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HomeMy WebLinkAboutUntitled (2960) MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 BELFAIR:360-275-4467,EXT 400 • K, ` . Public Health & Human Services ELMA: 360-482-5269,EXT 400 o w FAX:360-427-7787 PHILLIPS, RICHARD 4111 NE 92ND ST VANCOUVER, WA 98665 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2024-00011 490 W Clear Lake Dr 421355000025 The 2-party water system, 490 Clear Lake System (421355000025/421355000025), 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 "rr..r....k I— _____ MASON COUNTY Date Received 1COMM UNITY SERVICES Amou ce ed Raceme Building,Planning,Environmental Health Community Health __.- 415 N.6th Street,(Bldg 8)—Shelton,WA 98584 W E L 1,0 ) _ 000 I I Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 emm ... TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICAtr) PHONE KI. �l! at:1 (1es 3t0 - 6 4- -v4-i MAILING`ADDRESS-STT)REET,CITY,STATE,ZIP �- O/ / _ SITE D RESS-STREET,CITY,STATE,ZIP Cl qv 4A-4 L.( ` L r% b Sal 5-8 �I PRIMA Y PARCEL NUMBER(WELL SITE) Lizl 3 S SD nva z S SECONDAR PARCEL NUMBE�APPLI000 7-5 WATER SOURCE 3S GVr SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE ❑New Existing i Well 0 Spring z, �Lt c.c. PROPOSED WATER SYSTEM NAME(REQUIRED) —P* z'r4'cte qD -[rat'- Lct Qe S Cry, PROJECT DESCRIPTION (v,.. - e lcj4-1-N vt 5 -k-2 A'D U DIRECTIONS TO SITE/CONDITIONS W c--- p dam-- o a - l DI c - V-t-W. 3 q.Z. S" v+-, G -cam,. L.‘„ l��11 `/ l-C.— o g-. \,- L 51,,, — Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements.etc. .) l --e e v S fj tf FEB `G i 20Z4 By ` Submittals Checklist: (these additional items will be required for approval) PJ Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled) e 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) 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 Site Inspection: YES NO NA '`C►Wl,SG•. y6 06 ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) + J ❑ ❑ Are there roads within the 100 foot radius of the water source? If so, is roa._ County or State. What is distance to ROW? '-7 M ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) Cl V ❑ Is the well cap satisfactory? - 6/V, ' f boil"na5 ). Uri triOu- y ❑ ❑ Screened and vented? ❑ The well casing extends II above level ground/concrete slab? (circle one) X ❑ ❑ Is there evidence of a surface seal? LO.. 10-, a62y33 [ ' ❑ ❑ Does the seal appear adequate? G4111: - 17-3,I ML 4 ❑ X ❑ Is a variance necessary for well site approval? 745: /3 PF 0 Comments °)t.rz m Nall bolt 's, ' Q n iri, or'e n v i facP_ - cal eist e 3/r/?01 Pass ❑ Fail Inspector (fit....„------- Date T/ld 21-f Review Step 2: Two-Party Review: YES NO NA 0 ❑ Water Well Report with adequate pump test on file? LoyPwt 64M/41 : (ZOO,21 tahAl If NO, date of Capacity Test Qt 4/( 05 t, Driller iii-Vilf ri1 I GPM 20 f ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test (/6 70 z3 ❑ ❑ Received Signed, Notarized. and Recorded Notice? AFN Z Z O li4, (1 ❑ ❑ System appears adequate'to serve 2 single-family residences> based on information provided? Comments I'I GC cin l�4eG v' V&- Jt/(?(G0Z y '100 CI q ( le/rQl4i f!/ pev gApproved ❑ Denied Reviewer ,0Date 1/N(Z,0ri 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 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 :y WATER WELL REPORT ionsanil0EPAR1MEN' or Notice of intent No WE52163 E COLOGY Unique Ecology Well ID T No. (3Pf071 Type of work: State of Washington art t7+ Caaauction Site Well Name Of more than one well). D Decommission =^ Original installation Not No. Water Right Permit/Certificate No. Proposed 0 Oev u Eloe Dorstic 0 Industrial o Municipal Property Owner Name Rick Phillips sing 0 Irigauon 0 Test V.ell 0 Other Well Street Address Clear Lake Rd Construe-1km Type: Method: L'9 New well 0 Ake-radon 0 Driven ❑rer.tsd 0 Cable Tool City Shelton County Mason ❑wag 0 Other 0 Dug 9 Air- 0 Hind-Ratary Tax Parcel No 42135-50-00025 Dimmsiaa: Diameter of boring 6 a.,as 140 R. Was a variance approved for this well' 0 Yes E Na Depth of completed well 140 ft Cttatrvctiaa Deeds: Wall - tf yes,what was the variance for? Casing Liner Diameter from To Thickness Steel PVC Welded Thread © 1 0 6 in o - 136 .025 in. O i 0 ES ; D Location(see instructions on page 2). 3 WWM or D EWM ❑ 1 ❑ in. in. ❑ I ❑ ❑ 1 ❑ ❑ ! ❑ in in ❑ 1 ❑ ❑ l ❑ MN '/V.of the SW 'V.;Section 35 Township 21N Range 4W ❑ I ❑ _in in ❑ 1 ❑ ❑ 1 ❑ latitude(Example:47.12345) 47.262433 N Perforations: 0 Yes Eli No Type ofperforator used Longitude(Example:-120.12345j 123.159824 W No.of perforations Size of perforations in.by_in Driller's Log/Coostruetioa or Decommission Procedere Perforated from_fl to &below ground surface Formation.Describe by color.character.size of material and surraure,and the kind and nature of the material in each layer pcncaalcd,with at lust new entry fee each change of Screens: ®Yes 0 No 0 K-Father Depth 134 ft. informairon. Use additiornl sheets if necessary Manufacturer's Kane Alloy Machine Works Type Wire Wrapped Model No. Material from To Diameter 5- ska s ee.oie_in-Gam 13S a ic, 140 it, Fine to medium sandy grave!,silt,tight,dry 0 26 Diameter Slot sae in from ft.m f,. Brown gravelly fine sand,loose,dry 26 32 Black Sandll.ter paebe 0 Yes 1 attack No Sizc material is fine 9raYsand,gray sill bound.dry 32 44 >.tatcriaks placed from tD.to ft. Brown fine sandy gravel,silt bound,tight.dry 44 92 Surface Seal: Q Ycs 0 No To what depth" 19 6_ MU14iCOIOrC4 medium sand,gravel,sharp, 92 Slataial used in seal Bentonite Chips tight.dry 113 Did am strata contain unusable water? ❑Yts El MultiCdofed medium to coarse sandy gravel, 113 t Type of water" Depth of strata rater 140 Method of sealing mats oil tam': Manufacturer's Name Type: I I.P. Pump intake depth: t Designed tow rate. giro Waiter Levets: land-surface aeration above mean sea level 34a fl. Stick-up of top of well casing 1.2 ft.abuse ground surface Static water level 1115 ft.below top of well easing Date 8/423.5 Artesian pressure Ihs-per square merit Date Artesian water is controlled by (cap.rake,ere) '1 Well Tests: Was•ponying test performed? 19 No 0 Yes by whom? Yield gpm with ft_dmawdown after_lrs Yield gpm with_&drawdowe*ter his. Yield gpm will._ft drawdowa after lama 1 Reemery data(now•rcro when pump in nured nil-water level measured from well top to water level) Time Water level Time water Level Time Water Lcvet Date of pumping test Baiter test gpm with__fl Bran Sow a after_bra Air tea 20 gpm with stem ss at 120 ft In. 1 ors Date 8/4/23 lnessan flow_l Temperature of seater _`f Was a chiral analysis made° 0 Yes El No Start Date B/4123 Completed Date 614123 WELL C'ONSfRtiCTION CERTIFICATION: I constructed and/tic accept responsibility for construction of this well,and its compliance with all Washington well construction standards Materials used and the information reported above me true to my best knowledge and belief. Hi Driller 0 Trainee D PI.-Pnnt N R!,, Phythian Drilling Company Arcadia Drifting Inc. Signature -Z_ Address PO Box 1790 License No. 2053 ON,State,Zip Shelton,WA 9E1584 IF TRAINEE.Spwlsor's License No Contractor's Sponsor's Sierwtttre _ Registration No.ARCAD0I098K1 Date 8/4123 C Y 050-I- Rev 04/18) two nerd this dtxautau ai as a(umrut fgrrnat•please call the II aver Resourrrs Program of 36©-407-6571. P ii n eel T orl`gaY?1dF gr;ilirsiri»grrw XcJgr Service Persons urole a sprrc/r rhsahiltat can cal/877.433-b3J(. Printed from Mason County DME. .I Vanguard Laboratory • 2635 Parkmont Lone SW,'Suite A • Olympia WA 98502 Yju?RetnB 360-967-7010 COUFORM BACTERIA ANALYSIS FORM Date Sample Coleded Time Sample County collect08/15/2023 � ❑,, MASON U riCr Car Yea _ fa Pm Type of Water System(check only one boa) Group A 0 Group B I!Other Group A aid Group B Systems-Provide from Water Facirtbes Inventory(WFI) oysamName- RICK PHILLIPS Contact Perron-Arcadia Drilling,Inc Day Phone:(360 )426-3395 t Cell Phone.( ) Email: Eve.Phone:( ) Send results la(Pros ttl name.address ard rep cede ore-inert artRsearoeo+erYsarpcom MID auserookaorohn9 com • __-- SAMPLE INFORMATION sample cowed by(mar-Seth rSOeabc lorab n where sample collected: I Special instructions or comments: j.r8PF071 Lor ir9 Clear Lake Rd.Shelton Type of Sample(select only one type of sample from types 1 through 5 below) 1 0 Routine Distribution Sample(A/P) 2.❑ Repeat Sample(MP) CiuorInattd'Yes No_._-- tirorn ms;neu5pnsystem ahcr carat.rkIMI is Chlorine Residuat Total Free routine tab number 3 Ground Water Ruk Source Sample S I I I Unsatalactcry routine collectdale: t,hiornatea Yes No 0 Triggered(A,P) Chlorne Readuat Total Free 0 Assessment (AR) 4. Surface or DWI Raw Source Water Sample(Enumeration) I S 0 E col ❑Fecal cores rat_ rro _. 5 ®serve Comeded b Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and $Sutiafa,eary 0 Ecoi present 0 E.col absent ) t iBacterial Density Results Total Cobham /100m1 Ecof____ /100nd. Fecal Cohkxm_ /100mi_ HPC /1 mi. Replacement Sample Required: 0 TNTC 0 Sample too old 1 0 Sample Volume 0 Damaged Container ❑_ R T �-r-la6\77111.(7—i 0 AleTod Code DOtab- a l tat lee�lY V�� 3 V�r1 V DOH La-Sarre I reed From i' as � ��:sm,- ,�.�„ nrrtt�l .ar..7A +,.. Printed from Mason County CMS r 2207749 MASON CO WA 02/21/2024 10:43 PM NO10E Re um To pHILLIPS #195194 Rec Fee: $304.50 Pa es2 et ( 1 fiHHN 1II 1II 111111u 11111 IIu 1I 11111 111111111 III1II 1fll a.ylli ,vi ' 2 `• ' f . Grantor(s): (1) 2kdexu r✓'``[k` 105 (2) Grantee(s): (1) PUBLIC ( 3 S' T id iC Legal Description (1) W /Z 7 I7/A 3// S C/ `5 (Abbreviated form:i.e. lot, brock, plat r section, township, range) Assessor's Tax Parcel: (1) 2 I 3 s - S 4 - U Q C? �, S 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) L1_ Z 1 3 S - S U - 0 0 0 2, 5- Tax Parcel: (Connection 2) The system owner is responsible for keeping this system in compliance. The name of the water system is: q 4c L4GG G4Gw) 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 11 day of � / , 20 Z—( Signat of or(s): (1) , (2) Page 1 of 2 1...."1"1111111111111.111.1.m.111"gmill uiti State of Washington ) County of Mason ) I, the undersigned, a Nary Public in and for the above na ed County and State, do hereby --~certify that on this 2 f-- day of e VDYI.(c , 207 , T? C, L Yd Phi[11 . 5 person lly appeared before me, who is known to be signer of the above instrurhent, and acknowledged that he (she) (they) signed it. GIVEN under my hand and official seal the day and year last above written. TERESA L WAY Notary Publ and for the state o ashington, Notary Public residing at (, h State of Washington My commission expires: ()\ 16 2 License Number 135501 My Commission Expires Mar5, 2024 4 Page 2 of 2 Plot Pion g,c k + &i h a Ph;l 1;ps POrft$ if/135-50-00025 Zot,oH .v W CIrar Lake Dr " 70tr se4 Scale: i"= co ' Lgke a 30 r o go 120 1 °rca5rI �, A. ^' 1 v.., 0• `'� A- a 6= 7e Sf H 0 I 5 °� +�, O-Z5a —'�\ o{-KS c `' X Q 6-0 ___&s- —L-1S- ``E6-cS $3. I 1 1\ cz-. 0 ,Qs-- , _-4--‘,(3',Ltt o � 1 3 ,f r J, PROVE D JUL 12 2023 e, MASON COUNTY ENVIRONMENTAL HEALTH 1\ \ ..,.. .=\ ' JBW I\ \ • ,.. �‘' \ ..or %,..,..> NM ♦ 7. 3 Audio-Visual Alarm \ %. 3 Cleanout 3 1200 Gallon Septic Tank 2-Compartment with \ Effluent Filter O12,00 Gallon Pump Chamber j.k V eS • ..,fin Vim. et:. ti..FO a49 Alt 3 ...o..0 owp ULA JOY JOHI�'SON �� r ip 2 8C- % EXa" s , ''• 1 PrIrifed From Mason County DMS Printed from Mason County DMS