HomeMy WebLinkAboutWEL2023-00062 - WEL Application, Design, Letter - 11/14/2023 ON,
564
MASON COUNTY 415N 6THELTON:STREET,SHELT967 ,EXT 400
SHELTON:300427-4467,E%T 400
BELFAIR:360-275-4487,E%T 400 i
Public Health & Human Services El- A:360482-5269,EXT 400
FAX:360427-7787
Antonio Esteban
PO Box 3340
SHELTON, WA98584
RE: WATER SYSTEM PERMIT. TWO-PARTY
WEL2023-00062
469 E Capital Prairie Rd
320084290160
The 2-party water system, 473 and 469 E Capital Prairie Rd (3200642901601320084290160), 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
Sincere
317FIN2y
David Anderson
Environmental Health Specialist
Mason County Environmental Health
MASON COUNTY
COMMUNITY SERVICES Ammm R¢s ANGUYS By
yiMn4pWAiq.FmirmmmdHNM.Canm,nlry NrolJ, /��LY� � '\Il\)ll�,
Shrl,.n 360427-9690 x4013cI�ir81602 4]54 7 400 Ema ���60482-5269 x40
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT PHONE
ANTONIO ESTEBAN 360-401-9555
MAILING ADDRESS-STREET.CITY,STATE,DP
PO BOX 3340, SHELTON, WA. 98584
SITE ADDRESS-STREET,CITY,STATE,DP
469 AND 4M E CAPITAL PRAIRIE RD
PRIMARY PARCEL NUMBER(WELL SITE rVO V„I ,rY gOg9
32008-42-9016b C LJ
SECOND RT PAR N UMBER RFAPP.BLEl Ll
twoL -qI ?01160
WATER SOURCE $pURCETYPE RRAHCEL$LOT&2E
❑New ❑ Existing ❑ Well ❑Spring ACR J
PROPO${q WATER 5Y5 MNAMEIA�UINEDI ���(�
PROJECT.EESSCRIPTMH!
TWO PARTY WATER SYSTEM SERVING TWO RESIDENCES ON SAME PARCEL
GRECTWNS TO SmW CONdTIONS
GO EAST ON JOHNS PRAIRIE ROAD, TURN RIGHT ONTO PRODUCTION/CAPITAL HILL,
URN LEFT ONTE) GAPITAL PRAIRIE RBAB, PAI IS ell T'IE RIG'ITSIBE OF ROAD.
WELL LOCATION IS AT THE END OF THE WOOD FENCE THAT RUNS ALONG CAPITAL PRAIRIE RD.
s1
Site Plan: (may also be attached)
(property boundanes,structures,well site w/100'radius,driveways.roads,septio'se vor components and lines,easements,etc...)
Submittals Checklist: (these additional items will be required for approval)
Qf Satisfactory Bacteriological sample(this may be deferred if well is not yet drilled)
Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
Notice to Future Property Owners recording(record with Mason Co. Auditor, supply copy of recorded document)
14 Septic Records(additional locating requirements may apply if there is a lack of septic records on file)
Thialibrm maybe scanned and available for public New on the Mason County Web site. Revised: 10/13/2021
7
Page i Of 2
....--.--_----_--------_--------------------------______________Staff Use Only --------_---..r.__.�._.-____-__
Review Step 1: Well Site Inspection: 2i y3 - I�odu
YES NO NA 7U ^I" I R ✓ 7rulY�s It'/tf.
❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
�.x (drainfields,tanks, buildings; indicate distance on plot plan)
❑ ❑ Are there roads within the 100 It?clus of the water source?If so, is roa riv County or Stale.
�s( What is distance to ROW?
'F' ❑❑�r❑ Does the ground slope away from the water source site? (show slope on plot plan)
Eg+ ❑ Is the well cap satisfactory? uk. Pxe'a tx 610
❑ ❑ Screened and vented? (t
❑ The well casing extends -above level ground/concrete slab? (circle one)
p� [I El Is there evidence of a surface seal? tAl: 47,23q,II1
{
`f't ❑t��l El Does the seal appear adequate? toA( 'llZ 6p0$'11
ElY' ❑ isat_variance necessary for well site approval? TAq
Comments Jeff r't drmso' k'kn loyL ^Zri �nw Wl IWRoC
tp� ►hrN�_-- - �rrt� i�an Sa ' M '`�i . �e ni�leclall tG/mZti
0 ' Paas 456--Fail Inspector Date 1147
/7 �7a7?
j14
Review Step 2: Two-Party Review:
YES NO NA J-
Water Well Report with adequate pump test on file? {VOl/YI4Yl �Ij,
fri-
If NO,date of Capacity Test 10 "r/WI F Driller GPM �/w1�
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN
V ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments (lrrC
Iy1 Approved ❑ Denied Reviewer Date
(� 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 additirned hays mar apply to all new wells drilled after January 10, 2018 per ESSB 6091.
This form maybe scanned and available for public view on the Mason County Web site. Revised: 10/13/2021
Q Page 2 of 2
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Thurston County Environmental Health
2000 Lakeridge Dr.SW 1 Olympia,WA 98502
360 867-2631
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COLIFORM BACTERIA ANALYSIS
Dad Sample Colbcled ivm Sample County
i l i 6 i ,23 DWte ted
aqS o VIMaM OH Year —O
Type of Water System(check only am box) Privad No
❑GrwpA ❑Group B Od
Group A and Group B Systems-ProvrJe from Water citifies MArAdV623
ID# — RECEIVED
System Name:
G.mdrA Pemson: oN lO a a qs
Dar Phone:( 6) qDt_ q R 1 rj I Call Phone:C3toy 4N IF5' S-
EmaiL Swarm: )
Send resold la Prim Nliname.atl wkxiD nnxw all edtreul
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SAMPLE INFORMATION
Sample collected by(came):
Spedfic oration or address Wrese sample w5e&d'. Specialimbucfiom ortommems:
L{bR E W;W VcoLi('Je
ka Sk. EohOat Q53y
Type'- ample lmusl checkonlyoad box of#1 lhrou9h#4 listed below)
1. ftoulim DialrlbNlon Semple 2.Repeat Sample(after onset routine)
Chlorinated:Yes_No_ ❑Distribullm System
.' Chlorin Residual:Toll_Free_ Chlorinated:Yes_Nc_
3.Raw Water Source Sample Chlorine Residual:Total_Frae_
❑E.tali-GWR(A/P)
❑Fecal-Son—.GWt swire.(—..) Unsatlsfactcry."a db mamba,
Fiidreu.Yea_No _ _ ____
❑Assessment Mandan,(A,P) UnsaOslamory routine collect data
❑0ttler
S
4.❑Sample Collected for lnformefion On%
Inreslyame_ Cambucticnl Repairs_ Odw—
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coition Presenlmd fisfactory
❑E.mli present ❑E.cayabmnt .ColOmm detMed
Replacement Sample Required:
❑Sample do old(s30 boom) ❑TNTC ❑
BwtwiMDmsdy Resulls:ToWCokfwm It00M. E.co# /100m1.
F.1 Codomm MOml Enteromcci /1 Do mi.
Method Cade: SM 9223E ❑SM 9222D Dmawd r,.R
❑SM 9215E ❑EnterolerS
Ddeavd Tore Analyzed: -+- 23
Dad Report -�
.a.Nasn"c rrrararnre anatc, q UbUre0dy:
0 8 0
IXWFamX111d191rerufE 01n6 �� �O�
2204834 MASON CO ANOV�a
Return To 111221M23901 56 PM Nsc PmCEEIDO 50 Pa9es. Y
ANTONIO ESTEBAN ��������BBII��I� �I��� ��II��IN�II�� �I�II�����A��� ��INI �92023
PO BOX 3340 R��FryF�
SHELTON, WA. 98584
Grantor(s): (1) ANTONIO ESTEBAN (2)
Grantse(s): (1)PUBLIC
Legal Description (1) Ala our k lk SE Sri 0;1-6 j,
(Abbreviated tom:i.e.lot block.plat or section. township, range)
Assessor's Tax Parcel: (1) 3 2 0 0 8 _ 4 2 _ 9 0 1 6 0
NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM
1 (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) 3 2 0 0 8 _ 4 2 _ 9 0 1 6 0
3 2 0 0 8 4 2 9 0 1 6 0
Tax Parcel: (Connection 2)_____---------
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. t
Dated on this day of
Signature of Grantors):
Page 1 of 2
State of Washington )
County of Mason )
I, the undersigned, a N ry Public iqq and for the above named County and State,do hereby
erti that on this day of NOVA, 20 ,
_YI I)) �'ICl/V�If� �� .'I oersonally 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
p/[��e j�--
TERESA L WAY " j "
Notary Public Notary Public lig and forth State ashington,
State of Washington residing at
License Number 136501 My commission expires:
My Commission Expires
May16,2024
Page 2 of 2
Mason County WA GIS Web Map
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11/10/2023, 7:57:33 AM
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Tax Parcels (Zoom in to 1:30,000)
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