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HomeMy WebLinkAboutWEL2024-00036 - WEL Application, Design, Letter - 7/8/2024 SHELTON,WA MASON COUNTY 415N BTHELTON: , 0427-97 ,EXT Q4 SHELTON:360-2754410,EXT 400 4 BELFAIR:380-215446],EXT 000 Public Health & Human Services ELM:360482-5269,EXT 400 FAX:36042]-]]B] ROWLAND TRAVIS 1091 SE CRAIG RD SHELTON, WA 98584 RE: WATER SYSTEM PERMIT. TWO-PARTY WEL2024-00036 XXXX SE Craig Rd 319052190001 The 2-party water system, Rowland (319062190001/319052190002), 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, David Anderson Environmental Health Specialist Mason County Environmental Health 54 (la III 1 Dale R•celw]. MASON COUNTY COMMUNITY SERVICES AM,MNRA. 45 e•FN•Mw.MaFmYma,raW x�M,.c�.a.�mx•Ma 415 K 6-Sua,Bldg 8)-ShcI.1WA98584 WELP - 60b3(o Shelton.. 36041}96]0 x400 aelflir.3W-2154467xW0 Elai 360482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION LPPlK6NT PHONE rat 96o 5�01'* MNLIXO ADDRESS-STREET,DMY,ETRTE,LP I() l 1 bE Cyrsl (a 5 LA jWt SITE A'13U Sg.CIIY�STATE,LP PRIMMYPA0.0ELNUMNFACCiWE L I 31 V's- 2-) GClU 1 6ECONDARYPMCEL XDNBERRF APPLKGaLE1 9t9a3 21 �/GvaZ WATFA SOURCE SWRCETYPF PMDELI LOT I2E PPPLEL3LOT EME 1�New ❑ExistingWell ❑Spring `L,(JI PROPOSEDWATER SYSTEM NAME(REQUIRE ) R t PROJECT OESCRIPTNIN aREC?OHS TO SrtEI COXDNTIONSC 6 S Nu on �4 Site Plan: (may also be attached) (property boundaries,strucrurES,well site w/100'radius,driveways,roeds,sepliclaswer canponents and lines,easeme s,etc...) jU! F FiVFo JUL 0 8 2024 D By 1� 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 tNO NA ❑ 'kJ ❑ 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 foot radius of the water source? If so, is road private, County or State. 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? M ❑ ❑ Screened and vented? ^I ❑ The well casing extends b above level ground/concrete slab? (circle one) PC ❑ ❑ Is there evidence of a surface seal? 141. Y1:17181 ❑ ❑ Does the seal appear adequate? tog - 177.Olnl ❑ IF ❑ Is a variance necessary for well site approval? Ibli: BPNOf' Comments Pass ❑ Fail Inspector Date Review Step 2: Two-Party Review: YES NO NA Neal Q( Aj111,pg orl VZO&Vt Wf% d6169m fer �( ❑ ❑ Water Well Report with adequate pump test on file? 12111 (300J{1 *41) T� If NO, date of Capacity Test Driller GPM ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 6 7 7�7r ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN ZZ 171 �( ❑ ❑ System appears adequate to serve 2 single-family residences based on informs o 01dad? Comments I �-� 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 of the 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 of building permit per MCC 6.68. Water usage restrictions and additional fees may apply to all new wells d illed after January 19'b 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 WATER WELL REPORT Nmke of mtonr No. WE56731 1 Imqw Ecology Wcll ID Tag No. BPN 059 Type ar Wink: ^ a Sue\\'ell Name(if mule than one wclll: C Cr.ram.nnn ❑ Ih[uminmvn ca uoWouimollorm NUI No VVeler ltl¢lu Pm.64CY116—No,, PnPmed tl.r. • f4.. IMuavl Mwkipl pmp,,y Honer Nnme T2yIa ROW16M ❑IkuaKrrlN =1-1I.l .r.wnll -pHrr 1130 SE Ciao Rd \VVII SI rAd !I— ____— -_-- 6eVxclloPType: \IelYa: Cll) shelto11 Cmally MI wIrt F Nam'wAI ._Ahnmxm =Vtrn. C leum =t'Wa lwl Ilk".,, Ichfor M, p w- Mr Aoun 1'a, ?..1 N, 31905-21-90001 m0000m: uramnn ofhximl8 m173 h Waaovariancr appprvetl l'a Ibs xpll". DYea glNb Ikph rrfermmlexW well 173_II. CnnSM1anlnn DNaih: W.11 Iry,Y,xilal xaa Mc rpfianm foe! Caning LIMT Vwm In,m 'la lhkknn+ Na'I PVC wekkd lUrod ❑a I ❑ 6 m. 12 173 .25 K 10 1 ❑ la 1 D Lwliminaeinnmmiou,onpage3l: O EWM 11 1 _in � in. I I I A 1 I -I NW NE �G,Salion 5 T,.Aip 19N R., 3 ❑ I ❑ _in. ——io ❑ :1 :11 Istlrude❑aampla:47112W117.171760 ❑ m _ in. ❑ I 7 7 I 7 . ... 4mgiIWc1E\mnple-I20.L'NSI -123.091149 hrtunlbm: D1'm ANo Iglu of ledlxan.meJ Urllkr'sr.oglCanslrunbn of pVawnlFulnn Prueetlurr -- Sn.afpnf iiuru Sire Uf,ri. P.NIA Ra mlku,AM.vmclnmarr.aiaar®4,vlmJsvn'IW'.uW rh kiM vDl PttfmlM fnm_fl.m_H.Ikbw rrm "Aan nUlme afar nwaial ui c+eh bytt peoewlN.wolr has arc amry fur enfi clan,of S,.: • lb INo •K-Piker C+ r>ph 1W 0. ml6mulim. Fx sldiebUaLnnTC✓rwcnaary. Mnnf nnn'I Narrc Jtivem _._. __.._._.____. Mmmal From To lrle SWrbaa Nmkl Na. Brown Top Sol 0 4 1)..,5 in. 9b1 ave 12 in,N— L li.w In R. 4 Du tn_ in. Nha.ne_ in uom_n.h _n Brown Ga 20 Gray Clay Gravel 20 40 N.rrdrFtun wrk:Cln !vo sm'orprkrw .I Ir Gray Clay 40 60 lnmerml.pissed dom_h m_N Gray Clay WB Sand Mud 80 100 Nartnn Fnl: lras ❑N,, re%or dmlh" 19 n, Gray Clay Gravel 100 120 w.v,ial uaa m,cal eemaram OFiD Gray GaY 120 E 180 Da aPr.uau cnm+m amueFla xvcc fir.. ❑N'w Red Sand Mud WB 160 185 TVpcufwmrr Mua Fkywirg IkpM1 mfawm a61W ___ Mnhnlm.anli xlaW nD Casvd Past Gray Sand Comsa WS 165 173 Pump: MmwhrinmraNanr Type-. ILM._ Pump�Mkc MIPM1:�a l4ipnal Mveae�Rrm Winer Lereb: lunrkanfww elearwo chum me ..v lan'1_h snok.up of mr orwnlcmmP -2 n .W.e prwu.m Lea Slalic nnn k+el n.hl„a nq ul'wa n:ins a+m 6fl121fN24 Annun prnwrc_Iha.Irr WUarc irch Ilam 4nc wWa 6nmwlkd M1Y kap.,ahs ncl IVA Tnh: was a 9nmpiny Inl peN-rm u- A.. Zl 1'c. U M winm" V ield_nrm wnb_h,draadown+Hw_l" VbW_k\,m wrh_It JnwYwn aarr_hn, Y.w _apm aidr_fl.JnxW.xn aMr_ho. Ra,dala Oir ,-,whn puny e.IPTfd uD-xarm 1,,UI rmawd from xdl hp lU auly level) Timc Waett l�cl Tmw \Varcelnel 'linr \Ve¢Amel wn.orramrma lnr_. __— 'w",ua Ipm wnh_ndmn.bxn ann_M,. An lew =l'Mnanh uoi all/D k,,r2 M MIe D641RON Moron Ibx_l7tm -f lcmp,armTor..+m _'F wu.achmri,l—I ty mWei Crn IN No ,Gan pale 06I182024 CmrglkrN Dale 06212024 W EI.L CONSTRUCTION CERTIF'ICA'r1ON: 1 cumuucmrl vrrd n xcvpl lValxumbility for,'uluuwvim of dui%wall.alu[its cumplimme ailh all Washington oell ronAmelian xmodoo,,Matmu h aced.W the informolion reposed above arc true to my M.1 kroo IN a and beli,f GI Driller❑Tminee O PE-Print Name Roaed Laymon f 'll g Cutuno Advanced DrIUNA]LLC c;mp.t. q&dLA.y.1, AJJnv+11530 Stlwd Lend Rd SW Li,mw No.2588 0 City.Smr 2'n Ro eetef WA 98579 111Tt AINEF,S r' LkonxN.. Crntrxlllr. Sp Siyol licoorall.NI, ADVANDL804DL Date 08/24tN24 ECY 050-1-20IRa(IN Iq)11..ar ma Arbi,✓rkmnn+n m rm ubrrnury limner.plrua ,m!l rbr ju or,Bnnusc a Prngr'dm u1 JMbW)"M72. 1W.x'rrh Ivurinp Inc.inn roll 711 Ire 11'u,hirxmn A4., Svdre, P r.nn,arrh a apr.b✓i,obilln,nail a-"-b VA141 urston County Environmental Health 412 Lilly Rd NE•Olympia,WA 98506 360 867-2631 tiThurston COLIFORMSACTERIAANALYSIS TineSwn* Cxinly Daeded KM t yovv) Type ofWder Syemm(derAanly"box) NoueeyeN ❑Group A ❑GmW8 ❑Omar GmW A and Group B Syabme—Provide from Water FadOties Imanmry(WFI): System Name: ' CmlectPemn: /AUi Day Ph": ) CM PIpre:(No 70 E"'a1I4USQ h I i Eve.Phuma:( ) SMnWwb'. Pfim ene em elpmtlaaemvlWw) 17 I5 1 SO ' K�MA��0ys7fi _Sn -�Ae1 SAMPLE INFORMATION Smpb colbcbd by(name): nw'y PVW" SpadfmbretionmaddrmcwMesanpbmdecad: Special inewctionaor prearwna: Type of Sample lmud detkady aro hm Ntl1 lhmpha vied bebw) 1.❑RounqNQ— don SmpM 2.Rmpaat Semple(after umat.mulina) ChkamtNo_ ❑Dleeibution Sysam Chbme old_Free_ Chbdnebd.Yes_No3.RawWriSample Chbfine Residual:Total_Frea_❑E.cdIP).s.hw lnmernl Un,mmicbry routine lab roimber_No_ ___ _____ ❑AaenlmdlN(NP) UdatidclaY nwdne dlbd dde: ❑Guar 8 a Sempb Collacled for InfirammiJair,Only Invesdpauve nl Repsire_ Duet_ LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Uddbfa bery Total CDlifomi Presamand SardslarCdtiomloE b4♦64 ❑E.my Preead ❑E.cdlebeenl RapladmmlSempla Rpulnd: ❑Sarn*mo old P30 hours) ❑TNTC ❑ Bacmdd Daneily Reeulb:Tolal Cdtifum_ OOrM Ecou N00M. Fecal Cdibmi It00M EnY='d n00m4. Meubd SM92238 ❑SMSMD ward Tens ❑SM92158 ❑Enbmlwill e'-1 Daweb Tme Ar*An OWN 9enaawitrlomen.raerpV Mepal laEVaday: . 0 8 0 Thurston County Environmental Health 412 Lilly Rd. NE ! Olympia, WA 98506 360 867-2631 THURSTON COUNTY ® NITRATE TEST PANEL si—12 Report of Analysis Date Collected: (MM/DD ) t_/__/__ System Group Type:(dmm one) A B Other. /'d Water System ID Number: _ _ System Name: Lab as-Sam le M: 080 -- _ _ County: son Sample Location: q Source Number(s): (list interest if blew orcomposites! _ I?D SE to fPh IA* Sample Purpose: fosses awmoriere boil Date Received:(MMIDD/YY) / ❑ RC—Routine/Compliance(selisfiesmonitoringrequiremenu) Date AnalyuA: (MM/DDIYY) BOG / //i ❑ C—Confirmation(c riff fionofchcmiralmalt)' Date Repotted: (MM/DD/yY) -Z_/ 1—Investigative(does am satisfy moninu ng rcquiiementcl Sampler Comments: ❑ O—Other(spxi(y-does not satisfy momtonng requiremerns) s laC sii s: cb ke erooriere boil Sample Tvce: (mmt one) -treatmenVUntreated(Raw) S -Single Source Lj Post-trentment(Finished) ❑ B- Blended(lie somees in'Souree Number(O'field) ❑ Unknown or other ❑ C- Composite(lim aurem in'Sowce Number(s)'ficld) r{ Sample Collected by:(name) J !l1tlML ❑ D- Distributionsample Phone Number: '769 S7o IZ� d Report 1'O{{pp(( ailing ore-mail address): Aaus3 E? km lwa.a<<Osys�-rsce�iA. cLfHn �IaVlS Rray4mR D I CM SRaA a � EPA REGULATED AND STATE REGULATED OR REQUIRED DOH ANALYSE DATA RESULTS UNITS MRL SDRL TRIGGER MCL EXCEEDS METHOD/ tl QUALIPIF,R MCLY ANALYST (X if yes) 0020 Nitrate-N mg/L 0.5 0.5 5.0 10.0 SMISOD NO3D/ THE NITRATE LEVEL tN YOUR WATER SYSTEM IS: In Compliance- •10 mg/L is the maaimum contaminant level allowed. Out of Compliance NOTES: s'Confirmafion:Include fine original lab number,sample number,aM collection",of ongin d sample in tinter lab or sampler comments action. DATA QUALIFIER: A symbol or letterbo deore additional infomation atom the result. mg/L: milligrams per liter orparts per million. MRL(Melhud Repornng Limit): The lowest quantifiable concentration of an analyre. SDRL(StateDefection Reporting Wmit): OreminimummlamaWedeacrionofamm yteasesmblisb bythedepamoem. TRIGGER: DOH drinking water response level. Systems with compounds detected is roncemmnons in serene of Nis level nay be required ro mks ail itimil mmples or monitor more frequently. EXCEEDS MCL(maxsoum conbmimnt lenb: MarkM if the conmmimntarnoun,exceed MCL underchnpw.24629a aM 24S291 WAC. Reese conmm the department's drinking w'amr regional office in your area to determine follow-up undrn, Lab Commeran:: y C)-t IOyt '; 32� {n 2212971 MASON CO WA e7/0012026 02 55 PH NO10E FOYLBND, TRPVIS 0199251 qec Fee. 5300 50 P.9 2 Return To ' Imlluk�NnIIW1111111 Nil 1111IIINItl1IIIVl 111111111111lTff Uv 5 �ndf /Oq1 SE l�,� fd S Fr kVr,�S � 5 ES6�1 Grantor(s): (1) '-(GUI5 NX-1c k , (2) Grantee(s): (1) PUBLIC 60 Legal Description (1) 1o} 1 C�l I s Zyy7 4P 186 7z (Abbreviated fort: Le, at. block, plat or section, township, range) Assessor's Tax Parcel: (1) 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 5 - ? (-- y U 0 -Q_L_ Tax Parcel: (Connection 2) 4 D - 2 �_ 1� C U U z The system owner is responsible for keeping this system in compliance. The name of the water system is: R ft � 14,tj 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. Ott Dated on this Cl day of 4r� Ifs. 20 � ` Signature of Grantor(s): (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 this day of 2W- --rrV nM c 1,arul/2 yd 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. 9G a A A `S M i Notary Public in an for the State of Washington, ``�pj��ton�F T9 residing at „•'aFo'kO R y M commission expires: 6 S- :4 ' NGTAgY •: x Y Page 2 of 2 J LFC Z 6N � LL 0 � rc J � 5 - _ - � e g A — �r-�il � e L p x p ' IIII ' c Nxe � O \ _ - g_ 1 a ' m I 1________ ---- -'� 3 \ � � R S � — R� F I I $ ° I II IIjgStAI © �- I L_LL --------------------------