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Home My WebLink AboutWEL2024-00048 - WEL Application, Design, Letter - 11/7/2024 MASON COUNTY 415NBTHELTON: 0427-97EXT4 SH STREET: , ,SHEL-984 A9B5M BELFAIR360-2754467,EXT 400 Public Health & Human Services ELMA:360482-5269,EXT 400 FAX 360427-7787 FEWELL STEPHEN D 570 E Strong Rd SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2024-00048 570 E Strong Rd 221287790042 The 2-party water system, O.S.P Water System (221287790042/221287790042), 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 Il//9/101 y MASON COUNTY Ll ZOZ COMMUNITY SERVICES AmwnlR W 6 45 1 R WMB Bu1d'vq,VWnmgFm+anmemlNWthCmm,nlry NeelU p 415 N.6R Stmet,(aldg 8)-Shelton,WA 98584 WEL 2OZ-1- 0Wq Shelton: 360427-9670 x400 eehfair 360-275-0 69 x400 Elrna:3NA82-520 ON TWO-PARTY PRIVATE WATER SYSTEM APPLICATION 11PPL0.,.RM PNOME - MNl1NGRO 7 Sm'� .C ,STATE,EF STE ADORESS-STREET,CITY,BrRTE,3F via PROARY2_2_PAR�EINUYEEIY m'E�rtEI SECONDARY PA ELLLNUIOJMaER IF APPLFAaLE) Dy WATER SOURCE NDYRGE TYPE PPRCEL1LOTaME PARLFLI LOT 3Q ❑Nov, Existing Well ❑Spring 2,4f S welt. e PROPOSED WATER SYSTEM NAMEIR UIREOI rr� PROJECTOESCR;" n /� 1 LLOO rrVl4�C O�GF��// f/-��[F G S /bT DIRECTIONS To sDu couOMOMprtroxs 5 rp f uRv O Site Plan: (may also be attached) (property boundaries,structures,well site V 100'redius,driveways,roads,septidsewer components and lines,easements,a ..) Nov RFpF�0 FZG Submittals Checklist: (these additional items will be required for approval) �J 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(thismay be deferred if well is not yet drilled) Notice to Future Property Owners recording (record with Mason Co.Auditor, supply copy of recorded document) JI 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 ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source? M (drainfields,tanks, buildings; indicate distance on plot plan) ❑ g� ❑ 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? �cJ ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan) ❑ ❑ Is the well cap satisfactory? 6fd Sfyl'�. ❑ ❑ Screened and vented? ❑ The well casing extends above level ground I koncrete sla (circle one) ] ❑ ❑ Is there evidence of a surface seal? Wilt.. 4f.2"m 0,.y� El Does the seal appear adequate? LOgI-IZZ.sit1fz El1 ❑ Is a variance necessary for well site approval? Comments ] Pass ❑ Fail Inspector OIL, Date itZp[, Review Step 2: Two-Party Review: YES NO NA ❑ ❑ Water Well Report with adequate pump test on file? IE1rb3ill wrtl Ar%(IM a7 6/w//V9( ( IS 601 or V0 01M 0400141) If NO, date of Capacity Test Driller GPM �J ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test / Z ZOZ ❑ ❑ Received Signed, Notarized,and Recorded Notice? AFN L IYZ ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments I}7' Approved ❑ Denied Reviewer 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 or failure of this 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 of budding permit per MCC 6.68. Water usage restrictions and additional fees may apply to all new wells drilled after January l9'a, 2018 per ESSB 6091. Revised: 10/13/2021 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 WATER WELL REPORT btl•rrr ab38L�� . STATE of WArwgroM . r.y.Rlr•14y11 etl (1) OWNER PC6 cl.l r_ p �. (E) LOCATOR OF WELL. (E01 9MEET ADDOMW M WELL(r rrw rM••1} . (e) PROPOM Use: U I•&I•Rw CI M-M-Ow fl (IM WELL LOG M AVAIOOMINT PMCMDUM Doognwrw" ❑ DAVI Tr WM Ll ORr u •.Try o••MY uY aree.ry.ay, w r r.w r.tl�fl.e.. r rw KWrryLirWYW Wrr•aYrlyYyY•Yp (4) TYPE OF WOIIK:001==r •raWewwylyNyiyypaWyly °r`�• Ab"b In R e &'M• on ❑ Ror•C ❑ - wTwK IMw m Ar etl❑O C.M. W IIeIrM o 16) arcw(oRE: ow.tl.aL (' ylpeea (M CONSTRUCTION OETAE$ C••MP M•MMele _(e_• IYye.•a Cl Kro /y'r • __'. _ - RvW _' RIMLRM Kb— -.—.- tYleewa•Ley� • .. TI•mr0 Oya RM R.M __R. Prl•Ibtl011b YwO w ' 1 T1p•YPMvrbrWW ._ _ EEEMMMdr• wbyrrrn Ltl L . Mlortleryr Ktl_. .�L _ ' ey—__.—Af• L dNMtl YN w wwWyvf•Rrtl T' W Wer EMti. Yf M .tl A Oyn Melw y •r — ^ ab.MPbMele rr w Grrdra _ On�aar•RYi-- R4 _ reerRbRrR Yr� w0 Tare •yr1—. 40i �� etleylpvey•1 �• _ M PUW. NMbtla.+•x•N - IeD (E) WATER LEVELS. •ri•...... i1"ymr°• a . Atbry P•rb•__��MLsyeIr•Mee Del•-...._ . M•elr MubtlMFtly04 (s). WELL Tom y�pt•Oryeaylwyr veeeb Ewa Wry � I L4••prgeMKL•rlYr �Ib1bL1 ew.Mrsl..�i4 WELL CONSTRUCTOR CERTWICATIOfe rrly 1:' Rr/r bY—�..—R.bMvelr•ar Iva oo••Reeer r/s.4ow N•P -MMY b eorbsWr a Wtl rL :: _. Ntl R• noe•PEe•M rW Y WYIrNr •nR •iMIILYM •IVRlNdL . •• - WIMMtl Y••tl Mel Y 1NOeMNtl lop~•J1Rvb M UM b Y RM pp••rrwMeyyrrRr•MarrrrarNYrrieN{vbslrrrrtls R.•btleprbrr. trbYabPrYrrrly - f'�� n /n.. etleRuw s er.ew >r •r.l.rw RUE �VCY[7I[ti/ We�/ !//t�llM� iwryr (EIPMO , , llerr qaI rwYe�W.irL.w--S—R.rwwr.�—r • "y TG l,, Luba eeKhLaMeeMr•I Kb�—uw rGW�)pR••McNIr111R .�—•.Ra R•tl +.+.r...r..r_w.e••rrwwl..rn TMO IrB (uSE AODMONAL SHEETS F NECESSARY) rr•.r t�ererl .�w e�Me - V anguam Laboratory V 2635 Parkmont Lane SW,Suite A Olympia WA 98502 yuVAIID 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM one Sample Cdkcten Tone Sample County 10/22/2024 3Cde had a om MASON Ibtl Gi YW Type or west System(dask only one pna) ❑Group A QG"B ®Glher Gmup A and Group 8SYslems-Provide rrwn Warr FaalNes Imaevry(WFly 1D4 _ System Nam: STEVEN FEWELL Cmbct Person:Amelia wiping,Inc Day Phone'.(360 )426-3395 Cell Phonr( ) Email: Eve.Phone:( J Sad iesuYe b'.(Pnnl lWlna'rs.alarsss ad zipaUea emal) Mala'$aWaEnlln9�m ANpienn$ratletnlvp.am SAMPLE INFORMATION Samm wlkclet by mama):S.AM Sped Vaflion h sampscoPccbt: Speclel issbfiaswmmmene, 570 E Strong Rd, Shelton type of 5airyle(sekctmyane typealapngle ham types i Nrogh 5 Eeba') t.❑Routine DWbufim Sample(AIP) 2.❑ Repeat Sample(a) Chlonnmd:Ya No (uandeNEuron wsbm Munsa..0.) Ufsat'sfachM routine We numeer. Chbnne Raquel:Tosl_Free_ 3.Gmund Vidsr Rule Source Sample —— — — I� - - 1o75-�mue Cdbcttlak- - -- '. Chkrinmil Yes Nc 0Tr4pencl lyaP) Chkrine Resival:TosL_FM_ ❑Assessment (AIP) 4. Suftear UWl Raw Soume Walar Sample(EnumemSon) S O E.cp4 ❑Fecal coerce res_ w 5..Sands Cdk'ka b�Mrmabn Q.h: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coupon Present ant ®fuld"Hbry ❑Ecofflneset ❑Ecahasswt Bactedal Density Raub Taal CoMem 1100m1. EcoA n00ml Fecal C.K.rm 1100ML RPC Ii mi Replacamwt Sample Required: I7 TNTC ❑Sample too ale ❑ Sa Aa VWme ❑Demepet Conbrbr p Tme Lan RSlasseN. 4 Z "I Raegl Temp c. """tit ' SM9223B ose nexn�woDR InouwOnls: D-R Lah<a,d. 285- 02817 2218142 MASON CO WA t 11W/M24 11 05 PH NOTtE STEPHEN FENELL e203424 Rec Fee 5304 50 Ppez 2 Return To !III(hIIIIIIIII IIIIIIIIIIININ milli III KIllllllll JwLA, Fzw�l( 5-70 E 61 5 f2al S�/r yE58'f Grantor(s): (1) sr� ( . (2) Grantee(s): (1) PUBLIC �" Legal Description (1) T1'xaj- !q ofhSE y4 SE rw 28 —2f- MUL (Abbreviated form:i.e. tor, block, plat orsection, township, range) Assessor's Tax Parcel: (1) 2 L L 2 ,$_•ZZ-? o 0 aL y. 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 Z Z 8 - 7 7 - 4' O O 2 Tax Parcel: (Connection 2) Z z _ 2 $-Z2 • `/ O e) Z The system owner is responsible for keeping this system in compliance. The name of the water system is: 0-5- 10 WftW. 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 (ha as no been granted one or more waivers from specific provisions of the regulations. Dated on this 2- day Signature of Grantor(s): Page 1 bf 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 onthis ,lnel day of (JojW6rr , 201L, $ JFue �� 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 I st above written. " YYBR(/ olary Pub' inAfidf6rthe State Washington, trOTARY '"Py residing UlA Q�(.�i5r�1 zoaz7t j co fission expires: 01-/T-2/11 r PUBU ..O'.n m.... �dr w,w WA81f`"" Page 2 of 2 .: SOIL COMMENTS .. SITE FIELD �110- SIZE DEPTH TO MONTH WATER TABLE OF YEAR INSTALLER MARTIN BRAUNE SIZE DRAINFIELD FEET . . LENGTH TILE �. . . . . . ! . . El 91 RIGID ■ CEMENT . . TAL CLI. YDS. "PE 3V DEPTH SPACE RESERVED FOR .• i-REPLACEMENT DISTRIBUTION FIELD: SQ. 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