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Home My WebLink AboutWEL2024-00026 - WEL Application, Design, Letter - 5/28/2024 MASON COUNTY 415N B SHELTON: ,SHELT670,EXT 6HELFAIR 360-276 660,EXT 400 4 BELFAIR: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@masoncountywa.gov Sincerely, f`!� David Anderson Environmental Health Specialist Mason County Environmental Health MASON COUNTY COMMUNITY SERVICES o rR ul R ro aBr Na3nq Pl ry EmLmmeM1 Xnllh Co Wl HyIlh 415N.6"Street,(Bldg 8)-SbclroR,WA 98584 Wei doay - ocoj& 36clmn: 360427-9670X400 Bdfair:36027i51467x400 EIm2'}50 4 81-5 169 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT ETC H �� PMOXE MAI/OAOORg PREF •CTY�CE,M 4RTf Al toe �'j£G FpiR Wg 67 S5 z ^ $nE AOORNNBS-STREET,CITY,STATE.LP E PMIMRY PARCEL NUMBER(WELL SITEI a SECOX[IARY PA0.CEL NUMBER XF APPLKABLEI a 3• � WATER SOURCE SOURCE ME PARCEL I LOT S06 PARCFII LOTSQE ❑New 54EXisting ZWell ❑Spring G V5 � � /7G/( PROM!r WATER SYSTEM XAME IREOUIREm T ! /(G erzorecT oMEscMmlon WIECTONSTOSTOCONDmONS Site Plan: (may also be attached) (property boundaries,structures,well site wlI OU radius,ddveways,roads,septiclsewer components and lines,easements,etc...) ryare/,v Zoo 030 5 ih I C700 Z 0 { •�' Iv q00 z 3 Submittals Checklist: (these additional items will be required for approval) Ldrilled) ® Satisfactory Bacteriological sample([his may be deferred iF well is not yet drilled) Ql Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is �Bce to Future Property Owners recording (record with Mason Co.Auditor,supply copy of record Septic Records(additional locating requirements may apply if there is a lack of septic records on file) This form may be sunned and available for public view on the Mason County Web site. Revised: 10/13/2021 \ Page 1 of 2 W(at �APl�YCvugL �46RGK�9 Ft�YL Staff Use Only Review Step Step 1: 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 fqpLrpdius of the water source?If so, is roa private, unty or State. r 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? ❑ ❑ Screened and vented? r It ❑ The well casing extends 7 above level ground/concrete slab? (circle one) (� ❑ ❑ Is there evidence of a surface seal? [Q*.. 47.3YSi'ff ® ,.] ❑ Does the seal appear adequate? Let); /❑ [7 ❑ Is a variance necessary for well site approval? J. Comments IVI Pass ❑ Fail Inspector Date Jl/i�/IN Zy Review Step 2: Two-Party Review: YES NO NA ❑ ❑ Water Well Report with adequate pump.test on file? C rr�� t If NO,date of Capacity Test / Z le)? Driller ' S GPM 4Q ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test C4t *tat ❑ ❑ Received Signed, Notarized,and Recorded Notice? AFN �L13003 7 J ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments /7 [Approved ❑ Denied Reviewer Date �ll�/Zf Findings in this review reflect observed conditions as they existed on the day ofthe site inspection. No claim is made,express or implied ofthe 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 of building permit per MCC 6.68. Water usage restrictions and additional fees mqv apply to all new wells drilled after January 191" 2018 per F..SSB 6091. Revised: 10113/2021 This form maybe scanned and available for public view on the Mason County Web site. Page 2 of 2 ' � � ` ■ � . < # f y\ \ � # � ■ � � ) - .. � ! # ; w � . . , � . ■ . � . � . � y ' * m � d» w � 4r4t� \ � a tea. t C Thurston County Environmental Health 412 Lilly Rd NE •Olympia,WA 98506 360 867-2631 tXVxBIDN COVNIY COLIFORM BACTERIA ANALYSIS Date Sample Celle Time Smmb CwMy ar I�lD 1 co2�( 730� ow a /,0c5o/I,/ M m aw YN Type M Wane System(ded rely oM Ow) ❑ P.M.HowelroB ❑GrauPA 13Cmup8 ❑0har Group Aantl Gmn BSyseme-Proode 0um WeW Fedlms Inventory(WFI): ON _ System Name: Conbd Person: Day Phorie'.I ) cell Phww:I )3 E-nm HIn0 rP V OK Ew.Phma:( ) Sena wuM W.(NaM rmm,aloe and dpa>b wsmall adeem) SAMPLE INFORMATION Samweoama.dSr(namsInfTco M SpedOc bMtian oMtldrem xhme eampb mledetl:ftf— I SpaoallnstrusAonsorwmmenis: PuRPci arEy4TfAJ 914FAIR WA "z Typed Sample(mutr wk om Boxofe1Mmugh"Asbdbelow) d.❑RN.fl.DbtrRutle,Semple 2.Repeal Sample(afbr unwed.roudM) Chbrmmd:Yes_No_ ❑OWnbution Sysem Chlorine Rendual'.Tml Fsea ChlorneW:Yea No d.Rm Weler Sou me Sample Chlorine Reaitlual:Tobl_Free_ ❑Ec -GWR(AP) ❑Feral-ANa.SwemgrtnurmM) Unalnamry muAne le,nunber. Fill a Yw No ❑AmwrMnt Mmibd,(AP) Ungshfecbryneinewwdab: ❑Otlmr �_J a.❑Sample Colledid For Iddrmedon Only Inwngaow Conshud'onl Repairs_ 0tlw_ LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unea fadxey Total Colgoen Present and 9atlebcbry ❑Ere Presonl ❑Embalmml CalSormtlsbds0 Replacement Sample Required: ❑SamplebooB(>wlNnem) ❑TNTC ❑ B ft Omeily Resulb:ToWCobDn HOOK. EwS /I0GN. Fecd0:d mr I10Gnl EnAnamad H00 mi. wind Cotla smma6 ❑SM9222D peu ed Tm mdsse: ❑SM 9216B ❑EnbmledR DMeeMTm RneNted Wb Ran—S— .71( s.wxuNsmm�.we.pax.aUy lab Use Only 0 8 0 �— t e3t7 ��(1�03L 2213003 MASON CO WA My0sxIZ 024 M1r6M 51199279TR.. Pee $300 53 Pages. 2 Return To MITC14 M405 SI a � �uKPct N1�(LTt/JPL D LL fgI�( I w,g %g5 2 $J Grantor(s): (1) Y 1 I7d- N Grantee(s): (1) PUBLIC Legal Description (1) E lZ NE' %y 2.3 - I'L I (Abbreviatedlorm:f.e. lot, block,plat orsection, township, range) Assessor's Tax Parcel: (1) 3 3_ Z Z -- 7 ---0 O �(� _well 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 - O o O J Tax Parcel: (Connection 2) 3 2 z 3- 7 5 - q C] O Z 3 - (M4E&I 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 J WLY , 202I . Signature of Granttoorr(s)�: Page 1 of 2 JUG 0 9 2024 State of Washington ) County of Mason ) 1,the undersigned, a Notary Public in and for the above named County and State,do hereby certify that on this day of JU 1!4 , 20—UL, '4 ' P�"ti 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. 11111 I fll/Un r/,. . il*DER& I'll Notary P tic in a d for the State of Washington, �'�y`aoM,E#"''h�y r�iz residing at (I� FE# 0 6\bti _ My commission e�ryires:t L "u%`quo 0 g 1/1 Sl�'lilt..W`O`.P\�� /r�i'91TFlOF 100,5` Page 2 of 2