HomeMy WebLinkAboutWEL2024-00046 - WEL Application, Design, Letter - 11/4/2024 MASON COUNTY 415NBTHELTON: 0427-97 ,EXT40
SH STREET,
,SHEL ON,WA EX 8584
BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360482-5269,EXT 400
FAX:360427-7787
ZACK JASON L & KELLY J
1070 E EAGLE POINT DR
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2024-00046
1070 E Eagle Point Or
421221200020
The 2-party water system, Two is better than one (4212212000201421221200020), 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
IZll3t/ZoZy
MASON COUNTY °R""a°' /I-0q - 24
COMMUNITY SERVICES munr fl.d Wa: $y5 R.:N.a ey
F,YYiq PM Emi,mm H.W Comm,atyNdd
415 N.&sme Bldg 8)-Shelms,WA 98594 W E L 202'1 - 6004(p
Shehm: 360427-9670 x400 BelfaP 360-275 4467 x400 Elmo:360 82.5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
` �7 � PRONE
APPLIOAXI JQS O`^ Lp.(.� 3 O - rt0—
N W uxD ADDflEse-STREET.Cm'.BTATE.18'
IDS O E GL5k= owv t r;'0-
8nEP00RE98-STREET,LRT,Br^TE,DP �
DZ O E le Polk Or�Yra-
PmNMY PMCEL XUM6Efl W16Y81tE)
SECOXDMTPMLEL XU/ 1, IIFAPPLILAauQ
AaLE) By
WATERSDURCE SOURCE TYPE PA7.!L1LOi 6QE PMLEL9 LOT BQE
❑New XExisting Well ❑ Spring ') .ylL�crcS IJ/Q
PROPOSED WATERBYBTEM HAZE flEOUIRPD) -
�W O a: �7e
PRaELroEscNPTPN
6 Id a vuiuj ADu o r
DIRECTIONS TO SWCONDRMIXB D
F'r'o,�. tot � rooi- rr� ri IA,F ov, l oW(' r
A-J, QkcF.) -o Jkree, - n lk . \ltsa AIWE0 �a ! 1 o.J kt-kw ko
IL�rg t }qrN. Coro. arse.
Site Plan: (may also be attached)
v (pmpedy boundaries,sbuclums,well sge w/100'radius,drivim",roads.seplklseex eompalwnls and linen,eacema ft,ML...)
1 in
te",;" �
add
H
i� DriL.a«)4L,1 rp.ProQ� ADU
Submittals Checklist: (these additional items will be required for approval)
,9 Satisfactory Bacteriological sample(this may be deferred if well is not yet drilled)
IZ Well Log With pump test or 4-hour capacity test performed by driller(this may be deferred 0 well is not yet drilled)
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
------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?
(drainfields,tanks, buildings; indicate distance on plot plan)
❑ ❑ Are there roads within the 100 foot radius of the water source? If so, is road riva ,County or Stale.
What is distance to ROW? ^9
❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
❑ ❑ Is the well cap satisfactory?
❑ ❑ Screened and vented?
❑ The well casing extends � above level ground/concrete slab? (circle one)
❑ ❑ Is there evidence of a surface seal? Of: 4}.24YS6
❑ ❑ Does the seal appear adequate? LOpn--' -I
❑ PJ ❑ Is a variance necessary for well site approval?
Comments
IN Pass ❑ Fail Inspector Date
Review Step 2: Two-Party Review:
YES NO NA
K ❑ ❑ Water Well Report with adequate pump test on file?f)roAh Onrliq cn 20*P"*0b)?((7Vvw
If NO,date of Capacity Test Driller GPM
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test y
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN ZI-11111y El ElSystem appears adequate to serve 2 single-family residences based on information 'A''�A
Comments - I`�• , O VL`•�
4"4 O4 �w
��JJ(
iyJ Approved El 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 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 ofbuilding permit per MCC 6.68.
Water usage restrictions and additional fees may apply to all new wells drilled after January 190%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 CURRENT
ni J,Paxpr-Ecvlop,i^river-°wner•J"r^lo-dinner Notice of latent No. WF31955
ECOLOGY Contruftion/Decomm15S1on/'s"in Vice/e1 Unique F.colaW wee lDTag Nu. AL11985
Construction Water Right Eamon No.
❑ Decommission OR/GliVAL/NSTAI LA770N Popeny Dwncr Name J &K Ih% k
A'o(ice 0 mend Number
PROPOSED DSE: O fbr:eak ❑ Nd. ❑ Mwkipnl WCII Smarr Addran 1070 E Eagle Point Drive
❑ awwer ❑ lmpmm ❑ Ten welt ❑ Odur City Shelton County Mason _
TF1'f OFw'ORM1: Ox'mh m:mMnfwell(if:r"rtdunon)_ Location nW wl14ggj/4 Sajj- Tom 21.N' R4W EWM ❑
III Neww 11 ❑ EmorMaiorca AHvher:0 1), 0 Roma ❑ W.. la 4 r Still RF.QIIBIFOI Or
IH prned ❑ Cable ® R°my I] lenN WWM IN
DIMENSIONS: Doman—fwell 6 ixhe.dnl4d aen II LWLoog
Demofom emlvallare a. Wt Deg.47 tat Min/Sm ITU.917"N
CONSTItt CTION DETAILS Long lhg 12A Long MiNSce Iff 23.930"1A.
Can, ■ wclhol 6 Diene flom +1 flan 379 it Tax pared No.(Requircd19j3$$12WU20
ImmIIN: ❑ I inn imalIN Oum (ram_fl.t°_fl.
❑ Thor " Dean From_flw_fl.
perlemoms: Yee N. CONS'IRI,,ION OR RE(TIMMIMION PROCEDURE.
T)ee°fpttrwmnr raM formation fkstlllM M1)'e[:Inr,clwraeter,SiJYu(mmttinl elld slfaClure.
and the kind mxl nature of the material in each stratum peneiratW.with m
slzbofmrk_in to in vd to,vrpn6 hxm_ft or It leas)me entry fur each change of internment, R)SL ADUII'IONAI.
Nomura: 0 Ve, N No ❑ K4 I.ociten SMELTS IF NLCCSSARY.
Maranon— Name MATERIAL PROM TO
Type Model No Brown fine to medium Band• nit 0
an. 9mnm Non it .—it cobbles ti h d 14
Diem skn ram aom H.w fl. Brown silty la fine sand mid with 14
GremPlrTxrlmrrN: 0 vo ■ No sire.f rodvw_ cobbles tight,dU 51
Materials placed ltom_e.w_fl. Brown Rne to medium sandd 51 54
surf—Seth B Ye. ❑ No TOMmdepla m fl Brown fine to medium sandy sharp gravel 54
M, -lraadmmnl .••roar tight,rill baunall ll 111
ad an,came eumdnrm we
an ean 0Ym ■ No Blaek Bne to mediunumad ravel III
Ijyeorwewr! Deprhnfum Marc sill Maker,dry 126
Sbdmdolevat mamnR Brown fine to medium randy xmoml,d 126 133
11;61P: Mmu4cmert No— Franklin IM for/CeutriDm PUMP Black medium sand reve ray silty 133
Trot Submerbible Rp 3 HP 3PH 15 GPM da -bimlitigh dirt, 139
WATER LEVELS: LeNowfaverknoaacrbam meoeo lent 361 R Brown avoillylarcrolichty.dry f39 1.54
sonic leml 318 ft below top ofnelt her 7/19/2018 Became fine to medium...ally 9.111, 154
.-II-pmaum—lb,p a"on—voli Due sill bound moist 162
Aron—Wier a emnmhNn ,axle.Roe. Black&brown medium sand'gravel, 162
WELL TWS: Draxdown i,amuar,wun kod is luwrnN below raft limit vsilt bind in d 171
W,r.ramp ou 1m1, la vra O No Ifyagwhxm? Driller Oran silt bnuna brown ifirnmel,figil 171 184
Yield. 12 In.., wah9 n.mrwaormn mn2 Brown fine to medium sand'gravel, 134
Yield vrn.. wnb e.dmwnowx.aer I., rill I,...d.drr 252
Veld-_,d.lrwn.wio_n.amNww.Are_I— Brown medium fandv ravel home 252
loo-1"re, .ndrx ar ism xJnm PxxrP mmNrr(p lrwrrrr kwlxvar—diame moist wive a sit[tr 269
xel/cry.m Wirer lrrvlr
I., W'.mr Lcrxl Time worn level iinn W'um level Multi-aroloredm dart sand noel 269 h a fit Ar 281
Blackfinerand ravel m siltbouad 291 313
Brown medium sand rave ti ht wet 313 331
Black Bne sand' ravel rov ails bindin 331
awxrmn It lot d 346
nuderuu_ro—wbh_o dmw.mwnaner_ha. Gra clam fit it 346 364
Amon 20sa(nrdn wiawerxsmxt a7n n for I m,_ Brown medium sand ravel it It water 364 379
a.erion now_frpm IMm
Block tone rovell y Met,-clit ,d 279 380
Traoemmmorw,u,_Wer.cbemi onal,-road.+ 0 Yon O No SwnthR 71I0n018 ComMmed Duce 7f19/TOIA
W ELL COVSfRUCTION CERTIFICATION: 1 mnrtmtled ard.r"r acaPt reapomibiliry fan croswclion of this well.and its emnPllaar With all WMhingtm well
cmulruetim slmrdards Materials ui and the information reported above arc true to my best kmwlialp and belief
Ilmiler(:1 Imurear 71 Trai nee Nome fta D'll gC ram A d'a Drilling Inc.
MillerfF 'merfl'mil�5 dun Add. PO Be.17"
Drillerantrainea Lianahm 2053 City,State Zip Shelton WA 98584
IF'I RAINEE Driller's Liana No: Commentar'a
faillice,i Stinnett ftietntiun No ARCADD1098KI Dan, 7/19f201R
ECY 050-1-10(Rrr•OT-Soto) Tn erqunfADA rarommarbtl"n 1nrWAing mmeMls in aJ"rmvl/ar fbe virunLl•impafrcd.rnlf Erologv Wmer Roourca ProRwm
of J40-e0)-dRR. Persow'wHh impalnAHranng m�vnll n'asHinRfon FA")•Senire n/)Il. Prnons wl/b vpeeN�rkrnbi/iy mN'rvll]TYw/B))-dJJ-6JIf.
Vanguard Laboratory
2635 Parkmont Lane S W,Suite A
Olympia WA 98502
v.,Srg,7#D 360-967.7010
COLIFORM BACTERIA ANALYSIS FORM
Deb Semple CpkdeA Time Swnpe County
10/30/2024 6cal�a� MASON
Iwr Ow r.. —.—gym
TMcfWe S)+ (dwdo .ba)
❑Gn A ❑GapB 0131w
Gap A Greup B 4 -Prattle hm Wab F*Aim hnw"Wit
Da _ _ _ _ _
sy M-w e Jason Zack 1070 E Eagle Point Drive
QMWPwecn:Arradia Na,,Inc
Gey Fame'.(3W )426-3395
Em
Bwd wpa w(iMl ul Ware.eadess ad rb rwe a smeb
.eu.p.�awwrw.uan nnonmeaunwweae.a.n
SAMPLE INFORMATION
Sanwa mledetl by(panel
Speafc MxaSal wfiereownde m*w SpadY beburdpa acamwnb'.
Well head (Tag ALH985)
TN+awllwaW UNa1mM awtypedeemple hantyTw i OOalph5 blow)
1.0Ro naalaMbWbn Wa W(VM ZORaWa"W(AP)
Cab mw Yes w aan8w4wonaI bowlw )
Cabna Reequd'.Taal_Free_ Gwebbd y.Febbmmb.
3.GMW Wdw RA Bourn Sample -- —————
a 1MWFMMymulnembddM:
S
Calahrebtl:Ym_No_
❑Trigperetl(Arl MUm Ra al'.Tdel_Fee_
❑Amaement(ANI
4. Uu .rGWl Raw Bourn Wa Samp*(Enwne ) 1 1 1
❑E mr [IF"
$.Sande Cdwb]br bfamtlm Onl4: `
LAB USE ONLY ORHOUNG WATER RESULTS LAB USE ONLY
❑IWm ftcWq TdelCdi P.1n WSalMacpry
❑Fm6preeml ❑Emile t
Bacbdul Danaby Raub TOM CaNam Woad. Em j1cwt
Feral Caamn mO 1. NPC nW.
Raplacwnwa Swnpla RaaMnd: ❑TNTC ❑sbrofwM
0ela'fYre Ieb PaMwalhanM
IQ13b1V4
FeapTwmc•: 1.� wumcme'.
2233
oew wweoodON uelbe dnir
doR laLSarpaY
285-03011
Return To2217972 MASON CO WA
JG50v� �11M 1 11/0412034 01:3] F NO$30
1110 12024 0 F27 Fee ;304 EO Pagel 2
10-70 EQ"1 = Po'..ktf IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIN111IIIIIIIIEIIIIIII11$1IItII
SLe �I N C_ a
Grantor(s): (1) JaSo, Tor _ , (2)
Grantee(s): (1) PUBLIC SeG2.2L 1WP 2l 'tZ
Legal Description (1) :19, Z Oq 0 'A_ NE
(Abbreviated form:i.e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1) `�Z Z Z _ Z_ O Q Q Z O
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 1 2_ ( _ O Q d ZO
Tax Parcel: (Connection 2)
The system owner is responsible for keeping this system in compliance.
i Ay
The name of the water system is: nlo a'M loew '" �w O--'L
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. , I
Dated on this `4 day of N o 202=L�.
Signature c Granto
(1) . (2)
Page 1 of 2
State of Washington )
County of Mason )
I, the undersigned, a N. tary Publi and for the above na ed County and State, do hereby
certi at on this wt _ ay`8 of�, 20 A�
c Y personally appearebefore 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 ea last bove writ an.
0 SIR SE
'g910N E�,'Qi �
` TARlr P`"m+. ,: N to is i d for Stet of Washington,
• 23033426 6 ding atto
pUBLtC 3 My commission expires:
sN+ p'
•,,��•�F WASN�0
,I4W,,,1„I444�+,
1
fj{
1
Page 2 of 2
3
POW I ' . . FASMENT
1 71
PROPOSED%lM LOCAnON
I
HOUSEFUTM PUMP TAXr4
ON
nUNWWr UNE
PRBURYDRAUUMXI
PMERVE AM
SEMC SYSTEM SM PLAN
MPBNAOYR:
r L:(iLL�Ia17 s
1 1