HomeMy WebLinkAboutWEL2024-00035 - WEL Application, Design, Letter - 7/9/2024 MASON COUNTY 41fiNfi HELTON: 60427-O70.EXT 584
® $HEL70R:360-275 9 67,EM 400
BELFAIR:380-275446],EXT 400
Public Health & Human Services ELMA:3604825269,EXT 400
FAX 360427-7787
ISLAND LAKE ENTERPRISES LLC
P O BOX 1473
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT. TWO-PARTY
WEL2024-00035
1050 E Island Lake Dr
420014190041
The 2-party water system, Two Party Well (420014190041/420014190444), 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,
i'
David Anderson
Environmental Health Specialist
Mason County Environmental Health
MASON COUNTY
COMMUNITY SERVICES Am ` R.
RP Mmlm.[nwmmerW Nahh Camxnlry XeNIN
415 N.OF SUEs,(Bldg 8)-MCI",WA 98584 WEL 1� Z - Q(�p 3S
SnElrnn: 360427-9670.400 Belfeir:360-2754467%400 Blma:360482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APVLIcpxr PxoNE
Island Lake Enterprises, LLC 300.490.7843
MAILING ADDRESS-STREET.Cm'.STATE,MP
PO Box 1473
wIE AOOREShelt n, A STATE584 I✓/V �F. O!
Shelton, WA 98584 (Nr1 //r I
PRIMARY PARCEL NUMBER(YELL SITE)
42001-41-90041
SECONDJRY PARCEL NUMBER(IF APPUCABLEI
4200141-90444
WATER SOURCE SOURCE MF PAP 7E LOT SME
PARCEI2 LOT WE
QNew IM Existing D Well ❑ Spring ,75 acres 2.22 acres
PROPOSED WATER SYSTEM"MEIREOUIRED)
Two party well
PROJECT DESCRIPTION
Two party well for two single family dwelling units
DIRECTN)NS TO SITE/CONDITIONS
see attached
Site Plan: (may also be attached)
(property boundaries,sbuctures,well site w/100'radius,driveways, roads septic/sewer components and lines,ease enis,etc...
see attached J(/
lJ
62m
Rf�Fy��O
MPH
JUL 0 9 2024
By
Submittals Checklist: (these additional items will be required for approval)
13 Satisfactory Bacteriological sample(this may be deferred if well is not yet drilled)
6 Well Log with pump test or 4-hour capacity test performed by driller(this may be deterred if well is not yet ddlled)
B Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document)
Q Septic Records(additional locating requirements may apply if there is a lack of septic records on file)
This form may be scanned and avallable for public New on the Mason County Web site. Revised: 10/13/2021
Page 2 of 2
.._.___._.,.._.—--------. ......Staff Use Only-------- --
Review Step t: Well Site Inspection:
YES NO NA
❑ ❑ 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 cl us of the water source?If so, is road private oun or State.
What is distance to ROW? T
❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan)
❑ ❑ Is the well cap satisfactory?
❑ ❑ Screened and vented? A
❑ The well casing extends Zd above level ground/concrete slab? (circle one)
Y-' ❑ ❑ Is there evidence of a surface seal? (p f' 47.2tCM4
❑ ❑ Does the seal appear adequate? Co+l'. -I Z j,1701V
❑ ❑ Is a variance necessary for well site approval? TC.7< BIRSfr Z
Comments �y
XPass ❑ Fail Inspector Date � / l?
Review Step 2: Two-Party Review:
YES NO NA
P1 ❑ ❑ Water Well Report with adequate pump test on file? Nf/lslb QO/1#s 04 VVIM 4 0,117 f^
60 MYI (714 lot 010//
If NO,date of Capacity Test Driller GPM
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test W X TO
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Z Zl Zr
❑ ❑ System appears adequate to� rry serve 2 single-family residences based on Information provided?
Comments — 9Z WROZY —OW l Z 4 F f" AFV' iZI ZV8'
Approved ❑ Denied Reviewer Date Y/t /_
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 orfailure of this system. Well site approval does not constitute water system approval. Water
S stem approval is a two-part process.
All proposed connections to new wells are subject to water adequacy requirements at time of building permit perMCC 6.68.
Water usage restrictions and additional fees may apply to all new wells drilled after January 19`^ 2018 per ESSB 6091.
Revised: 10/13/2021
This form nun,be scomms!and available for public view an the Mason County Web site.
Page 2 of 2
WATER WELL REPORT a DEPARTMENT OF Noficeoflntwt No. VvE38245
ECOLOGY 1nquc1cic,1e91DTeg No. SMS112
Type o1 W ork Sete of WasM1N([on
® Comtm@on Site Well Name(ifmort then one roll)'.
❑ Oecam:nission b Onpwlimtal NO]No Wtla Right PenniUCertificeh No.
Peopse,e Uee: M Dommnu ❑Ideshoi ❑Moonrise] Propady Oxen Name Jenv&C c lM1ie Radtke
Dewaannp Int'.- ❑T.Well ❑Olen
Well Stmet Adder 1050 E IMand Lake Calve
Construction Type: Melbtl:
o New wen ❑Almosom ❑Dd.® ohsmal OCrbleTaw City Shelton Conety Meson
❑Deeeninx ❑Otte ❑Doi wAif- ❑hfi3Rmey Ten Pereel No. 4200141-00040
Dimensions: Diameneo'borm,6 m,m 78 A. WMavariance eppmvd for Nis v.ell? 0 Yes [9No
Dmdsofraonplmad-1175 g.
C. Deane: WN Ryes.w t.the vadaxe for?
Cases Ln:m Decrease Fmm To dirk® Ned PVC waded Tbassal
M 1 ❑ 9 ia, 0 771 250 0. 11 1 ❑ O 1 ❑ Loration(see restructure w point 2): pWWM or❑EWM
❑ ❑ —u' —u' ❑ 1 0 ❑ 1 ❑ NE Y Zofthe SE %;Secew 1 Township 2ON Reogis 4W
° 1 ° — — — — . ❑ 1 :3 ❑ 1 [30 1 ❑ — — _ _ n. ❑ 1 Cl ❑ 1 ❑ Witude(Exnmple:47.12345)47.2R8950
EaM1meet OF. Men TypeofpmbNmmed 14ngitde(Example:-12(1.12345) -123.120812
No.afpriseti®_ pobtaom_6by_e Drifter'sewtraeaon or Decommission PreareEne
Sim of Fmmetion:De beb/mlow,chaeem,aim ointment andommose,and theakid ed
Pmbntad eam_&b_e.Mbw aowdemfica mimeo(tM mstamlmoacn layeapercnntel,with at lase ore cony of fttaech bey
&re®: W Y. e M @ K Parker b 0.pb 6$_d. bePomution Use sdditioo onen.1 fnaweey.
Monnfietaer'.Nam Moy Machine Nbrka Melenel From To
TM Stainless Slotted Model Na
Oiaoetef 5_ Shot rns.= m enm 70 g b TS g Brown a sand end ravel,wbblea 0 3
Dummar Nbtom uNom _gb_g Brown slily Nord antl ravel,loose 3 33
9eodlFam psek:❑Yr ®No Simafpmk m✓mid—a Brown silty sand and graosi,wit 33 51
nwmwe pbeed firm ge A. MulSwlorad ravel median to wane brown Si
Sorf Set: 0Yu ❑No Towhoadmth?1_ft. send.loose,wl 78
Meant mW in Met Ben(onite Chin
Ud'strow ee am m mat,la e:ee? BY. 11%
Type ofwtldt DpIhef.
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Pomp:sdevufia:ua'a Nee Type:
RP._ Pumpinakedeplh:_R. D'dpW dowtw:_@m
watrfeveb: land-swficeek.on.baemmwlevel 280 8,
Sdrk-spotaepofweuttes, 15 s.shomam:mdeafia
9adewamkvel 25 g,palowbpofwallarma Dun S/14202D
Andean raw:es Ind.per eq—,.h Data
Ammon-mere:..11dhr its,rnlve,ele.1
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Wae a Pumping as prfimW1 pNo 0Yea b by whom?
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w ate arkml)
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WELL CONSTRUCTION CERTIFICATION: I conatm1d am acceptrmpnambiliryhr-wer Giw ofMu well,and iU compliance with ell Washington well
wnmwwtion slmderda.Materials used end the information rtpmted above art true to my beat knowledge and belief
lJ Drills,❑Traduce❑PE-Print Name Joshua KoeDO Orating Comp r,Arcadia Drilling lrv:.
Sigamltrt ® Ad&M PO Bon 1790
Lame No. 2874 I City,Sure,Zip Shelton.WA 98584
W TRAo4EE:Spseci ldca e:Ne. s � 3 Cantm wr's
Spolua s Signature Registration No.ARCAD0109SKI Date 5/152020
ECY 050.1-20(Rev 09/19) Ifyouneedlhisd=nwntinmallemiefo t,p4mwilth Waer Resources Pmg a1360.O7E72.
PermnswithhearkMlws=wll7llfprlPoWWonRelay Senior. Permwwilhaspeechdimbfhiy tmR877433-6341.
( 1786 SE Mile Hill Davc
SPECTRA Iaponmriee-lCiuep Port Ordmrd,WA98366
wwwspecma-Iab<om
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2212997 MASON CO WA
W10912020 10 20 RM NOTCE
CYIJTHIA RROTNE Y199272 Rec Fee $304 50 Pages. 2
IIIIIII IIIIII III IIII IIIIIII IIIIII IIII IIII IIIII111111111 IIE IIIII IIII IIII
Return To 1�, i la A ,
�1
�helm �- GSSSgN
Grantor(s): (1) az5la A
Grantee(s): (1) PUBLIC
Legal Description (1) 9LL'A i &-AA23-11 P�FA21iyiso PTO of Cio\rr I A 15
(Abbreviated form:i.e. lot, block,plat orsection, township, range)
Assessor's Tax Parcel: (4)�� U (� i -4 1 - U O ��
56\lTZ01 �LLA
NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM
I (We) the undersigned grantor(s), certify that the water source located on the above-described
real estate under Legal Description (1)and Assessors Tax Parcel (1) situated in Mason
County, State of Washington, has been designated to serve a source of water to the following
parcels situated in Mason County, State of Washington; herein described:
Tax Parcel: (Connection 1) 6 0 1 4 1 9 0 U 4 1
Tax Parcel: (Connection 2) y 2 (-J_- 4 L --I 0 4 -4-LL-
The system owner is responsible for keeping this system in compliance.
The name of the water system is: z� Well
This system is designed to provide for two service connections. Planning and design approvals
must be obtained from the department prior to expanding beyond this number of services.
Additionally, a water right, obtained from the Department of Ecology, is required if the water
system exceeds exemption standards.
This system (has/has not) been granted one or more waivers from specific provisions of the
regulations.
Dated on this �f+ day of J wl� , 20 Zr�.
Signature of Grantor(s):
(1) , (2)
IJ D Page 1 of 2
JUL 16 2024
By
State of Washington )
County of Mason )
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this -4 jay of Swk,$ , 20 j�,
A personally 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.
DAVID SCOrr JENSEN otary Public in and Tor the State of Washington,
Notary Public residing at /0 W. 7 a ar Av'
State of Washington M commission expires:_ r zot
CammissI.n g 23034862 y p
My Comm.Zphes Aug 16, 2027
Page 2 of 2
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2212458 MASON CO WA
%I2512024 01:55 PM EBSMT
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Return Address:
qa{fiw v4tt¢
PO 1Ek13 AFFIDAVIT
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GRANTOR: Island Lake Enterprises, LLC
GRANTEE: Island Lake Enterprises,LLC LEGAL DESCRIPTION ( iated : Resulting Parcels 4, 6, & 7 of BLA # 23.11,
PTN NE Y. SE '/. SW % S6, all in T20N, R4W (full legal
descriptio 2)
ASSESSOR'S PARCEL 1-41-90041,42001-41-90043,42001.41-90444
The Grantor, lspvKt7 rprises, LLC, a Washington limited liability company, is
the owner of full 1 described real estate in the County of Mason, State of
Washington:
PD
s Parcel 4 of Boundary Line Adjustment No. 23-11, as recorded June 29,
0 r Auditor's File Nos. 2198930 and 2198931, in the records of Mason
nty, Washington, being a portion of the Northeast quarter of the Southeast
er of Section 1 and the Northwest quarter of the Southwest quarter of Section
(� in Township 20 North, Range 4 West,W.M.;
\\ Assessor's Parcel No. 42001-41-9004I;
C� (hereafter"Parcel A").
Parcel B:
Resulting Parcel 6 of Boundary Line Adjustment No. 23-11, as recorded June 29,
2023, under Auditor's File Nos. 2198930 and 2198931, in the records of Mason
County, Washington, being a portion of the Northeast quarter of the Southeast
quarter of Section 1 and the Northwest quarter of the Southwest quarter of Section
6,all in Township 20 North,Range 4 West, W.M.;
Assessor's Parcel No.4200141-9W43;
F.al 01-Page 1 of 4
(hereafter"Parcel B").
Parcel C. -A,
Resulting Pazcel 7 of Boundary Line Adjustme . 3-1 1, as recorded June 29,
2023, under Auditor's File Nos. 2198930 , in the records of Mason
County, Washington, being a portion of a No quarter of the Southeast
quarter of Section 1 and the Northwest qu r of Southwest quarter of Section
6,all in Township 20 North, Range
Assessor's Parcel No.4200141-9
(hereafter"Parcel C'J.
WHEREAS, the Grantor dear o dilate the installation and maintenance of utility
lines and septic systems eloproem on the subject properties;
WHEREAS, the or gnizes that neighboring properties possess adequate land
area for the in on tic systems and utilities and seeks to secure easements to
access and Will such for the benefit of the subject properties;
WHEREAS`" is willing to accept the easements for utility access and septic
installs ' fdr�'de purpose of expanding the total available land area of the subject
e valent of one acre for future development;
FORE, in consideration of the premises and mutual benefits, the Grantor
es and declares the following easements:
1. ant for Parcel A:
Grantor grants a perpetual and non-exclusive easement over Parcel C for the purpose
f accessing,installing, maintaining and repairing utility lines and septic systems to serve
A.
2. Easement
2. Easement for Parcel B:
The Grantor grants a perpetual and non-exclusive easement over Parcel C for the purpose
of accessing, installing, maintaining and repairing utility lines and septic systems to serve
Parcel B.
Easement Paxc2of4
2212458 Page 2 of 4 06/25/2024 01:55:10 PM Mason County, WA
3. Scope of Easements:
The easements granted herein shall include the right of in as d egress for installation,
maintaining and repairing of utility lines and septic sys s, a C\. ssary, to facilitate the
development and utilization of Parcel A4an
dentia(purposes.
4. Binding Effect:
These easements shall run with the to described herein, shall be
binding on all parties having or acquor interest in the real estate
described herein or any part thereof, nefit and burden the owners
thereof.
5. Governing Law:
These Easements shall be governed by and construed in accordance with the laws of the
State of Washington
IN WITNESS WFI F, parties hereto have executed this Easement as of the date
written below.
Dated: 2024.
terprises, LLC
Radtke,Member
\\ his A. Radtke, Member
Esument—Page 3 of 4
2212458 Page 3 of 4 06/25/2024 01:55:10 PM Mason County, WA
STATE OF WASHINGTON ) A
COUNTY OF MASON )
On this 094' day of J t+ne ,2024,befo undersigned, a Notary Public
in and for the State of Washington, duly com d swom, personally appeared
Jerry P. Radtke and Cynthia A. Radtke to
w the Members of Island Lake
Enterprises, LLC, the limited liability comp that uted the foregoing instrument,
and acknowledged the said instrument tp-bc d voluntary act and deed of said
limited liability company,for the uses pus therein mentioned, and on oath stated
that they are authorized to execute the ins car.
WITNESS my hand and official seal hereto affixed the day and year first above written.
-Iqo—tary Public in and for the f
Washington, residing at tJ. 'Ice" Nat-
M Commission Ex Irea. LOL DAVM SCW7 JENSEN
Notary PubIIC
State of Wash nBton
Q
Cemmlssion p 230J9862
My Comm. Eaplres Auy 16, 2027
D
D
D
Do
DDD
�D
Easement--Page 4 of 4
2212458 Page 4 of 4 06/25/2024 01:55:10 PM Mason County, WA