HomeMy WebLinkAboutWEL2024-00050 - WEL Application, Design, Letter - 11/20/2024 584
MASON COUNTY 415N6 SHELTON: ,BHELT967 ,EXT 400
$HELTON:360427 67,EXT 400
BELFAIR:360-275-046],EXT 400
Public Health & Human Services ELMA:360-48M269,EXT 400
FAX 360427-7787
BROWNSTEIN CARL B TRUSTEE
2745 SE Bloomfield Rd
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT. TWO-PARTY
WEL2024-00050
2745 SE Bloomfe/d Rd
319221190011
The 2-party water system, Kamilche Passive House Well (319221190011/319221190012), 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 360427-9670 Ext.353 or email at
danderson@masoncountywa.gov
Sincerely,
David Anderson
Environmental Health Specialist
Mason County Environmental Health
I Z / MOLL/
nE ...1I
Nov MASON CO IIIu11n1�� DNR //- 20 Zf
COMMUNITY SE
wY&q Pl.n:q.rmwimMPl Ne.INCmmailry XetlA
415 N.6"Street(Bldg e)-Shellm WA 98584 WEL 000,0
Shelton: 360427-96/0a4W Belrair.360-2754467x400 Elma:360482-5269 14W
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLKAANT E
MA� l �RE33-ST� ITY,STAVL Z
SREADORESS-sTREET,LITY,BTAT IIP 7 W
2AR y S
pMMgRY PARCEL m'UMSER ELL SREI /
3 22 -I/- 9eo
SECONDARY PARCEL NUM DP RPPEN:70 O' 2 22— {/
y 9WRCETOE pARC41LOT a[CE PARCE13LOT 9QE
WATER SOURCE
❑New Pf Existing %Well ❑Spring
pROPOSEDWATER SYSTEM MME(REOVIREO)
PROJECT DESCR'noN 4 n Yw 27
OWECTpX9o—o CONDo—
site Plan: (may also be attached) 1
(property boundanes.structures,well site w1100'radius,egnsrMYS,roars,septic/sewer comlwnems and litres,easemems,etc
U I-
E
Submittals Checklist: (these additional items will be required for approval)
16
Satisfactory Bacteriological sample(this may be deferred If well is not yet drilled)
(d Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if 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 farm may be sunned 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:
70 }e fop
YES NO NA
❑ ❑ Evidence of existin our s of contamination within 100 foot radius of Water source?
(drainfields,tanks, ng ; indicate distance on plot plan)
❑ ❑ Are there roads wt in a 100 foottja_dius of the water source? If so, is roa privat ounty or State.
What is distance to ROW? 1
❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
❑ ❑ Is the well cap satisfactory?
❑ ❑ Screened and vented? t
❑ The well casing extends lif above level ground/concrete slab? (circle one)
❑ ❑ Is there evidence of a surface seal? Le `17.12`I 99
❑ ❑ Does the seal appear adequate? rN1t -I2),O11V
❑ ❑ ❑ Is a variance necessary for well site approval? 145 ;
Comments
XPass ❑ Fail Inspector Date
Review Step 2: Two-Parry Review:
YES NO NA
❑ ❑ Water Well Report with adequate pump test on file? Kdeff°1NII)1' 09 ?gmey W/206#07 On xqO 0uy) `
If NO,date of Capacity Test Driller �r GPM J
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test T(LIlAZH
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 2L14O(f' �
❑ ❑ System appears adequate to serve 2 single-family residences based on information provideC',1A^
Comments
y,J Approved ❑ Denied Reviewer Date /Z L 4
Findings in this review reflect observed conditions as they existed on the day of the site inspection. No claim is made, express 46%/
or implied of the future success orfai/ure ofthis 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 wafer adequacy requirements at time ofbutlding permit per MCC 6.68.
Water usage restrictions andadditional fees may apply to all new wells drilled after January 194, 2018 per ESSB 6091.
Revised: 10/13/2021
This form maybe scanned and available for public view on the Masan County Web site. OrPaae]of3 y_
WATER WELL REPORT CURRENT
Odpadel"mpy-Emlen.Te mpY-ewass,8^cepy-drDkr Notice of Intent No. W316M
ECOLOGY Constructlon/DecommLvion('k"in circle) Unique Ecology Well IDTag No. SJT941
® Construction Water Right Permit No.
❑ Decommission ORIGINAL INSTALLATION Property Owns Name Cad Rivimnst•_In
"Ohre O Intent Number
FROPOSEDUSE: ® Ixmemin ❑ idwaial ❑ Mmicyd Well Street Address 2743 hG nlo"ft d Rd
❑ Dew. ❑ bdg.dnn ❑ Ten well 0 ehhm City Shahan County Metal,
TYPEOPWORK: o.,:.rammntse-f—ll(iftenrcd:enoee)_ Location NEl/4-1/4 HMI/4 Sec,}t Two 1�n R3W ewno
❑wessm RecodinmM Usti❑ Dug ❑ Bud O Uilm
® c ❑ Relay ❑ leKd (a,t,r Still REQUIRED) want
DIMENSIONS: DimNm ofwdl$_ habe,tirdRd$1.
DIsfief,,ses4td wag5711,
CONSTRUCTION DETAILS Lat/Long Let Deg NIL Lat Min/Sec 12'30 95
O ng ® welded 6" Diw.r m 11.to g1 a. Long Deg W.123 Long Min/Sec 4'22.4.
Ineald: 0 Li.unread_" dess fmm —1.m _a. Tax Parcel No.(Requimd}i7922-11:g
❑ nutedul
Perfermses; Yea No CONSTRUCTION OR DECOMMISSION PROCEDURE
type dperidaeruRd Fmmetioe:Dmuiba bymbr,rbuala,sift dmmisl eel euuuwe,aW we kivd and
mden.dpmfs_1ou_1.m_1. Daum a(Wes. (US ivwA ONY SHEFtS wihuleSARY) lbrevb ehense
Se arpe6_io.by to didarertion. Nse ADDITIONAL SF@ets n'NeCEssAm
Seem: ® Yn ❑ No ® K-Pee I.pradm gQ MATERIAL FRlM1 I TO
M.:nredma's None Johnson Brown Top Soil O 1
Type Stainless,win, Model No. Sandy Loam i 4
uem. Sld aizc_flom n.m ft Brown Sandy Till 4 12
syi.m.5 sad ein:& ,to 7 e. Brolm Silly Sand w/Clayi-ensea 112 44
GrewuaMer Psched: ❑ Ym ® No saedae d/®d_ Brown SandgGra"Witetteanng M ST
Mwdmsplaeed Dom_1.to R Brown Clay 67 ->
sv,dueSW: 17 Yes ❑ No Towlawdep iAlk.
Mmennl red in eRl Rentonhe China
Mdany strnes cousin mossele unwell ❑ Ye IS No
Typsof.erl Depad.
Menoddaeliugaras oB
PUMP: Mn:deumrw'e NameF nki
Type:Sularnernible H.P. 1.25
WATERLEVEM: 1sn0.euA elerelion ebo�e mean wlevel_R
SYtick Ayi$/.below rep ofwell Dne 1-21-19
Adeaw pcwum_Ibr.w Kneeind Dd.
Nleeiaewata iaacMrvlW by (np.velw,lmJ
WELL TESTS: Dmwdodm uemountwwa Rwl h bde:dbeiow pane keel
wseyumpled sols? ❑ Ym ® No Hyea,bywbml
Ymld:�et/min. dnwdowndd hra
RYeerlodw_ytod wdrio egPra/lmlsh.me Lioln/d
eAn tmo w&ar@npawnmdvow:.,.s,flma pp_/(„wdhrnlr.
YieM ores flnsNer hn
Ti.
mr mre,.rm/ro.•
Wpd level Time West lsel Time Wahl leM
Dwsnftea —
nderten2 ,J.osm.wi0I4fi.drewdown dlm4hn.
Nand one uem sd._1.for�hn.
Adasim flaw_ap.m. Dae 3,15-19 Start Date /I1/2019 Co Ieted Date /2019
Tempenteed.—WssechcdW anot retail ❑ Ym 19No
WELL CONSTRUCTION CERTIFICATION: I cdnWded and/or accept tmponsibility for oanewetion Ofthis well,aW is cdnplianu with all Washington well
comtrudion mandads. Mmmials used and the information reported above arcane m Y bmr Imowledge and belief.
Drilling Company KNAPP DRILLING INC.
TWiller n emsom Tnim Name 0,sw) Dwme H Knapp Addrms E501.mam Dr
lhilim/EnRinm/TnirRe Sipamrc City,Snm,Zip Shelton We 98594
Driller m bminee Liwne No. 170d
IF T12AINEE:M11'ar's License No: Contractors
Drille'a Si emrc: atndan No. P �' DWe p
7 wa h sr J `A \rfJVVVJ7,,, 1'rn yl? _ 7j1'lfY 71 A 3 3I
gr {
Thurston County Environmental Health
412 Ully Rd NE •Olympia,WA 98506
360 867-2631
iHUPSIDN COIINIY
" COLIFORM BACTERIA ANALYSIS
Dale Sample Colbdad Tme Sampb Cmnty
71 2 120zy �)/caecmd 0µ {IlaSa>f
uma pn Y. L(L;-&DIr
Type of Water Sysbm(check only one box) ❑ Pdvate Household
❑GroupA ❑Group 0th
Group A and Group B Systems-Provde man Water Facilities In*nrory(WFQ:
ION - -
System Name:
Contact person:
Day phone:( I Cell phone:(30 )
Email: C D WAS D 1. 1 Em.P :( 1
COX
m:(Pnd tall non,add'am aM zip code v amyl addme)
2.710- sJ ctm Zia
SAMPLE INFORMATION
Semple odbded by(name): AT
Spedfic kration oradd wtero I�Q SpedalimWctloneamrremnb:
She VA 99SS9
Type of Sample(Met cl donly one box of#1 Nmah# law babw)
1. Rouim Mtributon Semple 2.Rapport Sample(efter unrest roulthe)
Chbnnated:Yea_No-)C- ❑Disbibubon System
Chbrne Residual:Total_Fme_ Chbnnated.Yes_No_
3.R.Wabr Somme Sample Chbnne Residml:Tool_Free_
❑E oay-GWR(Am)
❑Fecal-sums,ow.mmpinweyonl Unsatisfactory routine lab number
Filtered Y.—No— __
- ❑AxesmMd Mmibdm(vo) Unxdmeo,oryroubemlteptdate.
❑OW
8
a❑Sample Collected for Information Only
Investi9atm— Conere%on l Repair_ Other_
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Umatlahctory Tool Colifam Pmxm arM facbry
❑Ecoli present ❑E.wbabxm ifom debdad
Replacement Sample Required:
❑Samplaboold(>30houm) ❑TNTC ❑
Baclenal Densay Resold:Total Cdifam /100ml. E.cok /IOOmI.
Fxal Colrorm I100mI Entmoocai I1DD M.
Mabvd Code: SIA9223B ❑SM9222D oateaMTone RecdveG
SM92158 ❑Enbrobrs
Dreand Tme ArNnoad - Oele Wppmd:
SsipMxumpw(nMiwnlr qulhadbb) mUm Only:
0 8 0 C
n2FLL'l i']LJ'AAa ::2'74l/14:3—
2219017 MASON CO WA
12/0212024 11_47 AM NO10E
CPR' "A'SR'
IN 0204114 Rec Fee $304 50 Pages. 2
Return To
O
Grantor(s): (1) 0ACj 3C'DVK756Ar (2)
Grantee(s): (1)PUBLIC
Legal Description (1) 4eff 1 6f4PW 3/216 /��$� Z/f)TA'72 {��� 66 -
S �ynI�NF59/ (Abbreviatedlorm:i.e. lot, block, plat orsecfwn, township. range)
Assessor's Tax Pareel: (;T 3 L-12-1,-11-g��1
5 22 —1 19 - 'K3
NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM
I (We)the undersigned gantor(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,,/ atq JL
State of Washington: herein des�ccrriibed:
Tax Parcel: (Connection l) _ .2,2---L --2A lI
Tax Parcel: (Connection 2) .,3—j 11 =-11--2fi--0-12--
The system owner is responsible for keeping this sIystem in compliance.
The name of the water system is: Ka h r �rN 2ail V2 ` icgl 5e 1,0
ef I
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. G7
Dated on this / / day of Pa20 Zr'.
Signnaatt'u/_re of G/ra�ntor(s):
Page 1 of 2
Slate of Washington )
County of Mason )
I, the undersigned, a f ovary Public ig and fo the above named County and State,do hereby
certify that on is j day of 6bY '�� , 20 Z y ,
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.
NNE Co Orr
/i -Notary Public in"and for the State of Washington,
residing at 3 2� I SLR
S s a 40GS316 _ My commission e rel. I Z-' 1
J'r��4 7p.I
O F\WPI5
Page 2 of 2
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