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Home My WebLink AboutWEL2024-00026 - WEL Application, Design, Letter - 5/28/2024 MASON COUNTY 415NBTHELTON: 60427TO70,EXT 400 SHELTON:36027546]0,EXT 400 4 BELFAIR:360-2]5�46],EM 400 Public Health & Human Services ELMA:360J6 69,EXT 400 FAX:36042]-n8] MITCH MYDSKE 51 NE PURPLE MARTIN PL BELFAIR, WA98528 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@masoncountywa.gov Sincerely, V1 David Anderson Environmental Health Specialist Mason County Environmental Health MASON COUNTY °"`R" A COMMUNITY SERVICES Amunl P9m auafnG Plmnn9Emvcmm�pel Heeltl�LummnMNNM 415N.6-"Svicet(nldg8)-Shelwn,,WA98584 WELaoa L-I - 00 00& Shelton: 360-427-9670x400 Bdl:ui ]6n2754467 x4N Elma 360482-5269 z400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT i1e N QQ MYOs t PNGNE MA I,GAOORNNj Fj UA�LTE,Md/S'rrN ('G. [3 Fpi/r (q/q 676 L F ^ SREAOOR $-ETREET,CITT.STATE,ZIP E PNMART PARCEL NUMBER 1WELL SITE) a SECONOARYPARCELNUMBER1e APPLCJUM_0 a Qcxa WATER SOURCE SOORCETYPE RCELI LOT 56E PARCEL3LOT 3¢E ❑New 14Existing ID Well ❑Spring PA G �1.5 PROPOSEDWATERSYSTEM XAM7QUIREOI T S /I ( rr� PROJECT DESCRIPTION DIRECTORS TO SITV CONOITONS Site Plan: (may also be attached) (property boundanes,structures,well site wit W radius,driveways.Toads,sepbelsewer Components and lines,easements,etc...) (�� ✓ M9KrA/ \tL �1Ctyl � CEO �� 030 ars ,I•"b� �' I FIavSE � tv q00 20 4 IFG� I gOO23 n I dR Submittals Checklist: (these additional items will be required for approval) x o N O ® Satisfactory Bacteriological sample(this may be deferred if well is not yet dolled) a Q t EI Well Log with pump test or 4-hour capacity test performed by driller(this may be defamed if well is yet drilled) �v Notice to Future Property Owners recording (record with Mason Co.Auditor, supply copy of record oc® YSeptic Records(additional locating requirements may apply if there is a lack of septic records on file) This form may be scanned and available for public view on the Mason County Web site. Revised: 10/13/2021 page 1 of 2 wac � P�nr,��rr �{concvrDq Fr�✓L Staff Use Only Review Step 1: Well Site Inspection: YES NO t NA ❑ ft' ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields,tanks, buildings; indicate distance on plot plan) RI ❑ ❑ Are there roads within the 100 f t radius of the water source?If so, is roa private, unty or State. What is distance to ROW? _ ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan) Y" ❑ ❑ Is the well cap satisfactory? ❑ ❑ Screened and vented? 1 i ❑ The well casing extends above level ground/concrete slab?(circle one) 1� ❑ ❑ Is there evidence of a surface seal? 417.3mir con;❑ ❑ Does the seal appear adequate? _10.01 p� S l El ,y U7 ❑ Is a variance necessary for well site approval? Comments 11D Pass ❑ Fail Inspector Date //Review Step 2: Two-Parry Review: YES NO NA ❑ ❑ Water Well Report with adequate pump test on file? rya�t If NO, date of Capacity Test / Z ZOZ Driller "1 s A Mdre, GPM (� ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test S/(0/2nik .(�6 ya/ 16fRr, �' ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 7113003 J ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments /7 7�/ [Approved ❑ Denied Reviewer Date (C�L l 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 ofthis system. Well site approval does not constitute water system approval. Water Syslem approval is a i vo-part process. All proposed connections to new wells are subject to water adequacy requirements at ofbuilding permit per MCC 6.68. Water usage restrictions and additional fees may apply to all new wells drilled after January 19s, 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 / A � s w� ff� f k y a * 4 �. � o .r i b iw .' r lamp ti 00 F 4 @ 8 Thurston County Environmental Health 412 Lilly Rd NE •Olympia,WA 98506 xuTd� 360 867-2631 COLIFORM BACTERIA ANALYSIS D»Sample Calbded Time Swnpb County ti I zozq 7 alle3o ow IVA50,V Nmn pw Type NI Sysam(durk only one m) ❑ PRrate Hweahod ❑GwpA ❑Gov B ❑dhw GroupA ad Goup B S}alwm-P.1cle som Walar FacRtlea Inn nbry(WFI): IN system Name: cmleot Pweon: Day Phone:( ) cell Phom'.(Z )3 E.nwI gJaMMOSk E..Phom:l 1 Send N-IN N(PAY U n...atlarea rid rpwtla w awl a06®) SAMPLE INFORMATION SamplewINxbxJ (nme)IytrCH yy /iIS Spedru lLCddOn OradtlresewTwa sample cdkded: Spe®IinsWctionearwmnenb: yl NE PURPCz MBJSQfyN 4Gf W(9 2 Type OIWmple(mudchwkmlyomb ofpt NmghPli1 dbebw) 1.❑ROW.Dleb,Nlan Swnple 2 Repeat Sample(aftr uniat routim) Chbnnaled'.Y. NO_ ❑DieMbution Syss. Chbnne RedtlW:TaW_Fm_ Chbnnaled:Ym_No_ a.Raw Watw Sourm Sample Chbnne RmidNal:Told_Free ❑E.MI,-OWR(AP) ❑Fecal-swa.O..,lmiresml Umaddmwry routire leb wnEer: F.Yes No ❑Awmwnent Monaonrg lAN) Umatlalwbry mNm ndleatlr: ❑Oder _J 5 A❑Sample Collected for Infomadon Only lnvNI ConaWctionl Repass_ Oder_ LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Umatisfam,Taut Colibrm Proamtand 8edahObry ❑Eeop present ❑E.Coh ehrea oCelamndeNobtl Replacement Sample Re9ulred: ❑Sanple boeltl('�mute) ❑TNTC ❑ Bacterial Density Reaul9 TOW CdNOm IfOOnI. Emil N90m1. Fxel Colpom /109m1 E�rocoa /100 m1. Mdlwd Cade. SM9me ❑SM 92220 osawd TarepdNI /c ❑SM9215 ❑EnWdwtlB S" /O Z IO�S DaaM Tune Andyred OW PeFRQ$. .'Zif SanpNxenAerloax rvmawpnn exe9W1 bbU Only: 0 8 0 �— am 2213003 MASON CO WA 071091202E 10 50 Htl NOTCE MYOS" "ITCH p1992JB R c Fee $304 O Pages 2 IIIIIII oIIIIII Ii1i'lmIIIII91111111IIIV�Ili Hill Retum To M (TG14 /AV S 1 V E Kl rt pt t, /mil Jy�LT!/✓PL 6s6r'gif( "IA 985—0 Grantor(s):(1) M ITc. N 0 05Kl (2) Grantor(s): (1)PUBLIC Legal Description(i) E z NF Y/y Z3 -2z-3 (Abbreviated form:i.e.K hock,plat orsectbn, township, range) Assessor's Tax Parcel: (1) 3 -?— Z —t"e11 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, Stale 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 'L Z ?7 _ -7 S _ O Q O 3 CJ -COrlrlefifrt�+7 I Tax Parcel: (Connection 2)3 2 2 Z 3 - 7 5 -I O O Z 3 - C&?4t -,trr7 B'Z 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 9 the water system exceeds exemption standards. This system (hast has not) been granted one or more waivers from specific provisions of the regulations. Dated on this 2 day of JV&Y . 202E . Signature of Grant�toorr((s)�: UnPage 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 CA day of J U I q , 20—qAL, ljt loll (Ye 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. �y �,NDERSp rr// Notary P lic in a d for the State of Washington, residing at f iVon I 1 AbT A My commission expires:�If 10A o Page 2 of 2