HomeMy WebLinkAboutWEL2024-00019 TRUCK TRAIL WATER SYSTEM - WEL Application, Design, Letter - 3/25/2024 ® MASON COUNTY 415N BTH STREET, HELTON,%70, 8584 EX
SH ELTON: SHEL EXT400
BELFMR:380-2754487,EXT400
A:3804
Public Health & Human Services ELM82b289,EXT 400
FAX:360427-7787
MEDCALF JAMES & KARA
PO BOX 1552
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT., TWO-PARTY
WEL2024-00019
4880 E Brockdale Rd
421251450030
The 2-party water system, Truck Trall Water System (4212514500301421251450030), 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, �^
/V k —
David Anderson
Environmental Health Specialist
Mason County Environmental Health
7/z31j L/
0 MASON COUNTY CAUAK Z _ rj
COMMUNITY SERVICES
Ni 11AP i9._rn NaNlh Gmry SKRAM
415 N.6A Str«,(Bid&8)—Shelmn,WA98584 WE rl0 'L bCb
Shelton: 360429-%7Ox400 Belfair.360.2754467x400 Elms:36048b5269 x4W
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
A"MANJ osneS Y�AedcolF Pso-2_39 -T77 9
aA1UNGPfIQ6S-STREET.Lj'S57 Skdt6& e_ lz sq
CRYATEM
SRE ADDRESS D488oEET,E MGrpty e OuAap, Wo- 0424
PNMA_/ZI L.J M=E��LLJOO�O V1
SECONDARY iRCE}NUYSE0.pFAPP��e L17wz_
WATER SOURRCEe��J 11// ([�I1// SS��IyJ 111E TYPE PARCEL 11AT WE PjR 8.1LOTa6E
❑New IXExisting 'Well ❑Spring 7.63 &A 2.378 A
PROPOSED WATER SYSTEM NAME(RECVIREDTI
Trz LK 1
PROJECT DE9LRIPTIOH �� C..lo4G1
U PA R Zo — cm 0
DIRECTKRI TO SHEIC1 SITN)N,.
+'^�er5��-+ran.
Site Plan: (may also be attached)
(propedy boundaries,sbuctums,well site w/100'radius,driveways,roads,sepgc/se ver comporNSRs and lines,easemenb,etc...
MAR 25 you
i
Submittals Checklist: (these additional items will be required for approval)
Satisfactory Bacteriological sample(this maybe deferred if well is not yet drilled)
Well Log with pump test or 4-hour rapacity test performed by driller(this may be deferred if well is not yet drilled)
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
❑ Cp ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfelds,tanks, buildings; indicate distance on plot plan)
❑ y ❑ 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)
[�J ❑ ❑ Is the well cap satisfactory?
[X ❑ ❑ Screened and vented? sv
❑ The well casing extends 10 above level ground/concrete slab? (circle one)
�. ❑ ❑ Is there evidence of a surface seal? Lq¢: 11723%03o1T
[� ❑ ❑ Does the seal appear adequate? �0n; —123. IW16Z
❑ �fl ❑ Is a variance necessary for well site approval? TAJ : BNff 1L'
Comments
Pass ❑ Fail InspectorWV Date
Review Step 2: Two-Parry Review:
YES NO NA f'.i0�7PPI X 60 111 6)
JIy'e� ❑ ❑ Water Well Report with adequatte/e��p��ummp�t'esstt o ?
'n file
If NO, date of Capacity Test b/1 Driller19ff-,QfJ-tl GPM _
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test f 2
❑ ❑ Received Signed, Notarized,and Recorded Notice? AFN 2 7 13SZ 7
❑ ❑ System appears adequate to serve 2 single-family residences based on information prpr�tl /Ar
Comments
COG
[Approved ❑ Denied Reviewer Data IZj/WL /RONM�.. �.4
Findings in ibis review reflect observedcondilions as they existed on the day ofthe site inspection. No claim is made,express C yFq
or implied ofthe future success orfaiture of this system. Well site approval does not constitute water system approval. Water
System approval is a two pars process.
All proposed connections to nesv,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/9i°, 2018 per FSSB 6091.
Revised: 10/13/2021
This form may be scanned and available for public view on the Hawn County Web site.
Page 2 of 2
3
+
y W WATTERER WELL REPORT CURRENT
e
odpealal'npy-Eml.p,t"npy-oa.er,are spy-a.aM Notice of Intent No.WE 14804
ECOLOGY Construction/Dmommission ("x"incirele) Unique Ecology Well ID Tag No-BHH 129
e ® Construction Water Right Permit No.
❑ Decommission ORIGINALINSTALLATION
Property
Notice of/ntent Number Owner Nome J Metl a
moposen USE: ® cassette 0 bdaabl ❑ Ist,ok;iI Well Street Address E&ucktl b rd
+ ❑ new. ❑ lmptm ❑ Ten wen ❑ o0a City Shelton Canty Mason
TYPEOF WORI(: Ower'snaoMof,sY110lmmeehmm0_
® Ncw xsll 0 A<moditoeW Mnhod:0 Dug ❑ Brae ❑ nnvm ee Location NEI/4-1/4 AEI/4 S225 Twn� R4W ewer❑
3 ❑ ceepeam ❑ GNe ® gamy O dme (F 4 r Still REQOIRF.D) wwpat
DIMENSIONS: Mi mofsn1111 huha,ddllMMI
m of Me weh 175h.
CONSTRUCTION DETAILS Ist/Long Lat Deg 47' Lot MIPJSM 1327-N
Cedar 0 wade 6'• D. from .1 ft.w],2 ft Long Deg I= Long Min/Sec 511
laalle4: ❑ Laeramned_" Dian.ease_6,Is _ft. Tax Parcel No.(Required) 42125145DO30
❑ 11ueW _" a.m.Fmm_ftro ft.
Perfanaous: Yes No
CONSTRUCTION OR DECOMM13510N PROCEDURE
Type of pedaianr use Famuaa:lk baby cabr,eMeam,=:n of mamal avd murmc,and tle kud sad
slMdperfs_ia.Ly_j ,Qj m.ofpglr_6om_fl.a_fl. asweafwesewmblaaeb maOm Pasepwe.uima hn me mutt foresAebye
- Aiaamatod:(TISEA inoNALSIIEETSrFNECESSARY,)
setem: H Yes ❑ No IM 1t-Ps Iuwim 170
3 TO
Mood. ',Name Alloy Machine Works wave FROM
Type Stainless Slottel Model No
. land sly sand 8 grovel 0 3
3 Dun.S"s1was,.016momyjtft.w�ft. Brawn wily sand 8pravel 3
Dian. Sloui've from ft m ft 16
! c...evFure.wrlaa: 0 Yes 0 No smoraa.<umd_ Cobbles
a Mateals Plaae ftom_fte_R Small to medium grovel 18
medium brown soon with sift
A Surfausal: 0 Yes ❑ No ToW drpth'�. bllner 35
iMemel eed ro se BemorlRe ChinSmell to medium gravel 35
Diasoymmmwaioaaawbbwwar7. ❑ Yes 10 No mndllnn brown sand B MR
= Typeofoa , Deplhofmwe some water 71
s Mahotl otaaasstrau of Gray silty aey with gravel 71 135
a
PUMP: Mmubcrum'a Name Medlmrltn la epravel 135
Type: HP. 6ne Crown nnd,sift 151
WATER LEVELS: laadsafiae eleastan above m®sea less!Z ft. clas astOrnadklnld, e9rrle 1S1
C09Be boning 88M.
stmclewl 129ft.belowtnp geweu Due 0&12rz012 ,cater bearing 176
Arrmw Paeun_Ibs.Pa Rpwm mN Dae
S Maim waais mmrolle by (av saleme.)
A
WELL IESfS: Uawdowonunowu sate,lewlia loavad M1abwsmie boa
Was. u ptennade] 0 Yes ON. Hya,byu#oaT
Yield:�gaUmirt whh_ft.dnwdowm afla�s.
3 YbN.____jpUwn.wiN_fl.6.wdown wbrlus-
Yeld:�llmiv.whM1_ft drawdown afln Jua.
-Rsnswosse Rferel) um mamMs➢mnW 91(aver levtlaamv.dhuw
� Coll roprovmulew!/
Time Wem Level. Time Wewtessl Thee wwmlessl
p _ —
Des orteY — —
3 Babtea_MI/aia.whb_fl.dnMomaM_M.
� Ainm�QglJmin.wiN atmiase]¢QlL fv thn.
l Annia ro.. 'o, Das Start Date 06/122012 completed Date 06/1212012
Tempvatwa efwvm Ws afLemiuladyaomtleR 0 Yet ® No
WELL CONSTRUCTION CERTIFICATION: I cauwaed eed/a saeq oespwa3iliy for conswnion ofdds well,end b eanp5mce with al WMhingmn well
oomwaial smaade. Mrterias mad m M nfomlatian reported above net we to my ben Ynowlcdge and belief
Driller Enggxr Truna ed, s Kespp Drilling C pmY Arcadia Drilljn&c
Ugh /Engilua? Sim ` Address Po box 1790
Drilleratrainee Licame No.2ET4 City State,zip Shell W 985M
IF TRAINEE:Deillar's Lu ense No: Contreelor's
Driller's ftaane: Reaslrati N CADD1098K1 Dale 132012
ECY050-1-20(llev=10) 1lYa^eaGfhis dacunem v�mr ltema/efarmar,ylease Wlrhz Water Resources Program of 360J0768]2.
Persav with hearing loss ran call 711for Waahfsrgtm Relay Sersies. PeramswithaspaechdWbitiy.m118]]-833-6341.
Thurston County Environmental Health
412 Lilly Rd NE♦Olympia,WA 98506
a'xoRsmry courvry
360 867-2631
"" COLIFORMBACTERIAANALYSIS
Dap Sample Dreaded Time Sample County
r D" Zy co".
,, an
eon oe y®
Type of Water System loved onlyone bon) ❑ Pmmp HoumhoB
❑Group A ❑Group B Otlrer 2-
Group A and Group B Syndrome-Provide from Weer Fadlues Invenpry(WF9:
IDk _ _ _ _ _
Syria.Nanlg,�
/a'Lc(c /-6, f le.r S Ae."
Caned Peron: '-J'os,�e$ A
Day Phme:( L3I— If 1 Cell Phone:( )
E-mail: G-nto I, Ew.Fhom:( J
dr ro:(Prim fur moo,address and md Pe ladovee)
os1A�s�W\ �n�(`�
C� SSZ
Ib 4
SAMPLE INFORMATION
Sample comaled by(name):
Spofic location or address where sample olpcled Specielinatruatonsormmnanp:
Ll$so E aft'-"3VV
Type of Sample(mudem.1,only over box o#1 through#4lianed below)
1. Routna Dpbibuton Semple 2.Raped Sample(after unsat mow)
Chbrtwed'.Yes_No ❑DMibuton System
Chbnne Residual:Total_Fina_ Clllonnal Yea_No_
3.Raw Waler Source Sample Chonne Residual:Top(_Free_
❑E.oak-GWR(MP)
❑Fecal-sane,Gm.ape,,(,—r ) Unseasfopry routine lab number
Fiawad:Ya_No_
❑Assessment'AmilDnng(AP) Un lisfactoryroulpeolloodale:
Order
S
4.❑Sample Collecbd for IMomedion Only
InwsAgatl Coneuchur/Repairs_ Dtler_
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unaadpfactory Tapl G01iform Prewnten4 G"awbotory
❑E.og present ❑E.mWebwnt No Dollar.detoled
RBPlaement Sal Required:
[]Sam*Mold(130 hours) ❑TNTC ❑
Bndenal0maity Raots:Topl Coli[D /100mI. E..a /100n1.
Fecat Colifom 100mI Enummcd n00 ad
Method Code:ki SM 9223E ❑SM9222D Dap and ram Recgwd:I(p
❑SM 9215B�e�❑Errbmprlb 2S
Daw.orn M9yted: yj 'LY` Repolod:
oomph NuooclmRnuimerpNaaa.evAo lab L460dy:
0 8 0 / x �77-2 Ctr
Q
CCX hmq]1318�ema111/Lq.y�L Sl— xx fx,
221TG
352 NO E WA
IIIIIINNNIIIIIIaNIIIIIINIIIIII A. lies
Return To
Tosacd w�co\� �� �a
155Z. C131014
S �� rll W0. � RFCF/V�cO
Grantor(s): (1)
Grantee(s): (1)PUBLIC 1 '
Legal Description(1) _ T t L4 W
(Abbreviated form:i.e. lot block,plat orsection, township, range)
Assessor's Tax Parcel: (1) y Z J Z '5-- / �1-- O O 3 C�
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) Z 1 Z S- 1 - 5 Q 0 3 O CL®P 1
Tax Parcel: (Connection 2)
The system owner is responsible for keeping this system in compliance. `a
The name of the water system is: —1 ( 615� < yIV64 h
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 speck provisions of the
regulations. 'T
Dated on this Z Z day of J U��( , 20a-.
Signature o
(2)
Page 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
c rtie fy that on this _day of 20'a
t lJ�dC4.l�C pppeared 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.
O�J`�jrHulM CC���0�
Notary blic in and for the Stat of
\\�QO•F�;fi 2 +eGy�� residing at SY`Q�VHv�. UI{1
�o o`D oTARY •e';G� My commission expires: • lS •7M
n iy PUBL%
''.9�: ,N•umDer.r�a
Page 2 of 2
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