HomeMy WebLinkAboutWEL2024-00051 - WEL Application, Design, Letter - 11/25/2024 ON,
MASON COUNTY 415N6 SHELTON: ,SHELT967 ,EXT 400
SHELTON:360d27-9870,E%T 400
BELFAIR:360-275-4467,E%T 400
Public Health & Human Services ELMA:360482-5269,EXT 400
FAX 360427-7787
Amber Ensley
321 W Berry Ridge Rd
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT. TWO-PARTY
WEL2024-00051
320 W Berry Ridge Rd
420243490049
The 2-party water system, RP4 Huckleberry Ridge (420243490049/420243490049), 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
I(7/2azs
MASON COUNTY aM �I apr3
COMMUNITY SERVICES amM RK May
aiWWy%r.6i8Em4mmeAelNsllh CamrvniryMWN .�I1
415 N.6'S.,(Bldg 8)-ShLI(ca,WA 98584 WEL XaLA - O 51
Shelled: 3f0427-9670 x400 Bclfor.360-2754167x4(0 !lase:360J82-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
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�O\ PPoML RLEL NOERIER IWELL MEI � (
secasnav,sy pexClit an as as,1./iPRKI1LE)
_ WiTER 8011RLE .,ves MF I.M.I LOT. PARCEL..Lice
�New ❑Existing W Well ❑Spring
pROPoH. j RS TEM IR UREaI
Pa0JEeTT DeSLRIPTI M
MRECTLNISTOSREICOMMr /
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Site Plan: (may also be attached)
(property boundaries,smnsu es,well site w1100'radius,driveways,roads,septic/sever components and lines,easements,etc...j
f
Submittals Checklist: (dlese additional items will be required for approval)
Satisfactory Bacteriological sample(this map.be deferred if well is not yet drilled)
Well Log with pu(nbteor-4-hour apacity test performed by driller(this may be deferred if well is not yet drilled)
Notice to Future,Piop�erty Owners recording(record with Mason Co. Auditor, supply copy of recorded document)
Septic Recdrds(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 stee. Revised: 10/13/2021
d Pax i of 2 ,+�
--__ --__Staff Use Only-- — •-----
Review Step 1: Well Site Inspection: 77 /� I.-,
YES NO NA ' M ')6 P�& if ad Tf, fW10 -^44twf.
❑ ❑ 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 fool r i s of the water source?If so,is road 'va , Cur or State.
What is distance to ROW? -'V
❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan)
❑ ❑ Is the well cap satisfactory?
❑ ❑ Screened and vented? rs
❑ s The well casing extends I I above level ground/concrete slab? (circle one)
�] ❑ ❑ Is there evidence of a surface seal? 47,10443
® ❑.� ❑ Does the seal appear adequate? 1 M - It3. 13 546
❑ /a ❑ Is a variance necessary for well site approval?
Comments 1
1 Pass ❑ Fail Inspector Date
/Review Step 2: Two-Party Review:
YES NO NA
❑ ❑ Water Well Report with adequate pump test on NO A(4d+q 6n'(D+y dA 1044110tr( W/7,00mfa 60e.'
If NO,date of Capacity Test Driller GPM
❑ ❑ Received Satisfactory Bacteriological Analysis? Dale of lest I( S�LOLN
❑ ❑ Received Signed, Notarized,and Recorded Notice? AFN T720f
f� ❑ ❑ System appears adequate to serve 2 single-family residences based on information proviAAN
Comments
./ VIV21k. I. C'
Approved ❑ Denied Reviewer Date /qo*
A`H
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 ofbuddingpermit per MCC 6.68.
Water usage restrictions and additional fees may apply all new wells drilled after January 19' 1018 per BSSB 6091.
Revised: 10/13/2021
This form may be scanned and available for public view on the Masan County Web site.
Page 2 of 2
WATER WELL REPORT MOEPARTMENTOF Ncfmmflnttttr NO. WE580T9
ECOLOGY UngaaiE,,a YWellmTeg No. B00O22
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❑Dew+atm, ❑Immtion ❑Teuwer ❑Other WMl street Address + RM Rd
Caaa..Type: Method: City Shaltm c Puy, Mesas
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IxpAofamopbudwer 28U fl If,e,whet wm tha vmience kR
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Pmbaafiea: DYaMe. Typeofpmkltlm oats Dplller'rLog/Cpmkuc800 or Decwpmuaipa Pracaderc
No.ofperfatatiom_ Six ofperfitkm iu b/_ Fmmutkm.,Deecnye by coWr.rlmecb.aix ofmatvtul Wetmeturt.mtllMkiMmd
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of miak Plxcdwm_s.:o_e. Bmvmfirretrmaditmsi ,sand ravel lawae 48 116
5mrm.5eae WYm ONe Towlmdeptr 111 Brpvm fine to ls'edltm revel,bmvm A.M 118
Mmuul mad bask 1 tcmita aleita coarse it sand,tome 123
Did,mauweuinm:erekwmeN ❑Yin MI 13rownflne raves ail salts 123 126
T,fwuell oapeofmam &own ve flre sit send 128 148
Metliod ofxalim mamoR htbjfi.m.si sand 10 163
Pump: Mmufaa'Ima'e Nwe TYpe: &rWn floe to wame sets,heevin ,mast 153 187
NP._ N:mpiNiedepah—ft DmiplM e>wIR:_Bpm B mfimad ISM, am .W9e 18] 208
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.mast 208 228
Stick-Igoflapofwellneeiq 1_6 g.alone ammda Gfa aarM ale,wee8 228 240
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AM1mian pe.sux_IM.prraauue i.wh D6e 256 281
Mmbn want ieconuoaN by (eaP W.. Gm flneto WSM05ll send
Gr fine to Crelbe si 281
Well Tmh: water bearin 280
WMaPumPina Pun mrfievedl El No ❑YmO by wbmR
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Time Wum level Three Water Lewl Ti® WYlewl
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WELL CONSTRUCTION CERTIFICATION: I cortwuatN and/or emep rapansibility facomwGim ofthis Well,era es complreae wiN ell Wmhillgran Well
came anion slerEards.Metemals usM mM the inftnvurion reported shove ere true to my best ktlowlecIp am!belief
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IF TRAR4EE:Spauar's License No.21)53 Corthecur's
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SAMPLE INFORMATION i
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089
22200790TMASON CO WA
ASCII
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIMIIIIIIIIIIIIIIIIIIIIIIIIIICIIVIIllla9e,
Return To k I
DECL3 1 0 4
.4 Ct.J Zn[k-6 l�.Ir �rf
20 kJ 8 R3 DE 3 1 20Z4
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o,e
1 � 11 II
Grantor(s): (1) ASria� � nrlfy(yYm-kc, . (2)
Grantee(s): (1)PUBLIC _ �, _ n
Legal Description (1) S 24 j�
(Abbreviated iorm:2(]i.e.lot block,plat or section, township,range)
Assessor's Tax Parcel: (1) -Z-024- 4f '—go"'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, State of Washington; herein described:
Tax Parcel: (connection 1)— ---9—G_4a_
Tax Parcel: (Connection 2)
The system owner is responsible for keeping this's�y'stem in compliance.
The name of the water system is: RP-4 LkLe Dnrr✓. R 4e
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 (ha4;nPbeen granted one or more waivers from speck provisions of the
regulations. �O�
Dated on this may of
NC hl-, 20�M'
Signat f Gra tor(s
(1) •+ , (2)
Page 1 of 2
1
State of Washington )
County of Mason )
I, the undersigned, a Napry Public in and for the above n,,a�ed County and State, do hereby
certify that on this 1/ of pew • 2U i1•
A A ret.,, ),S'Q.g personally appeared before me,who is known to be
signer of the above instru ent, and acknowledged that®(she) (they)signed it.
GIVEN under my hand and official seal the day and ye last above wn
l)
, Notary Public in d for h State of Wa hi gton,
" RENEE residing at tv
c P •�)[pGes zJe;.. : My commission expires::u NOTARY m1
in PUBLIC
0
,V,aion M..............
C, x
Page 2 of 2
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i I Parent Parcel#42024-34-90049
Fr M.Halverson Design LLC
ASCW INVESTMENTS LLC Resulting Parcel 4 Of BLA2023-00042
PO Box 1519 Shelton We 98584 2000 W SHELTON VALLEY RD 9
Shelton,Wa 98584 AF#2212781
Halversondesi nllc outlook.com ro»