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Home My WebLink AboutWEL2024-00026 - WEL Application, Design, Letter - 5/28/2024 (2) MASON COUNTY 415N6THELTON:STREET,SHELT670,EXT SHELTON:360-275 667,EXT 400 4 eELFAIR:380-2]5448],EXT 400 Public Health & Human Services ELMA:3604825269,EXT 400 FAX:360427-7787 MITCH MYDSKE 51 NE PURPLE MARTIN PL BELFAIR, WA 98528 RE: WATER SYSTEM PERMIT. TWO-PARTY WEL2024-00026 XX NE Purple Martin PI 322237590020 The 2-party water system, The Hill (322237590020 to 322237500030/322237590023, 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@masoncount7ywa.gov Sinreerely, /Z-1— David Anderson Environmental Health Specialist Mason County Environmental Health �(��ZozY i GoMASON COUNTY I COMMUNITY SERVICES Aho RR.e R n.4eY Na4ng Pbinig EmvmrtewlNWn,CommuniryMMtX .�v 415 N.6' SUect,(Bldg 9)-Shelton,WA 98584 WEB aoay - 000040 Shclmn 360429-9670s400 Bcl feir.360-2)5-446]x400 Litne 350-4R2-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT a H Q(1[/YMr Y^ PXBNE MRILI/G A�E� p j •Cf12Y��TE, 15Afru PI; &(,Fyi/r W A �185 Z e ' SITE ADDRESS-STREET,CITY,STATE,DS E PRIMARY PAR,;NUMBER(WELL SITE) a SECOXDARYPARCELNUMBER(IFAPPL(LABLE) as WATER SOURCE SOURLETYPE I PARCEL t LOT4¢E PARCEL]LOT SBE ❑New ®Existing 14Well ❑Spring G f,5 � `� gC1Q� PROPoSEa WATER SYSTEM HAME(R ARED) T rat^ to(A PROJECT DESCRIPTION DIRECTIONS TO WE CONDITIONS Site Plan: (may also be attached) (property boundaries,structures,Well site w/100'radius,driveways,roads,septidsewer components and lines,easements,etc...) -� � >N9RrJV FS�� ®w\ F 0.3d Ks /�'rr Possrg� f: . Jc1tl� I Roo 20 q00 2 3 n r ISO U:R Submittals Checklist: (these additional items will be required for approval) m � ® Satisfactory Bacteriological sample(this may be deferred if well is not yet drilled) Q ® Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is yet drilled) yrni Notice to Future Property Owners recording (record with Mason Co.Auditor, supply copy of record c� (Th tic Records (additional locating requirements may apply if there is a lack of septick form may be sunned antl available for public view an the Mason County Web site. Revised: 10/13/2021 Page 2 of 2 Wlac ,9Pt�Ylvu�L j �coRvhDq �f4f'� -------_----------------_------------------------------------Staff Use Only--______—_----_-_--_---_--_-_-___----__-_-__—_- Review Step 1: Well Site Inspection: YES NO NA VP❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) ❑ ❑ Are there roads within the 100 fqpl rpdius of the water source? If so, is roa private, unty or State. What is distance to ROW? f� ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan) ❑ ❑ Is the well cap satisfactory? ❑ ❑ Screened and vented? ( )t ❑ The well casing extends 7 above level ground/concrete slab? (circle one) ❑ ❑ Is there evidence of a surface seal? Le. 47.mnr RI ,.] ❑ Does the seal appear adequate? LOA., _10- (Pll 7❑' lyi ❑ Is a variance necessary for well site approval? TQ9' 'Vf4 Comments Pass ❑ Fail Inspector Date 5129/wly Review Step 2: Two-Party Review: YES NO NA ❑ ❑ Water Well Report with adequate pump test on file? /� s If NO, date of Capacity Test f _? &? Driller M � S GPM ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test f/!6(19zb( (2(u t 'Aral) X�y ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 1 3 7 P ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments /7 7�/ [Approved ❑ Denied Reviewer Date �/CMG l Findings in this review reflect observed conditions as they existed on the day ofthe site inspection. No claim is made,express or implied of the future success or failure ofthis 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 ofin ilding permit per MCC 6.68. Water usage restrictions and additional fees may apply to all new wells drilledaffer January 196, 2018 per ESSB 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 w, i q�gg ,r r s 1 C v AL uAlp t. 40 r g •ti M trtti� • s -;,ate.-• __ :�=�_:__.._�,.:_ - a _ 00 Thurston County Environmental Health 412 Lilly Rd NE•Olympia,WA 98506 360867-2631 TN11R M CO[ COLIFORM BACTERIA ANALYSIS Dale Sample Collected Team sample Canty a Il(o i zozy 7`3de o MBsoN Nw our Type of Water Symm(rkecy only one box) ❑ Pmab Houashold ❑Group A ❑Gmup B ❑ONar Gmup A ale Gmup B Systems Pmindefrom Wider Facilities ImaMory(WFI): IN System Name: riadSl Pemn: Day Phma:l ) CelP ms:( )3W NA E-aaiI.HjnC YP Y OK E-..phone:( ) Sew meals b:(Pnm MI..'wdber aw Lp rotle or ew0 a lda) SAMPLE INFORMATION Sample staged by(name)/I(TcH H Yft Spedfcbca0anoraddmasarhmesxmpbdleded: Spaialinsbuctionsormmmenh fl0EI°uRPct "A"v rf.v 1916FAIR wit zrl Type of Sample(must d�ecF only orc boxoipt Nmgh W Ilabd bebe) 1.0 R.N.0bWlu0on Sample 2 Repeat Sample(wmer mail,.0.) Chbrinmed:Yes_No_ ❑Diwibution Syebm Chbdne Residual'.Total Fina_ Ch'ennebd:Yas_No_ 3.1tae Waler Source Sample Chbnm Reaiduel:Tdel_Fina_ ❑E.roX-GWR(A/P) ❑Fed- ......um.mnrw(rum ) unsa5sle"imtimlebmun6ar. FIMer.Yes—No ❑Aseeealent Mondbnng(W) tlnsatletecbry routine dbcldab'. ❑ONer 6 A❑Semple Collected far lefcmegon Only bvrtigaim Conaburkon/Repays_ Omer_ LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Dnsa0sfacemy Tobl Coliam Prosentand Selisfacm detery ❑E.wpmamt ❑E.pomabwm oLolilom cted Replacement Sample Rpudmd: ❑Sample tao.k E,X wma) ❑TNTC ❑ lammed Dmeil Rewdb:Total CaObm n00b. EwN H00mi. Fecal Colifom nOdnl Ememormo n00 mi. Method Code. SM9NM ❑BMg222D ONeaa 11m PemFmd: ❑SM9215B ❑Entmomt® Q( Oelsew imeRwYrw: ireammomm . •2Y aanMNurer mNnome.pwMaW) Wb—1 Gdy- 0 B 0 �Na 50 K'- IQ/ 2213003 MASON CO WA 01/a/2e34 'a 50 RM WTCE M091(E HITCH t1992]9 Re. Fee 304 50 Pages. 2 I III III�ml IV�I I I IUI nll IIII III I I IW h�lll I��III Ihl III Return To M Lug M 105k F SINE 6uKPIt t4StZT1AJft DuF4K ., wd lk ZFf Grantor(s): (1) Y 1 I7G H M(/05k-j , (2) Grantee(s): (1)PUBLIC Legal Description(1) E ,1Z NF Yy 23 -22-3 (Abbreviated form:i.e.lot block,plat or section, fownshlp,range) Assessors Tax Parcel: (1) 3 _y__Z_.I �- 7 = 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) -3 2 2. Z 3 _ 7 S - d o 0 3 C) -COf1rIGr C�r'a+� l Tax Parcel: (Connection 2) j Z Z z - -7 5 - c Z 3 - Co✓Lice frtrr7 L 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. Dated on this q day of Y , 20Z1 . Signature of Grantor(s): Page 1 of 2 JUG 0 9 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 __(day of Al I l4 , 2014L (�� 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 andyear last/above written. �NDERB '4rr Notary P119ic 1n a d for the State of Washington, d aewl O i r?�` , , residing at j)'((J� '1 (,Q(IA ri` o�r''r� '�+% My commission expires:(I 'T'' Page 2 of 2