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HomeMy WebLinkAboutWEL2024-00029 - WEL Application, Design, Letter - 6/4/2024 584 ® MASON COUNTY nt5N6 SHSTREET, 0H27-970,EXT 400 S HELTON'.360-2751467,EXT 400 BELFAIR.360-2]5-44fi],E%T 400 Public Health & Human Services ELMA'.360482-5269,EXT400 FAX 360427-7787 NEWTON JAMES E & RUTH WINGERT 4421 E NORTH ISLAND DR SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2024-00029 4421 E North Island Or 221251100080 The 2-party water system, Newton (221251100080/221251100090), 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 Sincerel David Anderson Environmental Health Specialist Mason County Environmental Health Y/ 2MozC( MASON COUNTY R"" (a COMMUNITY SERVICES n Rz lereh tl e 11 I (i0 J„Y6]II {Il al(.IHltlp%1 'h-I NS h\ r\VNI U m TWO-PARTY PRIVATE WATER SYSTEM APPLICATION PPPLICAi.1 � ` 11���� 11`)6-5 3ci 3 .vq- MAILINGAnnREIS-STREET CITY, jj nP "2159 r' SnE An RE55-STREELLIT1,RTATE,EIP : ►and ; 4-on 8n IM PRARYPARCEL Ne ER(WILL"''I � OOQ MYPAR[ELN RIIF APPLIGBLF xn 2 R �G TER souacE �( vow T.PL y ARCEL,LOT SEE 1"I LOL s EE 1[IINCl4 ❑ P.xisting ty w'cl ❑tiring s Paoaosso Rsysr�yyLE laeauwsol E N wsa oes alPnnx ew We'll arStRnels. : lafF wf�er\side. I/• Ssl�u� Y• nEiAOR4.Nmi. OR CT I Ne TOSMEI OROTIONS e t sf a v4 -ei oxes across 40M TiVex� , Site Plan: (may also be attached) (property boundaries,structures.well site w1100 radius,driveways.roads,septic/sewer corn ponenls and It nee,eesemenls,e'.c.. L Q c6 �e� U Submittals Checklist: (these additional items will be required for approval) ® Satisfactory Bacteriological sample (this may be deferred If well is not yet drilled) �IN T Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled) 4s Notice to Future Property Owners recording(record with Mason Co.Auditor, supply copy of recorded document) 10 Septic Records(additional locating requirements may apply if there is a lack of septic records on file) This form may be canned and available for public view on the Mason County web site. Itcviscd: 10'13'2021 Page l of 2 _________________________Staff Use Only.---------------.------------......____________-.....__________.... Review Step 1: Well Site Inspection: YES NO NA ❑ [ j ❑ 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) 101 ❑ ❑ Is the well cap satisfactory? ❑ ❑ Screened and vented? ❑ The well casing extends 16 —above level ground/concrete slab? (circle one) ❑ ❑ Is there evidence of a surface seal? (Ql .' Y7.7TXsl �j ❑ ❑ Does the seal appear adequate? W/�4 r --p177. XF73 ❑ ( ❑ Is a variance necessary for well site approval? 7" I/PFf`t y Comments J Pass ElFail Inspector / // ! / - DalelZ _ Review Step 2: Two-Party Review:`b" YES NO NA �1-� Ng��ra.,�� ❑ ❑ Water Well Report with adequate pump test on file?Avradth YIYI)rip Of 7?12WY W(&VR4r 4((ZOOP0 If NO, date of Capacity Test 7 Z Driller ! IZt Oti1GN . GPM ZO ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test ��GL 7 Xf ❑ El Received Signed, Notarized. and Recorded Notice? AFN_Z Zl Ityfj ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments �I Approved ❑ Denied Reviewer Date r [ hd,ng.cin tl, < i;llrt ] - 1 tr 'J rl1 , ! , t t ' .. I nri pl(eJ of Ji Jl r.mre si,hlilwx ol'lhn u=urn. N'el1_i np/rrr n(dn�unt,nnslinu / a.Ie,nnpp,oalll'em- .tiu.rrm nypr'urrtl ia o nvI-part pr'i ,�. 41111111,111d o111111 t 6'"I 1111r e[L'u ,,uiv 'II , u! ( p „ -/ "o iry rr ll [l S1 rnotpu 11U'6.6A'. 46 ter ..........r¢tinr.v rid...Nat nnnI l,r .... .. hto lIn„ naps Anll 1n/¢r lnnuu U ' 2018 prr 1SS11 RI9/. Rc�i.aL in'1320'1 This farm may be scanned and available for public view on the Mason County Web site. Page 2 of 2 y2pz4 �D WATER WELL REPORT ECOLOGY IniiL-log,,Vi[1) lagNi, BPE144 ___. .. ne , .____--- --- 1 ) II im hotl Al R J 1 p tll I1D ]ICJI I Iliss,I ptV N'. i HthNi LIO v p CI' A II llrt - q Il ll A In, 444 EN 11 a N 51 It t 111 O .n Il0 l v II( of - II inp eII In fII n J I1 .n � t l u 2212511 00080 n txpn f- I 1 ell 188 t 9 I. ¢e lluinow l.d P,C IJ ThnvJ ' p 6 Um J66 25 'l U L1 Crinpfr Impa']I 3NVNU oia FNN f0 ❑ I] I J BE_ '�dOIILu NE :.Section�5 1 uh, 21N Fu,,, 2W _in l l 1 1 I am 6r 0 s-pll 4 1 P V V 4P 2R969 U n 1 1 -Li c�mplc 1201214s) 122868)2 _. P Rontiov: llvea : IuNnfp6, •uN_ VI'lller',L IJ( nl,¢ � 11 0 -on it adore T Ip d Smofl f" hr - 1 I 1'b_ F f mf k nJ per Mea, 0. I below you J:ufay. ro[& nil ap'ne ol, ml m�i xe rtfo +F.NY ^I 182� 1 — OzcaJJu I I .�+up I fu., N v All.,MilliWorks ut,� IMkI Sald aM la p 6 SI a18 f i0J 0 1y9 II N � 1J --- 1 sl r If _6 Blue stiff clay Blue soft 56 101 'Ieei ,v -I 1 11, II1l Im . — Blue tff cl-�_ 107 169 _ M II col d sand end I favel.water 168 1 OB Ii 5e1. OI I, hi sed tl It 188 192 A I Bes tc hla _ . C ,,,I ull Isald9avel 192_ 141 ate. i "I ©N. _ M I 1 ( 1 N n r e AI r u Trw IIY 1 p d.ph f Ix d0 v�:n 1 Nv I. a 1 121 IYRI JI s I I v2 II I fmn D 7123124 1 1 I pc ay :n I _— q Nx,e s I'SI Wlt,sniEV, LlV n' i:m0 V hiul 1 ne V . Loal Tm. 20 yp n , i60 I f t Iit, 7I2V14_ ah.—.11 f ,.. Ell 1n )41e 7122124 moil[lne ]28(24 —__ 1uY.1.1 COFSI RI(11(IAfFRlll l<4TI05. 1 Isd 1.1I lucIll1 tIt illnucl 'its, 11,11,1[[11 it,o v'c1. mnN.uo„LI.n1ni n,a me nr,,i I I 1, ru, x.t ln,li Jrl A1,pue Nu eJos/h'Kea Be� ._ II �( nVv A hlo nmgl .; Ui PC Des 1790 sq No 2874 _IL TRAINEE tiP ju- I Ni ( - ( I ILI. s —. Spnnwr's Sigluue< Iv,=aloof AItbA[)DI090K1-- IJute ll2'f124 —. .. 1CV 91 ,1N 9I9) rq 'II 1 1 r 11 ( ) 1 as, 1 3 ✓i 3111 Il-181. 1..mrs atea.. hl ..ur ¢!I- f,111 8,1,, yll— PIIn.... , p. huaelb r.I If1",.SJJ.(13ll. V ntiKllam IAtyc uton Olympia 850 Suitc .4 � Olympia N A 9850.. yunvfU _ 30),967 7010 .-_COLIFORM BACTERIA ANALYSIS FORM T 4060 Odkv�C%be1 � T2[ Fk ^+W 06102f2024 . x..,. o !MASON RF 97p1 -- -- D Tep!d Wzsw sem casts •,-, G up.c argC .m BSr Ne•5 pwaelrn+ V 0.Fat�[w inext9 N2. RUTH NEWTON /JCLf31e5I�1(3�!% �� i Gmac+4nm Artada Ormny pW. _ .._ -� 4ep ak e seo +28 a�s5 I tvr- ': j SAitPIE 1lS6RMATION sa;roe s+rcr� MAX $(FYf4c wN+.'in Ya'Cry sNnPktt+u4Y1 5{lC6�RVU"iKnBIXUxnI'Y'td '. 4441 E Nom,Island Dr. Shelton', ` iM wLnple.xac�anr ona M+d *�hw*+mroou^Smo. : 1 (]WUana flu4dtnan Sampa IMP) � 1 11 Wpm EampM IAn'f ,• . mr C;>K:r:nvYW Yfls.... No ..� Cl',Yx PR 491.Tpp: � 3 Omwq Wam RUM Sawa Sampb S .. _. CJ T'Sptw x., eamAiN ,„ff .� �I , � SUNaer 0.Yn Raw Swrtea WrtbSamp4 tE rt eae.rn J43 JSE ONO DRINKING WATER RESULTS LAB SSE �urwmmca+�r'va.:c P�;w ',�s,lwanon ❑f:ua preset pFro-atem� Racsum UamM RnUln 'ma•„sr r..-n.. , c, T, RMaremant Son"Rgwk nTo•, ❑sa^GK xn af. i 2211615 MASON CO WA 06iee/2e24 03 Qt PM NorcE FU I NEWTON p198t 63 Fec Fee. $301 50 Pages 2 ill IIII IIIIII III IIII III'll IIIIII IIII IIII II III IIIII IIIIIII III IIIII IIIII IIII IIII Return To ® ai She 1 6(fN- C?3-yFy Grantor(s): (1) cja metKIP-W-6YL . (2) �i_ u_'Kl NR UL PrL- Grantee(s): (1) PUBLIC (r' /� 1 Legal Description (1) —,�pppp Ur n LOl ,j (Abbreviated form:i.e. lot, block, plat or/s�ection, township, range) Assessor's Tax Parcel: (1) �-z12�J_-TL szs, rzi, Rs 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 l)_2_2� _L_kS - -L- -0 40 O At Tax Parcel. (Connection 2)�2-I-J-IS-- f - in-a QQ 91 D_ The system owner is responsible for ke ping this system incompliance. The name of the water system is:NI UMPL 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 ;-'rf day of 20 sky Signature of Grantors) Or( (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 crtify that on this day of i`U�,c� , 201-1 , 'Y"fu�� i R u}h N z� he 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. � Y ' Notary Public in and for the State of Washington, residing at 0� 'Ml "t ,y c U;HFK My commission expires: "'L Z-S Loz 5. �013 3S c .FI :ES t Iz Page 2 of 2