HomeMy WebLinkAboutWEL2024-00036 - WEL Application, Design, Letter - 7/7/2024 A 985M
® MASON COUNTY 415 NBTHELTON:36427-96. EXT
$HELTON:360-27544]0,EXT 400
BELFAIR:360-T]5448],EXT 000
Public Health & Human Services ELMA:3604825269,EXT 400
FAX:36042]-778]
ROWLAND TRAVIS
1091 SE CRAIG RD
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT., TWO-PARTY
WEL2024-00036
JOOO SE Craig Rd
319052190001
The 2-party water system, Rowland (319052190001/31906219DW2), 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,
4-
David Anderson
Environmental Health Specialist
Mason County Environmental Health
$(t /lo It j
f
MASON COUNTY DateNaea' _ (�
COMMUNITY SERVICES ra
BUIMna PhnnYp EmYmmMel NnIMCamminMrV•IU
415 N.6^Soed,(Bldg B)—Shelron,WA 995M WEL -1,4_ 60b3�
Shelton: 360429-96/0 x400 Bel ir:36(1 x400 Elma:360482-5269 x4W
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
NT P
26— ow .Q. 260 5'20 11 S
NAILIIING ADDRESS-STREET,CITY,STATE,ME
10g1 ( OF 04t' 0 64* LA IW
SITE STREET CDDD
TE
56' C/^-`
1176 LP
PRIMARY PARCEL NUMBERIWELL I
SECONDARY PARCEL NUMBER(IF APPl1CABLEI
?)q ar 21 cl aW -2,
WATERSOURCE sona""TYPF PARCELILM9VE PARJL]LOTSIZE
ittNew ❑Existing Well ❑ Spring ZrU1 [,1. SZ
PROPOSED WATER SY5TErent TW IR I
R
PROJECT DESCNPTON
�I
dRECTIONS TO&TEI CONDITION9^I 1 1P nr Ica �1 i
Site Plan: (may also be.attached)
(progeny boundaries,structures,Well site w/100'radius,driveways,roads,septictsewer components and lines,easeme etc...)
i ` , .44)6-4-W qP 219
76
JUL 082024 D
By ��
Submittals Checklist: (these additional items will be required for approval)
Or/Satisfactory Bacteriological sample(this may be deferred if well is not yet drilled)
Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
b Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document)
Septic 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
--------Staff Use Only ------------------—
Review 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)
❑ IY1 ❑ 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?
�I ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan)
❑ ❑ Is the well cap satisfactory?
❑ ❑ Screened and vented? ��I
El The well casing extends above level ground/concrete slab? (circle one)
❑ ❑ is there evidence of a surface seal? 14f. y$.alei
❑ ❑ Does the seal appear adequate? loft. I- .T.O11111
❑ I� El is a variance necessary for well site approval?
j' BPNOS'�
Comments
Pass ❑ Fail Inspector Date �� I
Review Step 2: Two-Party Review:
YES NO NA1m1 ,GH(,�q on 6/LIl1bZY M1Cl �A fog
[� ❑ El Water Well Report with adequate pump test on file? 1700NI (31:4t h(ll)
/ If NO, date of Capacity Test Driller GPM
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 6
ZZ 7 7 1r
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 1 7
�( ❑ ❑ System appears adequate to serve 2 single-family residences based on informal o A'lllEd?
Comments I Rol-e^�
uu ]So / _p?��
OBI Approved ❑ Denied Reviewer Date
Findings in this review reflect observed conditions as they existed on the day of the site inspection No claim is made, express
or implied ofthe future success or failure of this 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 ofbudding permit per MCC 6.68.
Water usage restrictions and additional fees may apply to all new wells drilled after January 191°,2018 per ESSB 6091.
—•r( 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 WEM731
ECOLOGY Notim of lmml No.
Tylx"r Wml:: Uniyuc F.cM,,Well ID Tay No. BPN 059
0 —Ireten Sile Well Name(f.Ili.111;
❑ IMumnxaaun O (In,enm mwiten NUINu. Wali Right PrnniLCnlilicam co.
P..Pma or. . twin.« InAl l M..iewl Property Onm Name Travis Rowlantl
❑llvalvnly =Lnplwxl =Irn wcu =1M.
Well SITI A� 1130 SE Crap Rtl
<.N— ellnTF: MI*e Cil shenlXl ---
P_'�Nnw well _Apnamm =U.i.rn C I.m.J ._,fil<I.vl > Clxony Mason
' I lx T<nivg 11 11ug in \n. Nm-Rdaly lax Parai No. 3190521-90001
Dimemioe.: Div,+..rwi 5 m a in a -- —. - - --
N'asa veennre.gproved tix lhis.xdl". 7YIx �No
INMhwfc.mple.M well f73 Il.
Irym.xfiel W>h the Ym;atae ran
l veiny Liver Uvn.u+ rmm To IL'[ken. srml Ml WeikJ IMd
O 1 ❑ 6 x2 173 .4 in a ] 7 ] Loeauen lsccimtmcuon,on page 2l: 2IAI or❑EWM
LI II _A NW /.-'6oflhe NE 'L:Smtim 5 Township 19N Range 3
❑ 1 ❑ _ia, ❑ I ] ❑ I ❑ IalinWr ll'� k 47.0 LV}45) 41760
pird. in Lengiwdc U'.xamPlc-120. n3 51 -123.091149 _
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Mam1.111. i,Ni Jehnsan __. maninl Front T.
1 Y. 61m14ess MILLI Nn
omm�cr 5 m. Slm.ne 12 in f lee h.a In it B.Top Soil 0 6
Dnn.ler_ 11 sF.ain In linm_n.u —h emwn clay 4 20
RavNPmn weL._\., ry„ Ro..,41'w m+re,Yl_In Gray Clay Grave 20 40
Mamrmb pm'<Jr a Gray Clay 40 so
Serf�n 4a1: E vn ❑M. Tx wM1u 19 Gray Clay WS Sand Mud Ba 100
�"1i1—rt G Clay Grovel 100 120
Mmnhe m(a In uwl ya nemm�m Cap Gray Clay 120 160
Di4 anyawcanWi Flov <xa1cC R\'a ❑Y.
Typ[nf wear! Mudd Fbvnrg gPlMMwma eo-lm -__ Red sane Mud WB 16 165
Mahal nr.mhxg xma Mr casee vast G Sand Coarse WO 165 17373
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walmis.N: LrnJ,mr;nv[k,an:n ulnae m. ..a l<•vl_n
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WELL CONMUMOv CERTIFICATION: 1.o,lrectd mid orxv<p lespulubilitp fure-.1- im of Ihixx1I..M incomplimmexid,all N'enhirip leell
connnietian sunIalds.Malmials used aml the inl'onnmion lea Mn ,1101e.1.1111.1 hest kn M,and belief
I G ller❑Trainee❑PE- Prbl6ame Robed Layman fhillmy loin,.. Advanced Origii LLC
Mm., re M, Add., 11530 School Lend Rd SW
❑eenle No. 2586 City.style.Zip Rochester WA 88579
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Sponsor',Siuwm.. RcaNmlitm No.AMAND1.804DL Dinh,08124/2024
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Thurston County Environmental Health
412 Lilly Rd NE♦Olympia,WA 98506
360 867-2631
' nnlunoN rnurrrr
�� COLIFORM BACTERIA ANALYSIS
Dale Sanpb CotisWtl ilea Sarob Cm�^4
6 1?61 t L, Gpladld Al t1o5ft1
4xN b1 Y® �:V oP1A
Type M Water Syabm(deck only one box) �Pdvele HmoehoU
❑GmwA ❑GmgB ❑Omer
Group A eta Group B Sysbme-Pmhdafmm WebFaciies bone"pvFD:
ID# — — —
Syabm Name:
Cmted Paean: rnUl
Dal,papa:( ) Callphone:(Wo 47U
E . (a00.5 Q h / Eve.Plene:( )
�dsw vl oleo �.eeeneapmea«e,n.11.ao-wl
14ilst C � 6� 9bfS'6N
SAMPLE INFF/ORMATION
Sample mlbcm by(nato
re): rbv,y Pvw"
Speck kimtion aaddruewhae eumle mlbclsd: Spedalinetruceme orcanment
)YO 6F CM15
YLl
Type of Sample(name nnok only ore box of#t Ihr«ph"halm!tolow)
1.❑RoutiHSAMPIDDistribution Semple 2.Raoul Sample(after umeL mutiu)
Chbnule No_ ❑Distribution Syabm
ChbMe tal_Fme_ Chbnnaled:Yu_No_a.Raw Waample Chbdna Residual:Total Foe_❑EtaoiP)❑Fecal .wear lemer�n) UnmbWOry routine let,number No_ __
❑Auaument Monlbdnp(PIP) Unwiti lorymuEumlbcidate:
❑timer
S
Semple Colleeled for lnfam only
In,"oiIaie nl RepMn_ Omer_
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑UnaeBehcbr Total Califom Pmeemand patient ❑E. CSaNbman N�debWed
❑EwN patient coWeMail
Replacement Semple Rapulmd:
❑Sempleboold(>30houm) ❑TNTC ❑
Bxtadal Denary Ramb:TapIC IIIM /1DOM. E.mW H00m1.
Feml Culibm A00ml Enbrocaccl 1100ml.
Metlei SM92M ❑SM9222D oelead ybne w«I
❑SM 92158 ❑Enbrobd® (0 �1
MbeMTarw Mdyted Do
semexwewlecxnmesWaadyrl labl)ae OMy:
0 S 0 3 tJ
tar+'+ 3Z9-
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Thurston County Environmental Health
412 Lilly Rd. NE ! Olympia, WA 98506
360 867-2631
THURSTON COUNTY
NITRATE TEST PANEL
Stmc 2 Report of Analysis
Date Collected: (MMmm•Y) _/__/__ System Group Type:(circle ore) A B Other !tl
DZ
Water System ID — — — — — —
Number: System Name:
Lab#-Sam le#: O80 -- County, rh&SOY1
Sample Location: C wt_ 4* Source Number(s): (list source;if blended meomp atited
1?D SE /� (GI 7 7oh
SamplePu re•(d eek but Date Received:(M69DA'YY)
RC—Routine/Compliance(sntlsfiesmmitwingrequiremeom) Date Analyzed:(M1Af/piny)
❑ C-COnflln0ti0n(oonfimafion of chanlwl resul0• Date Reported: (M D/YY)
IffI-Investigative noes ant satisfy mraftring wquimaots) Sampler Comments:
O-Other(specify-don nor sedsfy mordtoring regdmrnemsl
Sample Cemnnalti ' f beck box] Swnplg Tv . fdre k -treetmenUUntremed(Raw)
ail�S -Single Source Post-treatment(Finished)
❑ B- Blended(list auren in'Source Numlxra)•field) .{❑� Unknown or other
❑ C- Composite(gat an.in•Source Numberlay field) Sample Collected by:(name) s1 IUM-4 R(a.i•K�r{�
❑ D- Distribution sample Phone Number. 910 610 I Z9-7
e�ent�d Report��oo(mailing or a-ma}��t1 address): ,B..jU to: (oiret
7/uusi P tbkA+olearastna.hie, KAv1 /�ft,es Ilrrul4.vsaY,
!D� CP
cS
EPA REGULATED AND STATE REGULATED OR REQUIRED
DOH ANALYTE DATA RESULTS UMTS MRL SDRL TRIGGER MCL I EXCEEDS METHOD/
If QUALIFIER MQ.•v
ANALYST
(X HYes)
0020 Nitrate-N mg/L 0.5 1 0.5 5.0 I0.0 SMA500 NO3D/ li ul-_
THE NITRATE LEVEL IN YOUR WATER SYSTEM IS: lAta�
In Compliance. •10 mg/L is the maximum contaminant level allowed.
Out of Compliance
NOTES:
"Confirmadom hmlude the original lab number,rumple number,and collection daze of original sample in either lab or sampler comments salon.
DATAQUALIFIER: A symbol orleveretdencre additional infomationabout the result.
.,IL: milligrams per litercrpints per million.
MRL(Madual Reporting;Linahn The lowest quantifiable coxentmtim of an aialyu,
SDRL(Stare Deledlon Reporting Utah): The minimum reportable detection of en aodyta as esmblished by dr department.
TRIGGER: DOH drinking water response level. Systems with mmpouds detected a oumentmdons in.ress of this lace]my be required to take additional samples or
monitor more frequently.
EXCEEDSMCL(madmurnommrainsntksx0: M.&Mifrheroammi..,amount.,eNs MCL.derchapren246290am24 -291 WAC. Aerie wmm�the
department's drinking water regional utfine in your area to determim follow upanions.
Lab Comments:
aL IOcr� JZ-r2-�
2212971 MASON CO WA
0710912024 02 55 Re NOTCE
ROW L AND, TRRVIS 0199251 Ree Fee S304 50 Pages 2
Return To IIIIIH NII1U1n11111HIMNil olliNIA1111 111
7rav 1,5
/OqI 5E lam;6 M
S ltik4art kA 19631-1
pp (
Grantor(s): (1) ,rrGU1-5 7Y1p+ (2)
Grantee(s): (1) PUBLIC 6U
Legal Description (1) 0' ) � zy ZiO AP 46 7z
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) U Q Q j_
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) 1 Q 5 -?(_- y U U Q�
Tax Parcel: (Connection 2) 4 5 - �C U QZ
The system owner is responsible for keeping this system in compliance.
The name of the water system is: R,ar.314,AJ
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 Cl Ot
day of C I ice, 201.
Signature of Grantor(s):
n' �t (2)
Page 1 of 2
State of Washington )
County of Mason )
I, the undersigned Notary Public in and for the above named County and State, do hereby
certify that on thisday of 202L,
TYCWi S `'&wtQ YA rsonally 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.
' ak
S'Wg f••ti"� Not ary n fort Washington,
' P• ''ps-on
.2 2 �
F�
a`2.sF .Q 9 '� residingat
pM1• a '
My commission expires: C S'
tr M/80C
i N:n 1o`"2F
�rygnunnnU�"
Page 2 of 2
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