The URL can be used to link to this page

Home My WebLink AboutWEL2024-00029 - WEL Application, Design, Letter - 8/28/2024 SHELTO ® 415 N 6TH STREET, 0-2754 6 ,E 90664 MASON COUNTY SHELTON 360427-9670,EXT 400 BELFAIR-.360-2J5446],EXT 000 Public Health & Human Services ELM 3604ea5269,EXT 400 FAX'.36042]-]787 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 Sinceerrel David Anderson Environmental Health Specialist Mason County Environmental Health Y/ 2Fl?FIzC-( --Staff Use Only-----------_------------------_------_______________________________ Review Step L Well Site Inspection: YES NO NA ❑ [ j ❑ Evidence of existing sources of contamination within 100 fool 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? M17f ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan) Ylpl' ❑ ❑ Is the well cap satisfactory? 7FYI' ❑ ❑ Screened and vented? r Y" ❑ extends 1 _above level ground/concrete pslab? (circle one) The well casing IRS ❑ ❑ Is there evidence of a surface seal? �Q{-1 4�•Z g�6O !�' ❑ ❑ Does the seal appear adequate? will , -I??, %$$/ ❑ � ❑ Is a variance necessary for well site approval? rg: grFiyY Comments ✓ //� - —. / /—,//>/ — YJ Pass —_ Date ❑ Fail Inspector Review Step 2: Two-Party Review: r�- YES NO NA ?AfCodlb Bf�'�IrAf 0� ��2yW/XIWryb'6pnN((2a0ye�� (H' ❑ ❑ Water Well Report with adequate pump test on file If NO, dale of Capacity Test � T Driller p/' 9,c�/�yQAf4`vy GPM ZO ❑ El Received Satisfactory Bacteriological Analysis? Date of lest ❑ [I Received Signed, Notarized, and Recorded Notice? AFN 7Z1110D K ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments —. _ — — — - -- Date Approved ❑ Denied Reviewer — __- - ��' ..... tJr ll xct Y J ! i. i.. li dngv to!/ nn,Jlr t h r'rzdrmdv ni !rl rr.-. ] di I I or lmp(ird r/th / h e.vc� nr (IGire u(Uu 1 L1111 liuit. ! i ustun 1//rr I Rner s I nd I / I I,,"- td lint " NGr ittil rli llu lli iSp p�rr�u 1/C(f4 tlaru tt I ivimu el !Ld<nnIf" nm ill urn' ll' it ll !nlVrr Jnr uu U ' _oM -1SS8 091- This form may be scanned and available for public view on the Mason County web site. Page 2 of 2 2211615 MASON CO WA 36104,2024 03 41 PM NOTCE RUTH NEWTON N198143 ,e, Fee $304 60 Pages 2 lf.11 iiilll!II IIII IIIIIII!IIII'IIII11il it II'Il IIIIIII II!IIIII II!li I11I!II1 Return To Shel f vi Wt} 9FrsBy Grantor(s): (1) ()Li mesIV a m-Aya � (2) RUA " -- W+yn Grantee(s): (1) PUBLIC N>!: Legal Description (1)T reo f " I Iat or secbonLtownshi range) (Abbreviated form:`i.e. lot, block,p I� Assessor's Tax Parcel: (1) „c_L-TL- •'tea�� R z 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)_2_;_L-L-kr5--1-,--� O G�� Tax Parcel: (Connection 2) �1-T_ - _a< 1- The system owner is responsible for ke ping this system In compliance. The name of the water system is: p 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. ii 44 Dated on this day of • 20 . Signature of Grantors) 0/I (1) (2) Page 1 of 2 Stale of Washington ) County of Mason ) I, the undersigned, a Notary Public in and for the above named County and State, do hereby c rtify that on this ZS�'^ day of J)),,( , 20 2`I 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. 6 i ' Notary Public in and for the State of Washington, residing at l ) ih ' `i My commission expires: "-2 2-S ZC: S c 1 I°43J ul TOJ r 5E� Page 2 of 2