HomeMy WebLinkAboutWEL2024-00003 - WEL Application, Design, Letter - 1/2/2024 MASON COUNTY 415N6TLTON 0427-97 ,EXT 400
BH HESTREET STREET,
ON, EXT 400
BELFAIR:360-275-0467,EXT 400
Public Health & Human Services ELMA:360482-5269,EXT 400
FAX 36"27-7787
ROHR REAL ESTATE LLC
2027 WALKER PARK RD
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2024-00003
)OO(SE Walker Park Rd
320215009014
The 2-party water system, Walker Park#1 (320215009014 to 320215009014/320215009017), 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 360427-9670 Ext.353 or email at
danderson@masoncountywa.gov
Sincerely,
a----
David Anderson
Environmental Health Specialist
Mason County Environmental Health
MASON COUNTY
COMMUNITY SERVICES A�uM Rrel
a,rs�an..:pEm:��n.Ix.Im�u.mX�lu -
415 N.6^Sumt,(Bldg 8)-Shdt%y WA 98584 WEL
Shelton: 360427-9670 xa00 Milan.360-2]54t6]AW Elma:36G482-5269 x400
3L
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION 1/
APPLICM I 253—3��vs•
MAI2AaOREB�/-~)BTREEj,CRY.STFT , P A a
�Ll�r/�2 War 1V'J'a l� YIJCYYVr A'
anEACprE amiE ,CITY,9TAT , J�,Y
PRI XYl/P RfELXIIiBERIWELLBnn � p^�I^ 014
SECOXOARYPAR2CEL XOMBE 16MPLICAC 'i M
iq
32Uz1 — — 0901 07l
WATERaWRCE 9W TYPF PPRCELI WT 9QE PARCELS LOT SQE
*ew ❑Existing X Well O Spring QA �, 0,
PW OW TER8Y8TE M
arEk #�
Pao.rECT OEscRwrxw
®� 3zoz%IpX Of Y 702 - - Ul7
%�TMwB TO BItF/COMB
r
Site Plan: (may also be attached)
(property boundaries,stmclums,v h site W 100'radiius,dnv ays,roads,septidsew r components and lines,easements,etc...)
Submittals Checklist: (these additional items will be required for approval)
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)
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 Masan County Web site. Revised: 10/13/2021
Page 1 of 2
Staff Use Only
Review Step 1: Well Site Inspection:
-5r fo sf l q)rr�/ pPru 1
YES NO NA
❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfelds,tanks, buildings; indicate distance on plot plan)
�f ❑ ❑ Are there roads within the 100 fcoLraQus of the water source?If so, is road private,County or State.
What is distance to ROW? SS z
❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan)
R6/f ❑ ❑ Is the well cap satisfactory?
PtJ ❑ ❑ Screened and vented? L.
d� ❑ The well casing extends_6 above level roun /concrete slab?(circle one)
W ❑ ❑ Is there evidence of a surface seal? W r : q�. 20(2-3 Tat
0 ❑ ❑ Does the seal appear adequate? w ; a.(Z j.w6ir
❑ 0 ❑ Is a variance necessary for well site approval? n-•.� ) p Ba a
Comments 1`l IV kill 06 *7-13 f N V! I
to we4lAK
Pass ❑ Fail Inspector Date ! 2
Review Step 2: Two-Party Review:
Y�5 NO NA
❑ . Water Well Report with adequate pump test on fie?
If NO, date of Capacity Test S/lef&?l Driller KIN S "WW 1 S GPM 20
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of t st r
[,�,/� ❑ ❑ Received Signed, Notarized,and Recorded Notice? AFN ZZO V60
Ig, ❑ Eln System appears adequate to serve 22 single-family residences based on information provided?
Comments 1h6( (atl((/ / hLf,& 4r,&y., 31UWq •
T
Approved ❑ Denied Reviewer Date ��10"Y
Findings in this review reflect observedconditions as they existed on the day ofthe site inspection. No claim iiss made,express
or implied ofthe future success orfailure 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 alter January 19e,2018 per FSSB 6091.
Revised: 10/13/2021
This tarts maybe scanned and available for public view on the Mason County Web site.
Page 2 of 2
amne,nis,P„to sedsrcceoasaealaaesaoasnoocaeoa
WATER WELL REPORT 00EPARTMENTOF NOdc,oflnbm No-VVE52S29
ECOLOGY Lot,Ecology W,I11D Tag No.BPC714
'pyeonport; sure dwashindten
® Cmrmmeon Si¢Well Namo IR emre thn one well):
❑ Deooe:muJo wnlledo NOl No. Winer Right PermipCerrificam No.
P .wil use aDined. OlidmviJ ❑Mori! iampcny Owner Name BAD ROHR _—
Dewnedpe ❑Imadod ❑Tin Wdl ❑Omw Wog Soovt Addresa0 WALKER PK RD
cwu.�<dw ryFe: Maaw, aty SHEL70N Cowry N
®Newwell OMlewdon ❑Ddwa ❑lad OCeb4Tod I'
❑DmaJns ❑ahor ❑Des ®Aa. ❑tdWxpmy T.palut No a�tlad0S0900f 320215009014 _ ON39/24
dmw.i...: D ewmhwmp8—h:.,0S5--d wosaverimmappmvedformiawoll4 DYm ®Tk
DeptbidamPlmedwJlT9_&
Coaamedwi DeMW: WJI Ifym,whaz wrthe variepce Wr1
Camp Lmv Mettler Foot, To lDkm<R SM1eI PVC WeNMTinW
® I ❑ Bb. w1_5 n 2_1n. ® 1 ❑ ® 1 ❑ Locedon lsee inatruc5om onpege 2): NWWM or❑EWM
❑ I ❑ —in — — la ❑ 1 ❑ ❑ 1 ❑ SW r r ofthe RF w:seenml21 TowmhT 20N Rww 3W
❑ 1 ❑ _it._ in. ❑ 1 ❑ ❑ 1 ❑ ta0mde(Eaaoplea.12395)aT pns'S3
Longitude(E..pie:-120.12345)-123.06103
Ikrf.rema: ❑Yin RNo typ<OrpW onnI DnEees L.WCommpcion or Decommintop Procedafe
No.ofpararmaos_ nmorpafmYma_m.M—m. Fmm.dw:Dmwb by abr,eh tw..iae of w:dJ and.ee<mn,ad me kind rid
PeRam<d dom_d.m_8bemwpaW auma oeh:mefthemmrvdiu umlamanm.w4 xim ulmwvmey fereah choaM
Senea: ❑Yea 0Ne ❑K-Pa. = Dapb_R. inm:nmm. U.Wtlidwal slam if.W,
bnmechom's Nam, Memri.1 From To
Type hbmi Na FlLL 0 2
Nwde _lu. sbrda_imftwo__Rb_a BROWN CLAY,GRAVEL 2
Mwmr_m. SM Jn_b(m_ftb_ft
30
GRAY SANDY CLAY 30 40
s.miFm<rpam❑Ym ONO S®,fwnk mmiJ GRAY CLAY,SOME GRAVEL 40 55
Mnedm Ple,dflem_mm_R GRAY CLAY,SILTY SAND 55 65
5urfna Sml: ®Yin ❑No T whod'ek7jui, f. SAND&GRAVEL 55 78
Wtenil used in aeJ
Did any sww<®edn wuade wile ❑Yw 0W
Type ofwdol! Deph ofm
Method of.mliup rpmoa
Pomp: Manufaelm<r'.N®e Trva
NP._ Pwpinnkede h'._R. DmiMrdflow,--�
winter t,wdi: I>mo-arfau davmioaabow min xm I<W 4C a
pdck.upof n,"FweRondos-15 aabove pound vufae
Sbt<nnd" nola B.bdowupof.Roming DmeW=
Anmimwm+ao--WC pw.9mre brh Wb W_
ATs'w wmwf.umwlld by (mN vJ.w.msd
Wa tun:
Wa.pumpnpmup,f—wrl ON. ❑Yin �' Mwhpmt
rich!_I9m with_k draw nwo adm_m.
YMd_roe with_ft mawdeww odor_ma.
Yield_amn work_ft mawdownafter_ma.
Remrwy den(thin=mo who Pump is n t d off-wmr lewd meowed flood woll
mpbwuerlowO
lion Wow Leal rime wowL l rime warwfsW
OJeprp�piaet<N —
dderap _ppo with_d.dnwdexa aflu_mn
Ahtml 22_ a.t Law.Adind Dm<RIW28_
Twop®nerepf. -F Complend Dom cnrvp3
WELL CONSTRUCTION CERTIFICATION: i otrotmebd nd/or accept smpo o hility forsamwnion ofthis well,nd'ns cmoPlience with'at Wmhinglon well
rgoswmion mdmds.Mmeri&used rid We odbOomien mpoded above me heu to my tun kdowldge and belief.
®Drillm O Treirme❑ Prim 1. DANIEL KING DrillingC KINGS WATER WELLS
S J �a Addrms 409.23 RETI RD
Cdy,Stale,Zip CENTRE WA
Lknse No.29se — 98531
IF TRAINEE:Spio.res LI..No - ConVooloes
Spmw'•S'pnaR Rcgispedon No.KINGSVWMiOM Onto
5124n3
ECY050-1-20(Revdd/18) IJ}w nod lhir document in an alrema
Penton with hearing loss con coll]11Jor Washitt3mn Refay SeMre. Persons wirhaspeech dimhiliN coo mll811�336341.
Thurston County Environmental Health
2000 Lakeridge Dr.SW •Olympia,WA 98502
360 867-2631
TxuBsmNmurm
` COLIFORM BACTERIA ANALYSIS
Dole Sample CalledetlTlmp Sample Cwnry
Cdeded
Wm I , l . 3-:LEO
Type of Water System(dedc only boil dyale Hauehdd
❑GropA ❑GmpB ❑Other
Group Aand Group B Systems-Pmyide from Wa er Fadlit es Inwntay(WFI):
Off — _ — - -
System Name:
Cantltl Person:
Day Phone:(2 _ Cell Pho:T=,—
E-mail: n04-4
Sendrem b'(an Iname,adme9a mane aema an.)
SAMPLE INFORMATION
Sanlpie'm"'1kdrT name):
clficirlionoraddresswheresamgamllactai`�
: Specidmskucfionsorcomme�.
Rt 3Z.�—Sb-04'O l
Type of Semple(must check a*one box of#1 through IN IiaLLH below)
1.❑Routine Distribution Sample 2 Replant Sample(after onset routine)
Chloiuiand:Yes_No ❑Distribution Syslem
Chlorine Residual:Topl_Free_ Chlonnaled:Yea_No_
3.Raw Water Sourte Sample Chlorine Residual:Total Free_
❑E.win-OWR(W)
❑Fecal-saw.W.apwlaua.aeoN Unsatisfactory routine lab number.
FlXerad:Ym_No_ __ _
❑Assessment Walariig(A>P) Unset6factuiy routrm collect dale:
❑Other
S
4 ample Collected forinformalon Only
Inwstige0w_ Gonsbuclonl Repay Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Conan,Pmsenfand tisMctory
❑E.colipaunt ❑E.cdiabsenl 0 Inxmdeleded
Replacement Sample Required:
❑Sempietwald(40hours) ❑TNTC ❑
Badedal Demity Rmub:Tdal COlifoml HOOml. E.odl I100ml.
Feral ColAoml 100m1 Enlemwal l00 m1.
Wtnod Gade: M9223B ❑SM 9222D Dowadlene
❑SM 9215E ❑Enter"
Dwwand Tlmekalyzed: DeeRepmed:
aampervumenlCW numMqu Rre Mghl we Vane Only:
0 8 0 —zn) —
ooxrpa�w�alsalmwdYmne1 I,—,
2206160 MASON CO WA
01102/2024 03.53 PM NOTLE
RORR REPL ESTRTE 41938M Fec Fee $304.50 Pages 2
1111 ff
Return To
?�27 a- Parka-
�ilA,a..
Grantor(s): (1) ROW r"" 1 � . (2)
Grantee(s): (1) PUBLIC "� k
Legal Description (1) u_ ", i A �Gf FL ) I.ft i q-/(� S So/23O
(Abbreviatedform:i.e. lot, block,plat orsection, township, range)
Assessor's Tax Parcel: (1) _q_
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) L�
Tax Parcel: (Connection 2)
The system owner is responsible for keeping this system'in compliance.
The name of the water system is: �g1W Pg� # I
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. I
Dated on this_a day of PPCPr46e.- , 20 2a.
Signature of Gra or
(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 12. day of 1�2.ceMbe>" , 20 2.3 . 'gradliey ROh(1 Q5
rv\rmmr nc Rohr Rial EMu#r. Ltc. personally appea d before me, w o 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.
nrbrriq Notary i Public in and for the State of Washington,
..........0 � -"+1• residing at OltACnOla
My commission expires: O
8 tl 1..
_o h TAR '
.UBO
b"wnuV ` }�
Page 2 of 2
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