 single-family residences based on Information provided?
Comments
Approved ❑ Denied Reviewer ` Date 37 (( /722 Y
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.
_ -
•
This form may be scanned and available for public view on the Mason County Web site. Revised: 10/13/2021
Page 2 of 2
Davis Drilling
340 NE Davis Farm Rd
Be!fair, WA 98528
275-5367
Test pump for: Juan Rivera
Project: 1950 E Rasor Rd W, Belfair WA
Pump: sub
Well Depth:
Static Level: 52'
Date: 01/18/2024
Well ID:
Draw Down
Time Water Level Flow GPM
0 min 52' 0
5 min 71' 17
30 min 72' 17
1 hr 72' 17
2 hr 72' 17
Recovery
Time Water Level
0 min 72'
1 min 62'
2 min 68'
3 min 67'
4 min 66'
5 min 66.5'
30 min 52'
einem +
26276 Twelve
Trees Ln NW
Ste.0
Poulsbo,WA
98370
(360)779-5(41
Date Sample Collected lime Sample -Minty
I . 11acct30d 1/1/kay,
Type of Water System(check only one boot)
0 Group A CI Group B thtrerY) K/1'Q
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name; I 1 .) r
Contact Person:
• Dey Phone _ Cell Phone:
En* Eve.Phone:
Send mutts b:(Print LI um,dbuand*code arsm ikon tor Nw4onk copy elmulls)
Al
6519EinitiMilEnigrii=
Step*c bcied bltO nek
Specific location where sample collected: Special instructions or comments
\")v .
1.❑Routine DI*ti Non Sefnpk(AM) 2.❑ Repeat Sample(AIPj
Chlorinated:Yes ❑ No(] (tiom distributor system after unsa.routine)
Unsatisfactory routine lab number.
Chlorine Residual:Total Free
3.Ground Water Rule Source Sample —— ————
S I I Unsatisfactory routine collect date:
Chlorinated:Yes No
❑Triggered( ) Chlorine Residual:Total_Free
❑Assessment(AP)
4.Surface or t3W1 Raw Source Water Sample(Enumeration) I 3
❑ E.con 0 Fecal Mond Ysa_No _
5. Sample Unwed Ix Infcsmetlpn Only,
C1 V...n t f 0.Y4.0 ' Pn p►'gs9n1411d e. ' etoty
&sot eeM`'• • ..a osenf.
y
•Ba il•11,iM i:l3MLfti.Thw i ?tip,. ,, piffir a0:061;,>, _,_it>Pnf1D0a
Fecal h ` . ltili:
RepIaceme(it. am,?l' lr -TNT ,D' jjpietgo.old
o:$ant leVoiume :Ilamagrtt}:OOnta :;
ntr; • /b00. '4:1211.143114Crtion lb
.. 38E'm, 0UN4T/SM92,.2o
rt. .•. . .nnpp.�rryy I ipmoner�pr,pp
• �aeerlriastnNl. .tM d' drrrZYI
4rer,Matbti �f'r lirlrbottp
—• _... 4 a •-_ pw: iinsnnw v.rwsp .vat ;
DOH Fall mwu(d id c i m)
•
2207207 MASON CO WA
02/05/2024 11:28 AM NOTCE
JUAN RIVERA *194744 Rec Fee: $304.BO Pages 2
Return To !Hill III III HI Illli N(MIHI►.IN V
JUAN RIVERA
PO BOX 1326
BELFAIR, WA. 98528
JUAN RIVERA
Grantor(s): (1) , (2)
Grantee(s): (1) PUBLIC
Legal Description (1) tR 51 OF SURVEY 5/94-96
(Abbreviated form:i.e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1) 1 2 20 7 - 7 5 - 0 05 1 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; herein described:
Tax Parcel: (Connection 1) 1 2 2 0 7 - 7 5 - 0 0 5 1 0
Tax Parcel: (Connection 2) 1 2 2 0 7 _ 7 5 _ 0 0 5 1 0
The system owner is responsible for keeping this system in compliance.
The name of the water system is:
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 { 5 day of \[l r1 k a , 20 2 LI.
Signature of Grantor(s):
(1) , (2)
Page 1 of 2
. t
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 I day of 3441 cc/ 20Zt ,
R, personlally 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 yea ove written.
�` ►.,,,a,
N lic'n and for the State of Washington,
�03R. a
NSMj,, ,
1:.,,11.6 ey y residing at (Sri►f
KOTARy "fe s My commission expires: O -1 / / '/2n2k
I 171724 1 ":
iJBLI
Page 2 of 2
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