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HomeMy WebLinkAboutWEL2024-00042 - WEL Application, Design, Letter - 9/20/2024 TON, WA MASON COUNTY 415N6SHELTONSTREET,SHEL-967 ,EXT 400 SHELFAIR 360-42]-96]0,EXT 400 BELFAIR'.360-2]5-446],E%T 400 Public Health & Human Services ELMA 360 482-5269,EXT 400 FAX 360427-7787 DAHL PROPERTIES LLC 261 HAMILTON RD NORTH CHEHALIS, WA 98532 RE: WATER SYSTEM PERMIT., TWO-PARTY WEL2024-00042 1505 W Highland Rd 520241350050 The 2-party water system, Highland Shared 5/6 (520241350050/520241350060), 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 to/6170Z (( MASON COUNTY n ,R W Of- 20 Z COMMUNITY SERVICES NmuMR.I.d:119) 5,4 R. waa aM1f nG%nnM Bni,mmeYl X W au Enn.nnb N W tl, 415N.6s SmxA,m1dg8)—SWWo.WA98584 WEL 202q - OM42 S6rlc 360421-%70 x400 eclfe ..360-2754467 x400 Ekm:360482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION PHONE MPS paYl xPY'D edits Ut 360 --140 034'S Mi1LIMG PGGRE89-STREFf.CRY.BrAIF.lP 2b1 N. 1�avvYilto9- {'� CYlcina��S WF1 g9ci3z 9REMGRE94-3IRFFT.CRY.STaIF ID xxx l lavvl 1�e Ol- W ) 'bV'30 of S PPoXMY PMCEL XVXBER(WELL$ 2D2 1 of 5� I}p 9ECONOMY PMLEL X V IRlFA nF MPlM4eLFa 5yo24 oobo lot b �i ' waTERgpVRGE 90VRCEME S PMCELi LOT ME ❑New t17/ ti Exiatiag (Wen ❑Spring 9•O t 3A(r< Peoroso waTER srmE91 x61E 1REoaweol la In�f P b PaascT OEacPom Well aRErn�t-oxa ro e11w eoxdnoxa `tFpN \ i'rl oyAb W 12-Ailro&A4owe covilitinmeDnto N w p Site Plan: (may also be attached) (property boundades.Muctures,well site w/100•radius,driveways,wads,aeptir/aewar canponenta a1W lines,easemenb,W..) Stt wirac�<d ceplic s1� ` .h" _�Pc. lot 5 4, Submittals Checklist: (these additional items will be required for approval) SEP Z 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 BY"1.not-yesaaued}_ 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 Stag Use Only Review Step 1: Well Site Inspection: YES NO NA ❑ ❑ 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 road pp atq, County or State. What is distance to ROW? ^1/ (z ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan) 7 ❑ ❑ Is the well cap satisfactory? J ❑ ❑ Screened and vented? r, ❑ The well casing extends_ above level ground/concrete slab? (circle one) IA' ❑ ❑ Is there evidence of a surface seal? lQ f; I f-101 Ir ❑ ❑ Does the seal appear adequate? ❑ Is a variance necessary for well site approval? erp,6 ! 0057 Comments Pass ❑ Fail Inspector Date /V/(,r/t)f'/Z r Y Review Step 2: Two-Party Review: YES NO NA ❑ ❑ Water Well Report with adequate pump test on file? ; ^ e"907 »���6 �vApty tt+ti, N(Q If NO,date of Capacity Test Driller GPM �r]� El ❑ Received Satisfactory Bad 1 enological Analysis? Date of test 7 3 W C A ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN Z �•/ ❑ ❑ System appears adequate to serve 2 single-family residences based on Information providetl. O Comments MASCNCn� OCT ✓q FNT O(Approvetl ❑ Denied Reviewer Date Findings in this review reflect observed conditions as they existed on the day ofthe site inspection. No claim is made,express or implied of the future success or failure ofthis system. Well site approval does not constitute water system approval. Water System approval is a two part process. All proposed ronnections to new wells are subject to water adequacy requirements at time of buildingpermit perMCC 6.68. Water usage restrictions and additional fees may apply to all new,wells drilled after January 19a, 2018 per ESSB 6091. Revised: 10/13/2021 ThIs farm may be scanned and avallablefer public dow,on Use Nose County Web sits Page 2I WATER WELL REPORT DEPARTMENT of NTRi, flmul No.WE5542] ECOLOGY Uni� bw WRU ID T.,N.. 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NIc OEIfdR034 Meaun Ibr_fryn Tempenoveafmu_•F xaaahnnid aomy.0 mde' ❑Va ®No 5tarr Dale 03'13I2020 Completed Date 0Ccf1dY102d WELL CONSTRUC]ION CERTIFTCATLOt4: 1 eaauwemed aedmorucepl mapormibiliy finema.acrioo oflhis well avd im wmplunw withal)Washingbw melt conswaion aenderdx Matenab and aM the inf lion mpvwd above eR vue To my bat bmwlcdge aM h.lkf. ®Driller❑Tnuv El PE-Prim Name ROBERT LAYMON Drigine Ca ,ADVANCED DRILLING LLC Sigma BIaV4` Address I ISID SCHOOL LAND RD SW Li.No.25B8 City.Slam Zip ROCHESTER WA 99579 IF TRASdEE 5lroasai a Liume No. Cmaecwr'e _Sponwr s SigoaNrc Rceimauon No.AOVANDLrf04OL Dia.O&t4/2024 ECY050-IjOlRev09/LEI /Jlav rweJrhia rdavmvva in wr ulmrrmeJ rwr.pAvm•wll the fl'erer Naaanrm Amgrumm360<0)bB]2. Penmrra'ifh/.•nrinR/av rmr raNl///ry 11'ad�ir{Rmrr Nrlm'A•nOra•. Persma xiihns/nrrh Aimhllln'wnrallNA.Y)3-034f. 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"'^e clDgmpw Wbiar ❑ 17N5x/3-4'R•DOO b R.adramc: aaeedcaes b_ U-DT 5 W�LL� Drwpa.Yd000x Imv.mc .;� :' uwr_,awt....m WtV VA 2216077 MASON CO WA 09/2012024 03 20 PM NOTCE DPHL PROPERTIES LLC .201001 Rec Fee $304 50 P., 2 Return To Do.L31 4Pcegec4er, Ik 2b1 N {{awulkol pd Chehalie w% `1lb531 Grantor(s): (1) DAW 'QronQ,<tQS LLC , (2) Grantee(s): (1) PUBLIC Legal Description (1) 1 atC�3 aC 115 WTI - M, AF 2205952 Sd ),1£ S -70 (Abbreviated form:i.e.lot, block,plat or section, township, range) Assessor's Tax Parcel: (1)�3 2- o 2- 4 - I -_2_ 0 O S v S24 'Tw1 a-S 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, Stale of Washington; herein described: Tax Parcel: (Connection 1) S 2 O ?4- 4-S. 0 O U Tax Parcel: (Connection 2) 'Z 0 2 --5 O O b O The system owner is responsible for keeping this system in compliance. The name of the water system is: 53't b SI.Arpd w Q 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 specific provisions of the regulations. ��''LL Dated on this 201- day of �Q b2Y 20 L Signature of rpntor(s): (1) (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 certify that on this 22e'day of Cgbttbnb& , 20 2L , Camn VAW 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. REBECCA R. MOISTERk" NOTARY PUBLIC Notary Public in and for the State of Washington, STATE OF WASHINGTON License Number 167937 residing at �Vd1C`O11 a. My Commission Expires April 14,2027 My commissionexpires: 4 • 14 9D2f Page 2 of 2 � | \\� � �\ `����«^ • ` � # � | � © � d d \ \ \ Q�k ,ezeeeee.e . , . • ! / Q , r o ; s 0000000000 ---------- AI �y