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Home My WebLink AboutWEL2024-00041 - WEL Application, Design, Letter - 9/4/2024 584 MASON COUNTY 415N6THELTON: , 0427-97 ,EXT 400 SHELTON:360d2]-9870,EXT 400 BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360482-5269,EXT 400 FAX:360427-7787 CANDACE VICKERY PO BOX 429 KEYPORT, WA 95345 RE: WATER SYSTEM PERMIT. TWO-PARTY WEL2024-00041 51 E Cascara Cove Ln 220202490091 The 2-party water system, STOKES 2-PARTY WELL (220202490091/220202490091), 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 lD/ Zl/?azy MASON COUNTY COMMUNITY SERVICES `�* C enldns P W FT4 Pmhn,mMJ Xuhh Garvnniry wM 415 N.6°SO (Bldg 8)-Shelton,WA 98584 WELQ�)aq _ C00L4I Shelton: 360427-9670 x400 BeVdr.360-2754 67 x400 El= 360482-5269 AW TWO-PARTY PRIVATE WATER SYSTEM APPLICATION MPLICRNT (d�)44o-5 ?D YRILWG ROGRE65-STREET.Lm'.ttnTa ZY EAGGREBP-STREET,CITV.tt E,ZP A Si E o PRIYMTPERCELXGMRE IWELL9RE1 2020-24< cF 1p� SECOHYI0.Y P/JiCEL MUWIR pPMRICRRLE) Q 22020-2¢- D / WPTER SOURCE ��.(( 9WRLETYPF PMGELtLm a� PMCELZ LOT 9YF ❑New p Existing well ❑Spring PROPOaEG WPTER PVRTEY X/JIE n1EGUIREG) S'o -Pk L PROJECTOEYRIPTpX OIREGBOW TC 9REI COXGIiM)Ne x i` Site Plan: (may also be attached) (property boundaries,structun:s,well site w1l 00'radius,driveways,roads,septic/sewer components and lines,easements,etc..) ATfAeAw, Submittals Checklist: (these additional items will be required for approval) Satisfactory Bacteriological sample(this may be defamed 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) Notice to Future Property Owners recording(record with Mason Co.Auditor,supply copy of recorded document) is Septic Records(additional locating requirements may apply if there is a lack of septic records on file)SWJ-2D24.00o41 This form may be scanned and available for public view on the Mason County Web site. Revised: 10/13/2021 Page 2 of 2 --_�.------'-----------.�.�---Staff Use Only Review Step 1: Well Site Inspection: YES NO NA ,v 3�r ❑ ❑ 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 foot radius of the water source? If so, is roe privet ounly or State. r What is distance to ROW? 9Z Pf ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan) �J ❑ ❑ Is the well cap satisfactory? ❑ ❑ Screened and vented? ❑ The well casing extends above level ground/concrete slab? (circle one) ❑ [y ❑ Is there evidence of a surface seal? ta f; y7.2105.1' fR( ❑ ❑ Does the seal appear adequate? �(,M.-121.Q05 -A ❑ X ❑ Is a variance necessary for well site approval? '-7 c CPv yy? Comments _4 f ed io cAlrefir l ( 112(M t -& efV vh r*o of 4ell Se0red Ao croo? 16fPil r/3d/LL jy �Pass ❑ Fail Inspector Data /rzi1vzY y Review Step 2: Two-Party Review: Y�(ES NO NA 7` ❑ ❑ Water Well Report with adequate pump test on file? RYM.rdSon Pfg% on 61tilemy Wit 80 A*r Oro reMi cyfco9.t) If NO,date of Capacity Test Driller GPM ❑ ElReceived Satisfactory Bacteriological Analysis? Date of test ` ❑ ❑ Received Signed, Notarized,and Recorded Notice? AFN 7, Z1S1G� ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments Approved Ell Denied ReviewerYM 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 orfailare ofilus 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 ofbui/ding permit per MCC 6.68. Water usage restrictions andadditional fees may apply to all new wells drilled after January 19'" 2018 per ESSB 6091. Revised: 10/13/2021 This form may be scanned and available for public view on the Maven County Web site. Page 2 of 2 WATER WELL REPORT 0 DEPARTMENT OF Notice of Intent No.WE55776 ECOLOGY Unique Ecology Well lD Tag No.SPU447 Tyq of work state of was hington ® Cwsnumlon Site Well Name(Ifmom than one well): ❑ Decosecoimiw b Odglml i:unllamn Not No. Water Right PermiUCertificatc No. "Orel Use: ®Domestic ❑IMwtlis ❑Monicitul Property Owner Name Hicks BrOdhisr6 Cosestrlmtldl ❑DrourrMg ❑loss w ❑Ten well ❑pher Well Street Address 51 E Caseard Cove On Couereman Tyq: Masked: ®New well ❑Alxmliar ❑Driven ❑leased ❑Gble Tool City Shelton County Manpn ❑Deepen., ❑O tar ❑Dug ®Ain ❑mod-Roods Tax Parccl No.220202490091 Dimensim: Dumemofimedgg_x.,to im A. Wu a variance approved for this well? ❑yes ®No CepN of cmmpldW well l4§,S�D Construction Dmmb: well Ifyn,what was the variance for? Cuing Lmcr Diameter From To Thickness SKKI PVC Welled Thdnd ® ❑ 5—in, +1.3- 14�2. m ® ❑ ❑ 1 ❑ Location(see instructions an pegc 2): ®W WM car❑EWM ❑ ❑ m. ❑ ❑ ❑ 1 ❑ oftheNl1'/V.;Sn 2ZQ Township 2QN Range 2W ❑ ❑ — ati—in ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ 1 ❑ Latimde(Example:47.13345)4721052 Longitude(Example:-120.12345).122 96001 Palanloe: ❑Yer 0NO 'type of,,m%mhruved Ddner'aLog/CONtratllOn or Decommission Praedurc No.of,mfi% u_ size dperhntiane_ia by_ Formation:Decribe bywbr,ehsrecM,anti ofineatiel mtl suucaue,aW Ne kind end Pefnl[d fiom_ftm_fl.Mlow BrouM aurfecc mast orrlre mercrisl iv tech leyn gnehated.with er lean tune envy fa each cbengeof seenec ®Yer ❑No ®K-PeC4n b Death 140.7 ft inI mion. Uu Witionel shaLL ifnlcedery. Manufcuer's Name .Materiel Prom To Tyq Model No. Diemmn¢TgC Slm see3g_in.Goon 143.3 R he14g.5 ft Dk brown cobbles gravel sand sift 0 2 Diameter— $Irk size_m.Goon _ft m_rt Gray cobbles gravel sand silt 2 9 Brown cobbles gravel sand clayey at 9 27 SndTlNergek:OYu ONO Size dpvY melnim_ate Gray silt fine sand 27 30 Mamiab plmed Goon_R m_ft. Gray gravel sand sand sift 30 104 Sarfincetmal: ®Yer ❑No To HIPS th?�ft Gray silty santl wet 104 109 Memel sued xmor a NTON TECHIPS Grey Bitt 109 128 Did sass soon comam unmblc water? ❑Yer ®No Tygofwenr+ DwM slttrw Grey sand sltt water 128 134 MethodofdalingmnasD Gray smell gravel Band sift water 134 149 U brown sift 149 15D Pump: MmufecNret's Name Type: H.P._ PwVimmkcdgD:_tL Dnigmd ftownx:_@m Ware LereR: LmSswficeelevsuon above ca wkvel_ft 9tiumup or"ofwell teeing♦•,.3 It moue gmwu surGe $tune more emi 86 R below rapofwell—i, Dme051L2024 Amnion prerrure_do M.,.neh One Ammon wale,u controlled by ("P.valve,mc.) Well Thar: Was a pure mg ern manned? 0No ❑Yee C by whom? Yield_@m with_ft drawdown after_M. Yold_NO.with_ft.dnwdown ufler_M. Yield_@m wsh_ft Mwdown after_se. Recovery Nn mow=eery wl o pow,n timed oR—work level m semen foes well wprowderlewp Time WderL l Time Water level Time W.Uvel Meofpmnping Wt sure,Om_@m wild_ft.Aawdown after_hrc AG Out III)p an with stem am.t IN fi.for 2 M. Den o8113rz02d AMimn flow_Nor Tmnpmue of wen,_-F was m chemial malysb made? ❑Yer ®No Smn Der,96/1=24 Conpktd Dow 011U2 024 WELT.CONSTRUCTION CERTHFICATION: I...mounted and/or accept rnponribilityfor comwmim of Nis well,end its munlimce with all Washu lawo well croswdon emdatds.Matefias used W the inNrde lum reported above me fee x my best kmwledge and belief. ®Driller❑Testae,❑PE—Pfmt Name Mark Wine Drillin¢Compmy RICHARDSON WELL DRILLING sign. Adduces PO BOX f4427 License No.24U City,Sex zip TACOMA,WA 98448 TF TRAD4EE:S Lteepae No Contractor's Spopaia Shoustacce, Registration No RICHAW'9210B Dare061114=4 ECY050-1-20(Rev091I8) Ifyw need fhudoamereMae altelwmfanot,please call the Water Resources Pre node at 36P407-6872. Penes with hearing foss rnn mfl111fwW hfngrm Relay Service. Penoar wirhaspeech duabifiNcan cafl877d33d341. 26276T.Wv f T.Le NW saac i1 SPECTRA Laboralorice - Kitsap Pm sbo,WA —__—_ ...�w1 ne ..brr vu• N3T0 C ^ (360)T/AS141 CO' YSIS FORM Dab S.*C0lwbd TlroBaanpb County celedad M am P.a vn 10 :10n Typed Web S0.(dad ad).bm) ❑Ga A ❑GwB ❑DSIw Gmry A and Glaq B SYMna-Pm"h.Wale Fodit kww"IAA: IDO Syahm Name. Cantad Peman: J .S ,' E Daymore:'3 Z Cd Plays 'I EnwJ:S L..Q �p E%.RIHw: 'I said resuh m:maaam.,.ea«..eM^rsrrn.rrar.w.an.+.i � I M SAMPLE INFORMATION Sample pokcbd by(name). S4W2 5(n f,, Z. Sl,a P ftnx reswnpbcpGeded: Spepal bsoucoms ncommenb: $I F �j.ScsJ r. �V1 �JrC TMd3m,o(darkany.b.) 1.❑Routlna Dlsbhulhn Sanph(AR) 2.❑Raped Sample VP) Chb W:Yaa ❑ WE] Inam aaromn.pxm.3w wa ndnl Ure fadory.1m,lab camber. Chbdm Raepial:Tota{_Free_ 3.0mmdW RJa Souris Sample ——— ----- UmelkMkrym6wmbtl dab: S CWnsbd:Yes_No_ ❑Tlppe W) Cbbdna RaWdt Tolml ❑Aeaeaemed(NP) A BurIwaGWI Rwa SoumaaVabr BemPle IE ) I e ❑ E cop ❑F.1 5.qs9 Wlecma M Ma .Darr. LAB USE ONLY DRNIIONG WATER RESULTS LASUSE ONLY ❑Unaadandory Tohl Cdllmm Presets and ahnmry ❑Emppmaent ❑Endebaanl 9aah,al DaMttyRaub:Tdtlt _pW/100m1.Emfi_P)ba100mL FwlCaflam d Wd. HPC cMtml. R ipwaamlana Sample RpWed El MC ❑Sxrybbbob ❑ Semple Vole. ❑DaewDn pd Canbver ❑ d Rd.uz dlv 0 -01 Raugliaap C: t ,1 le 0 Lq.0afI96M .....�rr....s..w.sra.ai r ppal.a.e..M., nwr..mNaaaw.+n Spectra Labs - Kitsap, LLC (Poulsbo) j SPECTRA Laboratories -Kitsap 26276 Twelve Trees Ln NW Ste.C Poulsbo,WA 98370 Phone: (360)779-5141 www.spectra-lab.com i Spectra labs-Kitsap,LLC (Poulsbo)received samples for Steve's Pump&Well Service on Wednesday, August 14, 2024 at I:10 pm.Unless otherwise noted, all samples were received in good condition and were tested in accordance with the laboratory's quality control procedures. A summary of the samples received are outlined below. Sample No. Description Location Sampled 243067-01 51 E Cascara Cove Ln Some 08/14/2024 10:37 243067-02 40 E Cascara Cove Ln source 08/14/2024 11:20 This report package contains laboratory sample results and any attachments listed below. If you have any questions please call (360)779-5141 or email us at wwwspectm-lab.com. I Attachments j 01) 1 { 1 I I I 7$ 3 1{t i j� 1 This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at 360443-7845 and destroy this report promptly. 1 These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced j except in full,without prior express written approval by Spectra Laboratories. 7 0820/2024 Page I of I I 2215101 MASON CO WA ecDA1. sno 'ioe2sVT szoe r.. S3., 111111 n I1111Id111111 1 1111ml111111 1111 1s1cm 1a.I 1. a Return To ,1);tJID S QrCS 29/0 SE DtiilFSf. Cr Grentor(s): (1) Urn S2*-ES . (2) Grantee($): (1)PUBLIC Legal Description(1) &r I��SIIoPr piJ O(253� (.466revleted loan:l.e. Act bbok,plat as section,township,range) Assessor's Tax Parcel: (11��Q2 !join -TaC) - 12 NOTICE TO FUTURE PR)PERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM I(We)the undersigned gral tors), certify that the water source located on the above-described real estate under legal Dencription (1)and Assessors Tax Parcel(1)situated In Meson County,State of Washirgto i, has been designated to serve a source of water to the following parcels situated in Mason County, State of Washington; herein described: Tex Parcel: (Connection 1) 2— 0 2 4- --1 Tax Parcel: (Connection 2) ,V _L fL-_,e- 4 - SLjL_LL The system owner is respor isible for keeping this system in compliance. The name of the water system is: ISJ7J� (_ _. This system is designed to rro%r de for two service connectlons. Planning and deslgn approvals must be obtained from the t apartment prior to expanding beyond this number of services. Additionally, a water right,cbtained from the Department of Ecology, is required If the water system exceeds exemption standards. This system (has es n I Ieen granted one or more waivers from specific provisions of the regulations. Dated on this O oo/rr((µµ day of 20_2_�. Signature of Grant Page t of 2 IIIIIIIJJIIsnUllll}}JJJII AUGt227 200241S By State of Washington ) County ofUsssn k=t�P ) I, the undersigned, a Notar) Pubsc In and for the above named County and State, do hereby wrfify tltat on this a1 dry of AkA -1- 20 1�q , I�%tV tc� SioY.e.spersonally appeared before me,who Is known to be signer of the above instrum mt and acknowledged that he(she)(they)signed it GIVEN under my hand and official seal the day and year la/s'tt above written. Notary Public and State of Washington, Q,� Cori �gOh My commission expires: ro 0 � [ o° NOTARYPUBL% c i C ai %�OF WASN�a ,��V/IIIIIIIIINM�, Page 2 of 2 � � 33k (J • . 4 § � ■ \ � | J Jv 4 § ƒ 3L { 3 k § § mt R y 7- - - - - - —� � - --- - --� ° » % \. ® — %—�— -- � �4 - § @ 5,Yimgam2001 / . to - -- - �� L -.« mrm p c r� ■ * \ \ teaA- -£ A \ � } ! ~ � R Sk E" '* �Ski ` + AA � z, , • � - - - - - - - - - - - - - - - - - - � I ; � — \� | � • ! | � � \ > _ ƒ�» � w CASCA | S | \\ \ �) � n ON � ; e . w