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Home My WebLink AboutWEL2024-00016 105-107 W STORY RD WATER SYSTEM - WEL Application, Design, Letter - 3/6/2024 584 MASON COUNTY 415N6TH STREET, 0427-97 ,EXT 400 SHELTON:360<27-98]0.EXT 400 SELFAIR:360-275-0467,EXT 400 Public Health & Human Services ELMA:360482-5269,EXT 400 FAX 360327-7787 Dohleman, Roderic 103 W. Story Rd Shelton, WA 98584 RE: WATER SYSTEM PERMIT. TWO-PARTY WEL2024-00016 105 W Story Rd 320311490010 The 2-party water system, 105-107 W Story Rd Water System (3203114900101320311490010), 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, David Anderson Environmental Health Specialist Mason County Environmental Health MASON COUNTY DnRWaNid j 6 LUL 0 COMMUNITY SERVICES nmwma ! ,•OQ R.viwa r BiiW PImYM,Fmimmanld NshA(nn��lry XWIM1 415N.6LSt L(91dg8)-Shel1nq WA98584 WEL ZO Z Ll - Qr) Sheltml: 360-421-967Ox400 Oelhir:360-2]5446]x400 Elma.360-482-5269 x4W Ixq TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT I' VU�(rn 90h lem PNONE 31 o - Z10 - 196 NAILINI DRES'S-$\TREEEET.CITY,sTA`TE,Z 1554 S-fa �ikp)fo/l WA SITE ADDR SS ESS-STREET CRY{e,E PRIMARYPARCELII...•MBERIWEL SITEI��1I11.• 37-031 o SECONDARY PARCEL NUNBERRF APPLICABLE) 3Z031 N NO10 WATERSOURCE I SOURCETYPf PARCELi LO m PARCEL Z LOT See P(New ❑Existing Well 0 Spring 4. Z PROPOSED WATER SYSTEM NAME IREDUIREDI PROJECT DESCRIPTION rvf urp- Z- ha DIRECTIONSTOBnEJCONDRpNS Site Plan: (may also be attached) (property boundaiieS,structures,Well site WIIW'radius.dr Weways,roads,seplic/seWer corrWrents and Imes,easements,etc...) Submittals Checklist: (these additional items will be required for approval) M Satisfactory Bacteriological sample(this maybe deferred if well is not yet drilled) Well Log with pump test or 4-hour capacity test performed by driller(this maybe deferred if well is not yet drilled) Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document) #4k $.Septic Records (additional locating requirements may apply if there is a lack of septic records on file) ibis 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 is Well Site Inspection: — Rv 467'G"pY YES NO NA — 1jrVZ ERG u6-0r ❑ ❑ Evidence of existing sources of Contamination within 100 foot radius of water source? (drainfelds,tanks, buildings; indicate distance on plot plan) ❑ ❑ Are there roads within the 100 foot radius of the water source? If so, is road private, County or State. What is distance to ROW? �] ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan) ❑ ❑ Is the well cap satisfactory? 2 go of S K/I Cal NWMF 601 fl to w , ❑ ❑ Screened and vented? I ❑ The well casing extends _ above level ground/concrete slab? (circle one) laJ ❑ ❑ Is there evidence of a surface seal? wfU V. WIWI �J ❑ ❑ Does the seal appear adequate? (,py(, ❑ 9 ❑ Is a variance necessary for well site approval? 7VJp IM pt/' Comments Inl Pass ❑ Fail Inspector Date 3/ Lm�Z0�7 Review Step 2: Two-Party Review: YES NO NA [Rf ❑ ❑ Water Well Report with adequate pump test on file? If NO,date of Capacity Test 2 1 LZ Z(fli4 Driller RlflP C#1 GPM A ��J•^ 1 t] ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments Approved }y Approved ❑ Denied Reviewer Dale / Findings in this review reflect observed conditions as pity,existed on the day ofute site inspection. No claim is made,express or implied ofthe frdum success or failure of this system. Well site approval does not constitute water system approval Water System approval is a nvo-part process. All proposed connections to new wells are subject to water adequacy requirements at time of building permit per A1CC 6.68. Water usage restrictions and additional fees mart,apply to all new wells drilled after January 19',2018 per E4SB 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 WATER WELL REPORT MDEPARTMENTOF Noticenflntent No. WE49596 ECOLOGY UniquulIu.W 1fDTa,,No. BPD941 '1)pe of we.l Stine a WnhuWou 19 Cowwnan Site Well Name(if..dun one well): ❑ Daonmdmw b 0,intlioeWbuov NOINa Weer Righ[PewiUCerti0®e No. Prpard Use BlMwrtie ❑Induniel ❑Muricipd Property 0.Name RODERIC DOHLEMAN ❑Dawermoe O heymon ❑Tatweu ❑odur Well Street Address 105 W STORY ROAD Covatr°e°oo Type` Muthnd' City SHELTON County MASON 6n Newwall Om. ❑Dmu ❑lured ❑Cddt Tool tY ❑Deepenurg ❑OrEa ❑Due D Aim ❑ dnd-Roomy Ten Parcel No. 320311490010 Di..I—: Diwrcmeofbmine 6 ni.00 in A. WEaaviounceepprovedforthiswellY ❑Yes ONO Dep0of.tepleedw4 11W-T n, construed-Demos: wall If Yes,whet was the vmierme foil Catiog l mu Diumter From To Thiuhoue Seal PVC Welde l Theted ❑e 1 ❑ e in. v18 114' 114 uz O 1 ❑ 0 1 ❑ Uxietimt(eceirutmctioneonpage2y ❑W oro WM ❑ 1 ❑ th. ❑ 1 ❑ ❑ ❑ SE A--'14ofthe NE %;Section 31 TowaaMp 20N Rangu 3W ❑ 1 ❑ —bz ❑ 1 ❑ ❑ I ❑ ❑ 1 ❑ ❑ 1 ❑ IatNde(Example:47.12345)4718112 ❑ 1 ❑ — _ —vr. L,cngitude(5aenple:-120.12345) 123 10189 Perfonnom: ❑Ya MNo Typeofpmmwfored DHHr'e Log/Cooatrnedonor Derammie0on Procedure N. ofperhrtliom_ Sis ofpuhuriom_iv.by_iv. Faemti..Dn hby wow.ch ..6.afmuedtl®d etrucMe.and tfs 4iod and Fumreed in. to_fi.below Bowicl' ce were ofehe entered m eeeh kym peoeeeed.with a lure eneeo,'faruah rlen,e.f serene: N Y. ❑No ❑E-Neku b DVuh 11T 8 lofrrwd®. U.edtliti-0 shah if.au Mawficwm'e Name Nged Munhitu Wort mmeried From To Type SST.io Model No. CLAY RN 0 6 D mauer 5 rm slut abe 14 e.Aom 113' n.m 119' fl. gamemr_ fi. SWaw_ =_@m_n. CLAY WIGRAVEL 14 CLAY W/GRAVEL PIECES ) 6 BRN 23 &a fierpaek:❑Yu OONo Sizaofpeetrwered—lea GRAVEL SAND S CIAY SRN 23 29 M.teriela pkW Aom_9.m_n. CLAY W/GRAVEL GREY 29 44 Srwfaasal: OYee ON. Towwduphl lV @ CLAY(STICKY) GREY 44 47 Memel new m ael are otAp Bemmrte Dies my eo-.m<ooee uvuubb wneA OYa MN. SILTY CLAY 47 61 GREY Depdh .e. SILTY CLAY W/OCC GRAVEL (BRN 72 51 mT}yeotwaeft Meted ofeatiog inner,off SILTY CLAY BR SILTY CLAY WET GREY 89 ` 104 Pomp: hlenu6n'°v's Nuu TY CLAY W/GRAVEL W/B BRN 104 106 NP_ Pump iweke de,&_A QaiBxd now note:_epm GRAVEL&SAND W/BIBM) 106 werel .: land-amfice elentiweeve me ea kwl_@ sdalr-pafmp fwell., T£• 9.aeve Bores euf< Surr w—level WP n.belawropofwelluvl Dee 2/3NTo24 gneeien prtsaue_le.pe" '-inch D.I. Muiev weeruemnoIkd by (cep,vWe,w) Wa Tub: Wuapumpurg euperfmnwdi ❑No OYes b br'weml Yield_gpm wiW_9.Aewdawn sere_eee, Yield_gpmwiM_@ dmvdowrraflar_hn YiNd_gpmwim_A.dmvdowo elkr_M. naowy alms(rime=um whey pup iv nvwdoff-wmv level mwued fiam we11 rep to wmu l w ue ta Time elavel TiBe ware larol rune WamrLml Dee ofpwpv,gwt — Beilermn_gpmwid_n.d anu— AmeD 35 IM &gpm withnw aum lW fort ne hu Dw 2I22J2024 Are»n now_gpm rempueweo£wam_°F Wua_.. .-•-lynkovdey ❑Yes ❑No $mntDrte 02/222024 Complerd Dees 121222024 WELL CONSTRUC3TON CERTMCATION: I ronstrucrcd edlor accept responsibility for construction oftbis well,end i4 complianm with all Wimbinglon well cwutructw soudgrds.Matoiels umd and fie information Muted above m the to my beoi lmowledp and belief ❑Driller❑Trainee,❑PE—Print NameD EL CARPENTER DnUnCcurauA,nerwn Pump&Ddlling siunoLhne��,_Q Az(-g. Address PO Sw 14996 Orion.No.2236 Cry Sete Zip Tumwater,WA 98511 IF TRAINEE'Sponsor's Li,:e vic No Contwtor's Sponsa's Sigmtrre Registration No AMERIPD781 JK Dee FAY 050-1-20(Ikv OM19)Ijyn.need IN,document in an alernarejornrar,Dkare call the Water Raoen see Programer 360-407E872. Perm widrherringlosscancal1711jor WwhwW nRelay Service. PersonswiMarpeecAdi dity=wII877-833-6341. Vanguard Laboratory 2635 Parkmont Lane SW Olyrnpia,WA 98502 360,967,7010 VANGUARD Report of Laboratory Analysis LABORATORY Collected by: American Pmnp and Dolling Matrix Drinking Water 360-7547867 Laboratory ID:V240227-8 Sampling Address: Date Sampled:2272412:00 103 West Story Rd Date Received:=413:14 Shelton,WA 98584 Date Reported:3/l207A Sample ID: Finn Analysis Result SDRL MCL Units DF Dare Analyzed Total Coliform&E.coli by SM 9223B(IDEXX) Batch ID:V240227-8 Analyrt NO Coliform,Total Negative 1 1 MPN/I W ml I 2272417.00 E.wli Negative I 1 MPN/100mL 1 2272417:00 Nitrate by EPA Method 3532 Batch M.V240227.8 Analyst:AF Nitrate(an N) ND 0.50 10.00 mg/L 1 2282410:00 Notes: MPN:Mnt Pmbable Nmnbcr ppm:parbpermJRon ml modetwt Reviewed by Robert Smeeing,Chemist on 03/012024 Wa mt appgubla SDRL:Smte Demmion Repoomil Limit Approved by Tod Johnson,Operations Manager on 03/0I2024 DP Ddution Factor Coro MCL:Matimim C mi onmnem lavel taa481� Pagel of samples mem raceived in acceptable cmtlima The oauhs)wdtis report elate only m the portion mine sample(s)tned.All awyan wee Wrfwmetl wminent wiMMe Qnalih Assurmce Pro®emof VanguaN Labortory Please wvmct Me labommry ifyan sMWd base arty 9wsdom abourrbe msWrs. 2635 Padanont Ln SW,Suite A,Olympia WA 98502 Office;360.967.70101 Wsdng@vanguudlaborawry.wm j www.vanguirdlaboratory.wm A PORTION OF THE F(1ATHBPURP09E OF OF FOE.ARYHN QMBfMGT Sm 11-Id_ A PORTION OF TNf 90UTXE.1fif BOAPTNROFTXENORfH6A5T Q1IA6fEX 9 ' PHE VONfNEAtlI'QOARTRROYTNENORTHTAST QIIAXT EP ALL W �vm 4 1 BRC1lON 9=.MWNOHIPM NO6TX,NAN(1R9 WNO=',WM. tl.1AON NVMY.WAONdO'tt=V m:ssmvmrtaem LLI e Isl i 5 I I � � ,% � evnn•..n. Pam.•,...; __ q•� L J m - ' 3 T , CA \ \ 3 4- 'r \ \ 3 a Q 1® '� 67 �A' Y \ m Cy ? \ \\ I � -r •,cam .y. Jd// \ W • � \ � 1 5959 C--6 \ m \. \ I I \ 3 � mi • N:Y T• I + I m �e O : I 2� Return To I 2208621 MASON CO WA 03114/2024 02,23 PM NOSE WLEMAN N1%934 Rec Fee- $304 50 P...s 2 Roderic Di 1111111 IN H Y11111111V11111111l1ll111 103 W. Story Rd Shelton,WA 98584 Grantor($): (1) Roderic Dohleman (2) Ryan Finn Grantee(s): (1)PUBLIC Legal Description(1) Res. PCL 1 BLA 21-18, PTN BE NE 31-20-3 (Abbreviated form:i.e. lot block,plat orsectlon, township, range) Assessor's Tax Parcel: (1) 3 2 0 3 1 - 1 4 - 9 0 0 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 icn 1)__—_—- 14__- 90010 ----- 32031 Tax Parcel: (Connection 2)_____- 14_-- 90010 ----- The system owner is responsible for keeping this system in compliance. The name of the water system is: 105-107 W Story Water System 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 exem�pttiiyn standards. This system(has/has riot) been granted one or more waivers from specific provisions of the regulations. Dated on this 14th day of March 20 24 Si nature of Gr , u (1) . (2) N` _ 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 IL4 day of NIQV CVI , 20Z:XL. P,odt6C k + 2-14 Pv, personally appeared before me,who is known to be signer of the above instrument, and acknowledged th ie s }Fth si nad GIVEN under my hand and official seat the day r ove .�" T�ANr Not ublic in and or the State of Was ington, ;' ' 5.••,• TO °., ding at al I oao� 2 G j\onii••,,'Y +: My commission expires: �y'o o°j U Mt MOO Page 2 of 2