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HomeMy WebLinkAboutPROPOSED EXPANSION OF WATER SYSTEM PUMPHOUSE - WEL Letters / Memos - 9/13/2012 f.�a°" °pDNrp MASON COUNTY Shelton (360) 427-9670 DEPARTMENT OF COMMUNITY DEVELOPMENT Belfair (360) 275-4467 Pldnning Elma (360)482-5269 Mason County Bldg.1 01 N.511, P.O.Box Shelton,WA 995B4 September 13, 2012 Vineyard Cove Corporation P.O. Box 53 Grapeview WA. 98546 RE: Proposed Expansion of Water System Pumphouse f 0 Vineyard Cove Corporation (attn. David Biermann): You met with the Dept. of Community Development Planner (Allan Borden) on September 6, 2012, to discuss a proposed wellhouse with interior tanks that need to protect the existing wellhead. The proposed building improvements are to implement certain elements of the Small Water System Management Program Plan approved in April 2011. - The September 6, 2012 meeting was arranged to address several concerns by Vineyard Cove about the location of the building improvements. A. The existing wellhead is contained within a pumphouse building that is 4.9 feet from the front property line along Stretch Island Rd. South. B. The improvements called for in the management plan (storage and pressure tanks) occupy a greater area than the existing pumphouse. C. The proposed community building would not meet the Mason County Development Regulations for structure setbacks. Allan Borden stated that the existing building is non-conforming in respect to property lines; the proper setback from the front property line or road is 10 feet(by review of an administrative variance). In addition, he discussed the provision in Mason Co. Development Regulations Section 17.05.014 Alterations and Enlargements: A. Unless otherwise specifically provided in this Ordinance, nonconforming buildings shall not be enlarged or structurally altered.unless the enlargement or alteration is required by law, or unless the enlarged building area is occupied by a conforming use. In this case, the Washington Dept. of Health has approved a water system management plan for Vineyard Cove to meet the current water supply health standards. The actions of that plan includes the needed improvements to the wellhouse structure, storage tanks, and protection of the wellhead. The proposal to replace the existing wellhouse meets the above provision regarding a non-conforming building and area of land use, and the water system components are a conforming land use. l This letter was prepared to note that the conceptual review of this proposed new wellhouse was done in early September 2012. With the conclusions stated above, no standard variance review is needed for the replaced wellhouse. Vineyard Cove may submit the necessary applications for the proposed wellhouse and improvements to replace the existing water system wellhouse. If you have further questions on this matter, please contact me. Allan Borden. - Long Range &Site Inspection P.O. Box 279, Shelton, WA 98584 (360) 427-9670 ext. 365 i i -52- 17.05 Administrative Procedures 17.05.005. Structures and Uses. 17.05.006. Review of Structures Structures which are assembled for a certain purpose or use shall be reviewed under the standards of that use(for example,boathouse,dock,boat lift,shed,or deck),whether secured in a fixed location or on a mobile framework. 17.05.010 Nonconforming Buildings and Uses 17.05.011 Applicability The provisions of this Section shall apply to buildings,lands or uses which become nonconforming as a result of the application of this Ordinance to them,or from the classification or reclassification of the property under this Ordinance,or any subsequent amendment thereto. 17.05.012 Continuing Existing Uses A. Any lawful use of land and/or building or structure,either existing or under construction, may be continued,without regard to whether the use or building becomes nonconforming as a result of application of this Ordinance. B. Any lawful use of land and/or building or structure for which a use or building permit has been applied may(subject to the issuance of such permit)be completed,and may be used as intended,without regard to whether the use or building would be nonconforming as a result of application of this Ordinance. C. Any lawful use of land and/or building or structure which is vested by application of state law may be completed,and may be used as intended,without regard to whether the use or building would be nonconforming as a result of application of this Ordinance. 17.05.014 Alterations and Enlargements A. Unless otherwise specifically provided in this Ordinance,nonconforming buildings shall not be enlarged or structurally altered unless the enlargement or alteration is required by law,or unless the enlarged building area is occupied by a conforming use. Any such enlargement or structural alteration shall meet the buffer requirements of this Ordinance, as those buffer requirements are applied to the entire parcel of land,subject to the determination of the Administrator,as set forth in Section 17.03.036(Cx3). B. Nonconforming non-residential uses and structures located outside Urban Growth Areas may be permitted to expand,subject to the following conditions: 1. The floor area of the existing building(s)shall not increase by more than twenty (20%)percent or ten thousand square feet,whichever is greater,and 2. The buffer yard requirements of this Ordinance shall be applied to the entire parcel of land,and shall be met,subject to the determination of the Administrator,as set forth in Section 17.03.036(C)(3). MASON COUNTY DEVELOPMENT REGULATIONS June 2,2009 - 53 - C. Normal upkeep,repair and maintenance of nonconforming structures is permitted, provided that such activities shall not increase the nonconformity of the use or structure(s). D. Unless otherwise specifically provided in this Ordinance,no nonconforming use shall be enlarged or increased,or extended to occupy a greater area of land than occupied by such use at the time this Ordinance becomes effective. E. Unless otherwise specifically provided in this Ordinance,no nonconforming use shall be moved, in whole or in part,to any other portion of the lot or parcel of land occupied by the nonconforming use at the time this Ordinance becomes effective. 17.05.016 Abandonment; reconstruction A. If any nonconforming use of land and/or building is abandoned,or ceases for my reason whatsoever(including destruction of the building)for a period of two years or more,then any future use of such land and/or building shall conform to the provisions of this Ordinance. Upon written request of the property owner,the Administrator shall grant one,one-year extension to the aforementioned two-year period. B. Any nonconforming building or structure which has been damaged or destroyed by fine, earthquake,flood,wind or other disaster may be rebuilt for the same nonconforming use only,subject to the following restrictions: 1. The restoration or repair of such nonconforming building shall not serve to extend or increase the nonconformance of the original building or use;and 2. A building permit allowing for such restoration or repair must be issued within two years of the disaster. Upon written request of the property owner,the Administrator shall grant one,one-year extension to the aforementioned two-year period. 17.05.018 Change of Use Any current nonconforming use of land or a structure shall not be changed to any other use,unless: 1. The new use conforms to the provisions of this Ordinance;or 2. The new use is of equal or lesser intensity than the most current use,as determined by the Classification of Land Uses,FIGURE 17.03.034;or 3. By Special Use permit,the new use is of equal to or less intensity than any prior use that occurred in a ten-year period preceding the date of application for said Special Use Permit,based upon the current site conditions and compatibility with area land uses;and 4. Provided that the land use has not been abandoned per Section 17.05.016. 17.05.020 Temporary Uses 17.05.022 Temporary Construction Buildings Temporary structures for the housing of tools and equipment,or buildings containing supervisory offices in connection with construction projects,may be established and maintained during the progress of construction on such progress. Such buildings and/or structures shall be abated and MASON COUNTY DEVELOPMENT REGULATIONS June 2,2009 4 MAY 6 2011 STATE OF WASHINGTON DEPARTMENT OF HEALTH�IypI��eeyY SOUTHWEST DRINKING WATER REGIONAI OPERATfONO 2011 PO Box 47813, Olympia, Washington 98504-7823 TDD Relay 1400-833-6388 April 28, 2011 Jonathan Wiley Northwest Water Systems Inc. Post Office Box 123 Port Orchard, Washington 98366-0123 Subject: Vineyard Cove Corporation, ID #91917C,Mason County; Small Water System Management Program Plan, ODW Project#10-0901 Dear Jonathan Wiley: The Small Water System Management Program (SWSMP)plan and project report with construction documents for system improvements received by the Office of Drinking Water (ODW)on September 17, 2010, along with subsequent submittals received on February 3, 2011, and April 8, 2011, have been reviewed and in accordance with the provisions of WAC 246-290, are APPROVED. Approval of this project is valid as it relates to current standards outlined in WAC 246-290 revised November 1,2010, WAC 246-293 revised September 1997,and RCW 70.116 (Municipal Water Law)effective September 2003, and is subject to the qualifications herein. Future changes in the rules and statutes may be more stringent and require facility modification or corrective action. This submittal has been reviewed as a Group A water system project submittal in accordance with WAC 246-290. The improvement project includes addition of a 6,100-gallon reservoir and two booster pumps to the system. As required in WAC 246-290-120(5)-within sixty days following the completion of and prior to use of the improvements,the enclosed construction completion report must be completed by a professional engineer and returned to ODW. Per WAC 246-290-120(6),please revise the enclosed water facilities inventory(WFI) report form and submit with the construction completion report to reflect the changes or additions resulting from this project. Based on information provided in this SWSMP, the number of approved service connections is 31 residential connections. This is an increase from 28 to 31 connections,but the additional Jonathan Wiley April 28, 2011 Page 2 MAY 6 2011 connections are considered infill with the existing service area and this system is not expanding. Contact ODW if this system intends to expand service to new customers. This system will be required to submit planning or engineering documents to ODW prior to gaining approval to serve additional customers. Operating Permit. At that time, this system's operating permit will also be changed to green to reflect the system being in substantial compliance with applicable drinking water regulations. WATER RESOURCES This approval does not provide any guarantee and should not be considered to provide any guarantee concerning legal use of water or any subsequent water right decisions by the Department of Ecology(Ecology). A copy of this document was sent to Ecology on September 17,2010. As of the date of this letter, comments have not been received from Ecology. ODW is making this approval based upon the system's water right analysis. WATERSHED PLANNING Ecology has not determined if this SWSMP is"not inconsistent"with the adopted watershed plan for WRIA 14. Please contact Ecology for more information. If you have any questions,please contact me at (360) 236-3031 or Regina Grimm at (360) 236- 3035. /�Siinnc�enelllyy,, gonna d2yes RegAB Grimm, P.E. Office of Drinking Water, Regional Planner Office of Drinking Water, Regional Engineer Enclosures cc: Todd Krause,Northwest Water Systems Inc. Mason County Health Department Mason County Planning Department Amy Nielson, Department of Ecology Element 16: List of System Improvements Update as needed with addition or repair of system components *All costs are approximate and in 2010 dollars. Item Year Cost Financing method (borrow, surcharge $s, Pay as you go, use existing reserves) Upgrade or replace pumphouse 2013 $ 4,000 Reserves Add storage and booster station 2013 $20,000 Reserves Replace Service Laterals 2016 $30,000 Reserves Replace Mains 2030+ $50,000 Reserves Element 4: Sanitary Survey Previous Survey Task Completion Notes Date Date of Survey 11/19/2007 Received Sanitary Survey Report 12/21/2007 Install screened vent 2/12/2008 Complete Coliform Monitoring Plan July 2009 Revised June 2010 Upgrades, Budget, Schedule 2/18/2010 Capacity Analysis June 2010 SWSMP Ma 2010 Upgrade Pum house Controls Aug. 2010 Authorize Booster Station Design Seal wires at access port in wellhead 2/12/2008 Do not store generator in pumphouse n/a Propane fuel not a high hazard for contamination Have pressure tanks checked May 2010 All but 1 removed,cycle stop installed Low pressure at peak usage 2/18/2010 Capacity Analysis Aug. 2010 Authorize Booster Station Design Complete SWSMP I Aug. 2009 1 Updated June 2010 Additional Items Not in Sanitary Sury Fill knock-out with pea vel Au Se `10 antici ated Install grate on floor drain Au `10 I anticipated Provide for rodent control A e `10 I anticipated Next Survey—Fall 2012 Task Completed Notes System contacted for next Sanitary Survey x Scheduled for October 24,2012 Arrange for appropriate staff to be available x NWS &Paula Dillard Water Comm System records organized and available x Final preparation completed Survey follow-up letter received Needed Corrections Scheduled Next Survey—Fall 2017 Task Completed Notes System contacted for next Sanitary Survey Arrange for appropriate staff to be available System records organized and available Final arauon completed Survey follow-up letter received Needed Corrections Scheduled RVRr Tg �"1 ,e N STATE OF WASHINGTON DEPARTMENT OF HEALTH SOUTHWEST DRINKING WATER REGIONAL OPERATIONS PO Box 47823,Olympia, Washington 98504-7823 TDD Relay 1-800-833-6388 March 31,2008 Vineyard Cove Corporation Vineyard Cove Corporation Post Office Box 53 Grapeview, Washington 98546 Subject: Vineyard Cove Corporation, ID#91917C, Mason County; Sanitary Survey Inspection on September 26, 2007 Dear Water System Owner: Thank you for taking the time to meet with Arlene Hyatt for the Sanitary Survey. You should have received a copy of the completed Sanitary Survey Inspection(SSO Report. Please read the report carefully as it describes the results of the inspection. This report has been prepared to assist you in providing safe and reliable drinking water. It is your responsibility to correct any deficiencies noted in the Report. By completing this SSI, the regulatory requirement for a physical inspection of the facilities,records,and operations has been met, WAC 246- 290-300 (6)and 416. Regulations establishing a schedule of fees for sanitary surveys were adopted May 1,2002,(WAC 246- 290-990(3) (c)). An invoice for$297 is enclosed. I appreciate your assistance during the SSI process. If you have questions,please contact me at (360) 236-3028 or by e-mail at denise.grant@doh.wa.gov. Sincerely, , 1J5L�-A� DENISE GRANT Office of Drinking Water, Sanitary Survey Program Manager Enclosures ce: James Stark,Vineyard Cove Corporation MASON COUNTY PUBLIC HEALTH X,IMENTAL HFJLLW PERSONAL HEALTH W.Cedot 303 N.Fourth PO Box 1666 PO Box 1666 y,�n ,WA 98W4 Shelton.WA 9&%4 (360)427-9670 , Foe(360)427-7798 • Elmo(36M 4825269 • BoMir(360)275-4467 • wwweo.rrwson.wa.us Vineyard Cove Corporation December 21,2007 C/O•.Fames Static P.O. But S45 Grapeview,TVA 9S546 SUBJECT: Vineyard Cove Corporation M k 91917C Mason County Third Party Sanitary Survey inspection Report Dray Water System Manager: This letter and inspection report serve as a follow-up to the recent sanitary survey physical inspection of your water system facilities,records and operations. This office is duly authorized to perform sanitary survey inspections under Chapter 246-290.416 of the Washington Administrative Code(WAC)under contract to lie Washington State Department of Health,Office of Drinking Water. Thank you for taking the time to meet with me to show me your water system and explain its operations. A copy of the completed Sanitary Survey Checklist Report is enclosed. Please review the report carefully,as it describes deficiencies observed and recommendations for improvements. Unless otherwise rioted,all deficiencies need to be taken care of in your routine operations and maintenance wort:. We will verify completion during our next sanitary survey. Recommendations: ➢ tnsW[a screened well cront. ��*-EC"Q"'� �r-21"6 f�'"C r•/v�ng ➢ Complete the Small Water System Management Program Guide. ➢ Complete a Colifmtm Monitoring Plan,which should include a map and at least three routine sampling locations. ➢ The system should begin work on a budget to address upgrades. Storage seems inadequate for system size and distribution lines will likely require replacement in the near future. The system does not appear capable of serving all connections should they become full-time residences in the future. ➢ Seal wires st access port in wellhead. Z-rZ-oT• Qi ➢ Do not store generator in the well house. Recommend storing it in a member's garage until it is needed or sealing off in a separate room attached to the well house. ➢ Have pressure tanks checked one appears waterlogged. a+ •�^- �—dg� ➢ Pressure drops during peak use periods. Recommend inc asi system storage capacity. : s(rv[>.e, P.i�Eywc. - � .sa �"-zx..rF.-�rtA1 3Go-za4-9s Always working fora safar and heanhier Mason County A copy of this letter and checklist is being forwarded to the appropriate Department of Health(DOH) staff for their review. DOH will contact you if they identify my deficiencies of high public health risk that require your immediate attention. Please contact Denise Grant at Southwest Regional Office of the Office of Drinking Water at(360)236-3028, if you need their assistance. If you have any questions regarding your Sanitary Survey Checklist Report,please call me at(360)427- 9670 ext. 293. Sincerely, Arlene Hyatt Environmental Health Specialist Enclosure: Sanitary Survey Checklist Report cc: DOH Southwest Regional Office, Denise Grant ru lot& cl �. - Y3 GroupA Small WaterSystern Sanitary Survey WASHINGTON STATE DEPARTMENT OF HEALTH >yslem Name: Vineyard Cove Corporation Survey Date: ' November 19,2007 PWS ID#: 91917C County: Mason County PWS Representative Attending Inspection: Jim Stark Other Persons Attending Inspection: Inspectors Name: Arlene Hyatt QSS ID#: 480 PART A: SUMMARY OF •N FINDINGS&RECOMMENDATIONS The following Is a completed sanitary survey checklist and summary of inspection findings. Read the report cerefuly,es it descnbes deficiencies observed and recommendations for improvements.You are responsible for correcting all deficiencies. Bolded checklist questions represent deficiencies that may have a greater potential to affect the water system's rapacity to serve safe and reliable water. Department of Health Office of Drinking Water(DOH ODW)regional office serving your county is available to answer questions you may have about this survey. DOH ODW contact information can be found at httpJhvww.doh.wa.gov/ehp/dwl. DeficienciesjPjjte4tiaI High Public Health Risk(HPHR) Observed Deficiencies that may meet the criteria for potential HPHR are noted below. HPHR deficiencies are hems DOH ODW has determined need immediate attention. DOH ODW will review and confirm potential HPHR deficiencies and notify you in writing If any Immediate follow-up action is required. ❑ None observed ❑ Susceptible sources with high risk sanitary control area threats. ❑ Inoperable treatment facilities,when treatment is required by DOH for primary acute contaminants(such as surhce water, required disinfecton,nitrate remedis0on)._ ❑ Newly discovered unfiltered surface water sources and/or unapproved groundwater sources in use with no water quality history and not listed on the WFI. - - ❑ Confirmed be ckflow incidents. Documented cases of fraudulent operation and/or reporting or wiltrul neglect by the operator. Other man based on professional Judgment. _ Brief description of potential HPHR deficiencies checked above: �.Other DeficlencAes Observed Other deficiencies are items observed during the sanitary survey that should be convicted as soon as feasible.Inspectors will check on their completion at the next site visit. Deficiencies corrected since the last santtary survey: .. t. 2. 3. ' Deficiencies that remain from the last sanitary survey: . . I. AIJ scv K.f-.✓12.d r.�C�� ✓G✓l� _...._ 2. 9. ^ther deficiencies observed during this sanitary survey and recommendations for improvements: t.. ... 7�lC �PI�t�,91'_/�/✓no-�l Wa9f.✓ ..SVS-1"?e�-7_ Nlaf,lR9fNYIP�y1 _. ._ ._.._-. 002g(16) Todownbad an electrank,version of this checklist,veft htlp:ltw ,dohwagov/ehp/dwfPPrograms/ss_thirdyany.htm DOH Group A Small Water System Sanitary Survey Checklist11 or PWS IDN: 91917C Survey Date: 11A9/07 Deficiencies • . inner deficiencies observed during this sanitary survey and recommendations for Improvements(cony): 2. ale I, x �l�,-.� ✓ ", -� p" e�.,Wpk w �e , �t 3. .5ys�c.,, Y SS art VlOj 'ace-5 - Sfo_✓19 SreenrS inac�!P ;aa--, 4. �� SyS�ev 5/ ze A cl R/l �113�r, 6u fr✓+ /yes /,ke(� f[Zufre dp j(oc-i , ri 44q rleax r-Fi.,4o.r2 , S s-�e.v; .See.nel-y5 6. NlCw,,Ut ' D (�� Sk���e.--1� �4 Lfij co.nnec4 ,s s sko /J 4-k S�+s1� Screerle� (� I 6. 7. .�' w l C c—e S. Vo 144 54-bre �2X12�o�-- e-�- YirI K)d Iny,.rCOe �S-Fel tee. 14 �'¢vn1. &t-__�tu�.__bNl�✓��tlrn . --�rzr�Lc���` 5-- - - 9. �:; Ce S`�r� ko n1L,S � l pen.x s t4 -'4tv '012,.4 - 10. �SSw✓2 aro�5r rod _ . .vAftqsl5'.~ 12.. 13. 14. ,6. (1012006) To download an elec,ronic version of this checklist,visit hdp:t/ .doh.wa,gov/ehp/dw/Programslss_third_pany.htm DOH Group A Small Water System Sanitary Survey Checklist PWS ID#: 91917C,RT IS: GENERAL Survey Dete: 11rt9A7 DESCRIPTION i General description of the water system including estimated total population and number of connections,direction of flow(from source to distribution), how the controls function,storage,treatment if any,and number of pressure zones. ✓n.c AJa..�tr . ys4--e_w 6:e.r✓e (7) -F l/— -f,me rr �s,c�%/,/ ee S, fiJPM "frJO Cud PaN'�--{"rMf �'eslc�fil'i LC.S Al e/if C t ) Connecl,on , f11t F�/� � •,+e IOoP 1 m i5 13 , a1,✓ o% a�S , �!e Py-I---i,.W< �'B.v.la,.-l-fo-n ✓zrrtS -�-w�9 14 12. iho�r ✓�o�.✓.a �s �er wrn.vrl A. d At (eerea-/✓av l ..ft/'diU �aS �cf �steh dSE�' DOCUMENTS 2. Has the water system completed the following elements of a Small Water System Management Program(WAC 246-29(1-105)? Element 1:Water Facilities Inventory(WFI)Records � Elyse []No[]Partial Element 2:Water Quality Monitoring Program(including Colifono Monitoring Plan) (✓�erK r✓.O pq ,�' []Yes'ONo[]Partial Element 3:Consumer Confidence Report ,Jy A- []Yes[]No[]Partial Element 4:Sanitary Survey Records 29es[]No[]Partial Element 5:Annual Operating Permit Records Was[]No[]Partial Element 6:Cross-Connection Control Program (as per WAC 246-290.490) []Yes CRNo[]Partial Element 7:Emergency Response Plan []Yes Otto[]Partial Element 8:Service Area and Facility Map 19Yes[]No[]Partial Element 9:Operation and Maintenance Program []Yes)RNo[]Partial Element 10:Wellhead Protection Program []Yes JgNo[]Partial Element 11:Water Right Documentation L.E64-Lt LoP4 ErYes[]No[]Partial Element 12: Record of Source Water Pumped []Yes[]No[]Partial Element 13:Water Usage Records Fryers []No[]Partial Element 14:Water Conservation Program []Yes:BNo[]Partial Element 15: Component Inventory and Assessment []Yes jallo[]Partial Element 16: List of System Improvements 1` []Yes VNo[]Partial �C Element 17:Operating Budget #{ Jt.( fl,04e (Y1 []Yes'lEgNo[]Perfisl Element 18:System Management Practices and Processes []Yes[]No KPartial 3. Does the system have emergency power? 'RYes[]No 4. If yes to question#3,what type of emergency power is available: El Generator,automatic swhchover [] Portable with transfer switch Transfer switch only ❑Generator, manual switchover []Other: 5. If yes to question#4,frequency of testing: 1 [] Monthly ❑Quarterly O Annually ❑ Infrequently ❑ Never 6.Water system's current and future water quality monitoring plans were reviewed (check all that apply): []Coliform monitoring plan ❑ D/DSP monitoring plan ❑WQMR monitoring plan ❑ Other: 7. According to DOH records,the certified operator for this water system is: 8. If the certified operator on record is not correct,who is the certified operator9 Instmet the operator to contact the DOH Operator Certification Program at 1-800525-2536 to update their records. Note:Transient Non-Community water systems are not typically required to have a certified operator. c Comments: (10/2006) To download an electronic version of this checklist visit http./Mt .d-h.m.gov/ehp/dw/Programslssjhird_pafty.htm DOH Group A Small Water System Sanitary Survey Checklist I PWS ID#: 91917C Survey Date: 11/19/07 reproduced�.RT D: SOURCE FACILITIES (This page maybe , more sources) .D.DOH Source Number. SO# 1 SO# it. Source Name ftom the WFI:(For example, North Well;Well#2 ABC334 J 12. Dept of Ecology Wefl Tag Number.(Use Well tag ID# None or Not readable) ___ .._ _ _.. .. _ ___. T.- _ ..._ "—_— .. —. _ .--_.._. 13.Sou- Use: P_Permanent S-Seasonal E•Emergency 14. If this Is an emergency source,is N physically disconnected? ❑Yak ONO ❑Yee ONO UgkDgkm nu"k09Y01.._.... 15.What is the physical location of the source?Use reterencea such as cross street,address or directions to locate in the field. _ SO#. A"O SO# 16.In the source listed on the Water Facilities Inventory(WFI)report? N3Yw ONO _❑Yes❑No 17.H no to question#78 indicate source type: _— __ SQ# ❑Groundwater ❑Surface Water ❑Sprerg ❑ Intartle SO# - ❑Groundwater ❑Surface Water 1 ❑Spring ❑ Intertie 18. Is the source more than set feet from—suro,the water AND the top ofpotential first open ������////// Interval Is more than 60 het deep?H no,the source Is conaldered a porendal �es [:)No ❑Yes ONO groundwater under the influence of surface water(GWI)and will need additional Unknown ❑Unknown review by DOH to confirm GWI status. 19. Is source Sanitary Control Area(SCA)protected from any obvious biological or � chemical sources of onto�qInants?(100 feet of wells and 200 feet of springs and ❑Yee QNO ❑Yes ONO surface water). aal� _ _ .. _ I ,. 20. If no to question#19, use the SCA drawing to locate and describe potential contaminants. 21. Is the source protected from any obvious He 1.k of being covered by floodwaters? es ONO ❑Yes ONO 22.Is the area immediately around the wellhead graded to prevent water from Ryes ONO ❑Yes ONO ponding around the casing? _ .,,. Is the well constructed with a pitiess adaptor? _ ❑Ye No___screened ❑Yes❑No_ Is there a properly constructed screened vent on the wall cap? � ❑Yes�flo ❑Yes ONO ' .Is there a watertight,sealed well cap with no unprotected openings73PV t%v' _ ❑Yes o_ ❑_Yes ONO -26.Are conduits and Junction boxes sealed to prevent contaminants from entering ❑yes oNo ❑Yes ONO the well casing? 27. Does the top of the casing extend at least 6 inches above the floor or ground? Yes ONO ❑Yes ONO 28. Is the lop of the wellhead located above grade(not In a pH)? RYes ONO ❑Yes ONO 29.If no to question#28,is the pit drained to daylight and screened at the discharge []Yes ONo ❑Yes ONO end to prevent contaminants from entering? 30. Is a raw water sampling tap provided at the source? Xyes ONO ❑Yes ONO 31. Is the source metered? 'Ples ONO Oyes ONO 32. If the water system uses source meters,Poov often are the meters read: ❑ Daily ❑Weekly Amonthly ❑Quarterly 1 ❑Annually ❑ infrequently 1 ❑ Never 33.Are well enclosures oybuildings constructed or maintained to provide(check all that apply): ,R Lighting 9 Venting ❑ Protection from freezing P No storage of toxISH hazardous chemicals67am ra-14 ❑Floor drain with screen at discharge end O-Locks to prevent unauthorized entry 'rolecfion from rodent infestation 34.Are the sources protected from unauthorized access(check all that apply)? ❑Yea ONO ❑Locked well cap ❑Fenced w/locked gate ❑ Signs ❑Alarm system ❑Telemetry 35. Is water supplied from a spring source?If yes,answer questions#36 through#40. OYes 36. Is the spring enclosed by a structure with watertight seals to keep out surface water? ❑Yes ONO 37. Is the drain pipe on the collection box screened? Dyes ONO 3a. Is the overflow pipe on the collection box screened? ❑Yes ONO Is direct surface drainage diverted around or away from the spring? ❑Yee ONO 40. Is the area around the spring fenced to prevent unauthorized entry? ❑Yes ONO 41. Comments: (100006) ` To download an electronic version of this checklist,visit http:iA .dOh.wa.gov/ehpidwfProgmms/ss_third—pany.htm DOH Group A Small Water System Sanitary Survey Checklist LPWS ID#: 91917C Survey Date: 11A9N7 SOURCEs PUMPING FACILITIES (This page may he reproduced to add mom pumps) U. DOH Source Number: 43. Pump Type: 02 70 04 }'Submersible ❑Jet ❑Vertical or Deep Well Pump ❑Other. __- 44. Pump make and model: 45. Pump capacity: HP: — _.` _ 5 GPM. J� 46. Indicate location of the pressure gauge: El On suction line On discharge line ❑Both ❑ Not present 47. Pressure reading: Pump Cut In(psi): Pump Cut Out(psi): 48. Pump Controls: ❑ Float Switches to'p-ssum Switches ❑ Lead/Leg Controls Sequencers ❑ Run Hour Meters ❑ Pump Protector ❑ Manual ❑Other: 49.Are backup pumps, motors or other critical spare parts kept on-site? E]Yes)9110 OUnknown 50. Does the purveyor know where to obtain spare parts in an emergency? I�Ves ❑No 51.Are pump records maintained?For example,drawdown; static level;pressure;pump run hours;amp;and repairs. 7 OYes [:]No 52.When was this pump installed? Date: O Unknown TT 53. Is the pump enclosure or building constructed or maintained to provide(check all that apply): ❑ Lighting ❑Venting ❑ Protection from freezing ❑ No storage of toxic or hazardous chemicals ❑Floor drain with screen at discharge end ❑Locks to prevent unauthorized entry ❑ Protection from rodent infestation 54.Comments: 65. DOH Source Number: 56. Pump Type: ❑Submersible ❑Jet ❑Vertical or Deep Well Pump ❑Other: 57.Pump make and model: 58. Pump capacity: HP: GPM: 59. Indicate location of the pressure gauge: ❑ On suction line ❑On discharge line ❑ Both ❑Not present 60. Pressure reading: Pump Cut In(psi): Pump Cut Out(psi): 61.Pump Controls: ❑Float Switches ❑ Pressure Switches ❑ Lead/Leg Controls ❑ Sequencers ❑ Run Hour Meters ❑ Pump Protector ❑ Manual ❑ Other: 62.Are backup pumps, motors or critical spare parts kept on-site? OYes ONO 63.Does the purveyor know where to obtain spare parts in an emergency? OYes ONo 64.Are pump records maintained?For example,drawdown;static level;pressure; pump run hours;amp;and repairs. OYes ONO 66.When was this pump installed? Date: ❑ Unknown 66. Is the pump enclosure or building constructed or maintained to provide(check all that apply): ❑Lighting ❑Venting ❑Protection from freezing ❑No storage of toxic or hazardous chemicals ❑Floor drain with screen at discharge and ❑ Locks to prevent unauthorized entry ❑Protection from rodent infestation 67. Comments: (10/2006) To download an electronic version of this checklist,visa htteltwww doh.wa.gov/ehp/dwfPrWmmslss_third—party.htm DOH Group A Small Water System Sanitary Survey Checklist PWS OM91917C Survey Date: 11A9107 RT F: SOURCE TREATMENT sAyPochlorination 68, DOH Source Number: 69. Does the system have DOH approval to do periodic shock chlorination unrelated to any Dyes o DUnknown unsatisfactory coliforn samples?If system Is not shock chlorinating,skip question. 70, If they do periodic shock chlorination, indicate frequency end reason for shock chlorination: ❑ Periodic shock chlorination D Seasonal shock chlorination ❑ Reason: 71. Is there continuous chlorination at the source? Dyes ONO 72. If the source is continuously chlorinated, identify the reasons for treatment(check all that apply): 0 Unsatisfactory colifonn samples 0 DOH required disinfection ❑GWI program requirement ❑ Hydrogen Sulfide - ❑ Iron removal ❑Manganese removal ❑ CT=6 is required by DOH ❑WS precautionary ❑Other: 73. If Chlorine Contact Time(CT)Is required by DOH,does the system provide a minimum CT of 6? Dyes DNo 74. If DOH requires a free chlorine residual at the entry point, is it maintained at the required level? Required residual level(mg/L): Dyes 0No 75. If DOH requires a chlorine residual in the distribution system,is it Required residual level(mg/L): Dyes DNo maintained at the required level? 76. Is the chlorine disinfection system functioning properly? Dyes DNo D Unknown 77. If no to question#76,have they experienced any of the following problems in the last 2 months(check all that apply)? D No chlorine residual(0.0 mg/L) ❑ Out of chlorine solution ❑ Hypochlorinstor breakdown ❑ Less than minimum entry residual ❑ Chlorine overfeed incident ❑Chlorine not proportional D Less then minimum distribution residual ❑ Other: 78. Chlorination Chemical: ❑5 1/4%chlorine bleach D Chlorine dioxide ❑Gas chlorine ❑ 12%sodium hypochlonte ❑On-she chlorine generation ❑ Chlommines ❑ Calcium hypochlorite ❑Other: 79. Is a backup chemical feed pump or other critical spare parts kept on-she? Dyes DNo 80.Are free chlorine residuals monitored and recorded at least 5 days per week? Dyes DNo 81.Are monthly free chlorine residual records submitted to DOH by the 10th of each month? Dyes 0No 82. Is the purveyor using an approved DPD free chlorine residual test kit and unexpired test chemicals? Dyes 0No 83. Is the purveyor using proper testing procedures? Dyes DNo 84. Please have the purveyor check the free chlorine residual and note test resuhs in Part K, question#152. 85.Comments: 86.Are all types of active treatment noted on the WFI? DYes DNo 87. If no to question#86,identify the treatment process and objective using the blank source treatment form. 88. Has any treatment system listed on the WFI been discontinued? Dyes DNo 89. If yes to question#88,am the unused facilities physically disconnected from the rest of the water system? ! Dyes DNo Treatment Plant 90. Is the treatment plant for the source associated with other sources? For example, blended or in a well Sell DYes 0No 91. If yes to question#90,list all sources associated with this treatment plant: Comments: (10/2006) To download an electronic version of thm checklist,visit htlp:/A w .doh.we.gov/ehpddw/Pmgmm$fs_thirdyady him DOH Group A Small Water System Sanitary Survey Checklist PWS ID#: 91917C Survey Date. 11A9N7 BOOSTER PUMP STATIONS rs. Does the system have booster pump stations? ❑Vea 94. If yes to question#93,describe booster pumps: BP Station#or Name: HP/GPM: Location: SP Station#or Name: HP/GPM: Location: BP Station#or Name: I i HP/GPM: Location: PART H:PRESSURE TANKS 95.Are there pressure tanks present? If no,skip to next seGiplt. Was❑No 96. If yes to question#95,where ere they located? i i,h 14i) 97.Type of pressure tanks: J af tC aptive Air I Bladder Tank ❑Hydropneumatic Tank [I Both 98.Make and Model: 99.Number and tank size(gals): '. � \tiQ \ .�✓ 100. Is there an operable pressure gauge on each p2 ssure tank? ,Ira Tes❑No 101. Is there a testable ASME pressure relief valve installed between the tank and any shutoff valve?(To prated \' against catastrophic failure from high va 'oyes []NO 9 p g por pressure,such as steam in case of fire.) �0 Is the air/water level adequate?For example, not waterlogged;no excessive pump cycling;or continuous runfime. ayes❑No 103. Can the tank be isolated with a shutoff valve for repairs or replacement? EjYes[]No 104. Is there a drain line on each tank? ! ❑yesjRNo 105. If a hydropneumatic pressure tank is used,how is the air/water level maintained? ❑ Manual(such as a bicycle pump) ❑Air compressor ❑Snifter valve(Schrader valve) IOther. 106. For hytlropneumatic pressure tanks, is there an oil-less air compressor In service? ❑Yes❑No❑Unknown 107. Comments: PART 1: DISTRIBUTION 108. Is an adequate map of the distribution system maintained? L ee❑No❑ known 109.Do any pressure zones experience low pressure? t�rf, r�a�J vJ� 1�MN []Yes[]Moo Unknown 110. If yes to question#109,descdbe: --- -- - -- _- _ _._._ . 111.Is the system di-signed b_provxle fire ibw7 ❑yesF_- .o 112. If yes to question#111,what is the designed Bow rate?For exampl9,500 gpm far 30 minutes. i 119.Are proper procedures followed for disinfection of new construction or repsire7 g(T ❑No 114.Are there bbwoffs to flush system? _ �, es❑No 115.Are valves penotlk:alty exeroieed7 ___ � t,`,ea❑N_o_ 118. If yes to question#115 frequenq ❑Monthy ❑t]wns� Annualy ❑Other I 117. Is there a flushing program? ❑ryp 118. If yes to question#117 frequency O Monthly ❑Guansrly _na■6y p Other _ _ _ 119.Is the system protected from any obvious cress connections observed during the survey? e,hc- r ,,.,❑No 120.If no to qugdon#118,dasMbe: - 121.Is the system protected from any potential high h a1 hanrQe t connections requiring promises ❑yns[]No Isolation per Table 9 of WAC 246-280�80? �B'41f �//� 122.If no to question#121,describe: 123.Are backBow prevention assemblies used such as reduced-pressure and double cheek vaivai t ❑Ya3Nl(o 124.If yes to question#123,are the backflow,assemblies tested on an annual basis d records mdMalnsd7 LYp [ No r o5. Check the appropriate box that describes the system layout: ❑Looped NrBmnchad with diad-ends ❑Both Comments(Include general condition of dis0ibWbn system,such as frequency M leaks and repaint: Ilbo s --V & (102006) To download an electronic version of this checklist,visit hnp:/M^.wedoh,wa.gov/ehpldw/ProgramslsS_third_pany.him DOH Group A Small Water System Sanitary Survey Che Mass cklist I PWS ID#: 91917C Survey Date: IIA9A7 sSTORAGE[7. Is there a non-pressurized storage tank? []Ye o 128. If yes to question#127,identify storage tank type: []Underground or partially buried ❑Ground level ❑Elevated ❑ Standpipe 129.Storage tank material: _ ❑ Concrete ❑Concrete with wood roof ❑ Steel(welded or bolted) ❑ Plastic or fiberglass ❑Wood stave ❑Open reservoir []Other: 130.Storage volume,in gallons: 131.Is access to top of storage tank protected from unauthorized entry or vandalism? []Yes[]No 132.Is the access hatch watertight with an over-lapping lip,Framed opening,seal strip,etc.? []Yes []No 133.Is the access hatch locked? []Yes ONO 134. Is there a dedicated air vent on the storage tank? []Yes []NO 135.If yes to question#134,is the air vent screened with an Intact non-corrodible mesh screen(24 mesh for DYes[:]No ground level or 4 mesh for elevated tanks and standpipes)? 136. If unable to physically inspect the reservoir hatch or vent,select method used to document their condition: ❑ Review and discussion of maintenance records with purveyor. ❑ Photos to be taken and mailed by purveyor later. ❑ Purveyor unable to document,additional follow-up required. 137. Is the overflow line protected by a screen or Flapper valve to prevent contaminants from entering or []Yes []No plugging line? 138.How does the overflow line discharge? ❑ Directly out of the side of the tank ❑ Near ground level directly on the ground ❑Near ground level onto a splash plate ❑ Into a storm or sewer drain ❑ Into a body of water ❑ Other: �.If the overflow line discharges Into a storm/sewer drain or body of water,Is there an approved []Yes []No backsiphonage protection used,such as an air gap or approved baekfiow preventer assembly? 140. Is there a separate drain line on the tank? []Yes[]No 141.Is the drain line protected by a semen or flapper valve to prevent contaminants from entering or plugging []YM[]No line? 142.When was the tank inspected Iasi? ❑ 1 yr or less ❑2-4 yes ❑ 5-10 yes ❑ Over 10 yrs ❑Never ❑Unknown 143.What is the tank cleaning frequency? ❑ Every year ❑ 2.4 yes ❑5-10 yrs ❑Over 10 yea ❑Never ❑Unknown 144. How is the tank cleaned and disinfected? 145. Does the location of the inlet/outlet lines provide for good water turnover in the lank? []Yes[]No[]Unknown 146. Can the tank be isolated from the system for repairs or cleaning? []Yes[]No 147. Is there a water sampling tap provided at the tank outlet? []Yes[]No 148. Comments: OTHER •149•Has this water system received any significant customer complaints within the last 5 years? []Yes[]No[]Unknown 150. Describe purveyors method of documenting and responding to customer complaints: 151. The water system's compliance status: ❑Was reviewed with purveyor. ❑Was not reviewed with purveyor. 152. Describe any tests you may have performed during the inspection(such as chlorine residual, pressure,or temperature): 153. Describe any simple repairs the purveyor may have performed during the inspection: (10/2006) To download an electronic version of the checklist,visit http:/Mw .dnhwa.gov/ehp/dw/Progmms/ss_third_.party.htm DOH Group A Small Water System Sanitary Survey Checklist PWS IDu: 91917C Survey Daie: 11A9N7 - I ! J Coliform information packet ❑Emergency disirdedion fed sheel ❑Certified Operator information ❑Coliform health advisory packet ❑Disinfection standards for water mains and"Its ❑Group A WAC 246-290 ].Colfform monitoring plan ❑SWSMP guide ❑Regional office staff roster O Nitrate information packet ❑Cross Connection Control guide 'glech Tips-Openings in Wellhead ❑Nitrate health advisory packet ❑Existing System Approval package ❑Tech Tips-Reservoir Vents ❑Monthly morale report form ❑Wellhead Protection Program Tech Tips-Reservoir Hatches ❑Sampling procedure forms UWater Conservation Program ❑Tech Tips-Troubleshooting Pressure Tanks ❑Dairy chlorination report form ❑Preparing For Sanitary Survey booklet ❑Tech Tips-Chlorine CT For Small Systems Preventative Maintenance Program Guide for Small Systems ❑Sted-Up and Shut-down lueustance for Seasonal Non-Communay Systems ❑Other: Documents submitted with survey report: E5 Reviewed and signed WFI IRPhotographs labeled and attached or delivered electronically O Well log ay Field system schematic ,(�7 Field SCA drawing ❑Coldorm monitoring plan Source treatment process form ❑ Other: Field Notes: DOH Reviewer Review Date: Comments: (10/20M) To download an electronic version of this checklist,visit hap:/Iwww.dch.wa.govlehp/dw/Programslss_thirdyaM him DOH Group A Small Water System Sanitary Survey Checklist I PWS ID#: 91917C Survey Dale: j 11/19N7 SOURCE • AND OBJECTIVES the system is practicing treatment not noted on the WFI,use this form to identify the treatment process and objectives. Check the treatment objective boxes that apply for each process selected. If needed, provide additional comments below to clarify selections. Source Name I I Source Number Treatment Process Treatment Objectives' A B C D E F G H I J 'i 7:0, :1: 2 CHLORINATION, GASEOUS ❑ ❑ ❑ ❑ 3- CHLORINATION,HYPOCHLORITE ❑ ❑ ❑ ❑ 4 CHLORINE DIOXIDE ❑ 5 IODINATION ❑ 6 OZONATION ❑ ❑ ❑ ❑ 7 ULTRAVIOLET RADIATION '❑ 8 RAPID MIX/IN-LINE BLENDER ❑ ❑ 1-1 ❑ El 9 COAGULATION ❑ Cl ❑ ❑ ❑ . - 10 FLOCCULATION ❑ ❑ ❑ ❑ ❑ 11 SEDIMENTATION. ❑ ❑ ❑. ❑ - ❑: 12 FILTRATION,CARTRIDGE ❑ 13 FILTRATION,DIATOMACEOUS,EARTH ❑ 14 FILTRATION,GREENSAND ❑ 15 FILTRATION,PRESSURE.SAND - - ❑ ' ❑ -❑ ❑ ❑ - 16 FILTRATION, RAPID SAND ❑ ❑ ❑ ❑ ❑ ❑ FILTRATION,SLOW SAND ❑ . ❑ id PH ADJUSTMENT ❑ ❑ ❑ ❑ ❑ ❑ ❑ 19. "ION EXCHANGE - ❑ ❑ 20 LIME-SODA SOFTENING ❑ ❑ ❑ 21. AERATIOWAIR STRIPPING ❑ ❑ ❑ ❑ 22 PERMANGANATE ❑ ❑ ❑ 23: -ACTIVATED CARBON,GRANULAR _ ❑ ❑ ❑ El 24 ACTIVATED CARBON,POWDERED ❑ ❑ ❑ 25 'REVERSE:OSMOSIS - ❑ ❑ ❑. ❑ ❑ 26 DISTILLATION ❑ ❑ ❑ ❑ ❑ 27. ELECTRODIALYSIS ❑.. 28 SEQUESTRATION ❑ ❑ ❑ ❑ 29 CORROSION INHIBITORS-PHOSPfSILICA - '❑ 30 FLUORIDATION ❑ 31 REDUCING AGENTS-SULFUR COMPOUNDS '_`�.. ❑ - ❑ 32 SLUDGE TREATMENT ❑ ❑ ❑ ❑ 33 OTHER PROCESSES/OBJECTIVES " ' '.4n- ❑ �;�'( Ll�. ❑- ❑ - ❑ ❑ ❑ _❑ . ❑`` Treatment Objective Types Comments: A=DISINFECTION B=PARTICULATE(TURBIDITY)REMOVAL C=SOFTENING(HARDNESS REMOVAL) D=IRON 8 MANGANESE REMOVAL F.=ORGANICS AND COLOR REMOVAL BASTE/ODOR CONTROL S DECHLORINATION )ISINFECTON BY-PRODUCTS CONTROL -INORGANICS REMOVAL =CORROSION CONTROL J=DENTAL HEALTH (1012006) To download an electronic version of this checklist,visit hap://w ,doh.wa.gov/ehp/dw/Pmgmms ss_thirdyarty.htm Group A Small Water System Sanitary Survey Cbecklist Report I""e the graph below to locate any potential biological and chemical contaminants found within the source's Sanitary Control Area iCA).The SCA is the protective area within-100 feetofwells or 200 feet of surface water such es,aprings,lakes,or rivers. Source Name: Source Number: V �3Lf ' T l men V c -16L' Description of Features Shown on the SCAScbematic A. C. E. B. D. F. 46U e rcescfContamin I ation root Sources ofContamination Feet Sources of C�ontamination F car j Abandoned water wells Dumpsters Pesticide storage Animal burial Fuel tanks(above or below ground) Roads and parking lots Biological contaminants Graveyards Sewer lines,gravity or preuura uiktings Hazardous waste disposal eke Storm water catch basins nloal contaminants Hazardous waste facility Surface water Drainfields and septic tanks Initiation canal Wastewater spray irrigation Drip lab landfill,dump,disposal area Other Dry wells Pesticide application (102006) To download an electronic version of this SCA drawing,visit hftpl/www'.doh.".gov/ehp/dw/Protiremstss third any.Mm Group A Small Water System Sanitary Survey Checklist Report XARIT P: WATER SYSTEM FACILITIES FIELD SCHEMATIC the space below to sketch a simple schematic of the water system facilities.You may use the templates shown below to help build ..,r schematic.The sketch should show location of sources,treatment,pressure tanks, booster pumps,storage tanks,and a simple .epresentation of the distribution system. Include direction of flow(directional arrows)and brief description of how the controls function. Source Name: ISource Number: Example templates you can use to build your schematic: Pressure Distribution Well w/Pump Switch Chorine Pressure Booster Reservoir Injection Point Tannkk pump System f (tOR006) To download an electronic version of this system schematic,visit http:lM .doh,wa.gov/ehpldw/Programs/ss_third party.htm RECORD OF SURVEY N A PORTION OF SOUTHWEST QUARTER OF THE SOUTNEASTQUARTER �, SECTION 8, TOWNSHIP 21 NORTH,RANGE I WEST, W.M., wQ}jc►c MASONCOUNTY, WASHNGTON s Rdf1COFHid H1N/)• ew00W [ n LOT 1 . 4 mm a i i i i 1 � i i °o.m• ma. LOT! 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