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HomeMy WebLinkAboutWEL2024-00052 - WEL Application, Design, Letter - 11/25/2024 MASON COUNTY 415NBTHELTONSTREET, 0427-9 70,EXT 400 SHELTON:360-027-4467,EXT 400 BELFAIR:380-275-0467,EXT 400 Public Health & Human Services ELMA:360462-5269,EXT 400 FAX:360427-7787 BARNES DARREL E & SHERRIE C 410 SE SEA DER HOK LN SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2024-00052 410 SE Sea Der Hok Ln 220203390050 The 2-party water system, Barnes Sea Der Hok(220203390050/220203390090), 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, J David Anderson Environmental Health Specialist Mason County Environmental Health IZ/2317P LI MASON COUNTY I lAca 1604 COMMUNITY SERVICES R m Ram wE ^� ^r d IS N.6-B (BW98)-Shelton,WA 985M WEL r�V�tA— , o Shshoo: 36 27-96'10 xd00 Belt,..36 2'/S 7xd00 Elmo:360482-5269 xdW �/V TWO-PARTY PRIVATE WATER SYSTEM APPLICATION Px¢xc xuux¢AooRras-smelr,ary re,a / 91iE es8_xnm T.ear...AiRa PPo MYVRRC ¢xe61 MELLMI) 2 9oas sEcoxawrP xulaaa9R AreuesaLll 6— WAT RSOURCE e¢uRCEM! pMCFLI LOTe@ PAR9FLRLOt et& W New ❑Existing ®Well ❑Spring PR EowAvrearamrxAraart¢u Ot Pao.recr olsrnvrwx Z2o7 O , _o - -Yob-So pRECrI¢N61e PI C CC f. f 0 ...J�C e 1 -7 S -7 Site Plan:(may also be attached) (pmpedy boundanes,stmclures,Wall site wl1 W'radius,dnveways,roads,seplirlsewer components and lines,easements,etc...) Submittals Checklist: (these additional items will be required for approval) Satisfactory Bacteriological sample(this may be deferred it well is not yet dnlled) Well Log with pump test or 4-hour capacity test performed by duller(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) rnis form may be scanned and avalleble for public view on the Mason County Web aft. Revised: 10/13/2021 Page 1 of 2 Staff Use Only-._....._.._..._..__—�._.._._.._--_.. Review Step 1: Well Site Inspection: YES NO NA ❑ 1% ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (dminfields,tanks, buildings; indicate distance on plot plan) ❑ �f ❑ Are there roads within the 100 foot radius of the water source?If so, is roa privet , Ip County or State. What is distance to ROW? n f p YJ ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan) ❑ ❑ Is the well cap sa0sfaclory? ❑ ❑ Screened and vented? t t ❑ The well casing extends above level ground/concrete slab? (circle one) �( ❑ ❑ Is there evidence of a surface seal? 14f: y J,wif I ❑ ❑ Does the seal appear adequate? Lon; _12Z. y6OZ u )6 ❑ Is a variance necessary for well site approval? Tog: Blk Losp lComments 111 Pass ❑ Fail Inspector12: Dale !Review Step 2: Two-Party Review: YES NO NA F1�S ❑ ❑ Water Well Report with adequate pump test on file?ordA Orifo dq 910m it dl ?vofpl fw 60M4(I"$4 If NO,date of Capacity Test Driller GPM �`J ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test rO /l h7 zjr �J ❑ ❑ Received Signed, Notarized,and Recorded Notice? AFN 2 17 115 &q ❑ ❑ System appears adequate to serve 2 single-family residences based on infortra0o Q? Comments # _, 2 O 'YfN—c01` pt ? Approved ❑ Denied Reviewer Data F Al W( Findings in this review reflect observed conditions as they existed rim the day ofthe site inspection. No claim is made,express or implied ofthe future success orfailum afthis system. Well site approval does not mmli ate water system approwxl. 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 194,2018 per ESSB 6091. Revised: 10/13/2021 This farm in y be otammd eM avaaaMe for public Now on the Mum County Web di Page 2d2 PanlawmbmcomaxN lvmrzd WATER WELL REPORT I MDEPARTMENT OF mhos fNtenl No. WEMIN ECOLOGY Unpw Ecology WCIIIDTag No B00059 1)p M Wort Sate M.ohlo ron IN Cmeo-wxioo Sia Well Name lit more Uan uric well)'. ❑ IhwmmedmC OdpmlimWhdw N0l No. Wew Right PermilMatifeae No Rropreed Uw: a9waaia ❑lui:ainl DNe;vl property Owner Nerve Derral Bemes ❑Dewewhg ❑lk4n a^ ❑Tw Wa ❑tdmn Well Street A lreav 410 SE Sea Da NM N Cmhredm TYR: N<Wd:EN-1 ❑Allmadw ❑wo- ❑d OG Tad City Shegm Cainty hdnIIII ❑0.apeamp ❑oiler ❑Dy a M- ❑M Ralep Tax Porcel No. 2202043-90050 Im—l—: Urmmmofbmi:ga ia,b 220 R Wise vniarce appmvd for mis w 1110 Y. IM No Depx orcwmkw w.0 219 a C—.d..Me : We0 Ifya;vf'at wi the vmietce fo(! 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WELL CONSTRUCT M CERTIFICATION: I consmmted riNa ecapt rnpomibility fa comtruaim ofthis will,aN ks complimce wiN all Wuhillglon cell camtadian slmdald5.MabRielsuaed and the intbimeiian repwled above are hue to mY ben kemwlNge aril belief p Ocilla O Trainee O M-P a Jmll K0e ,oll C A is Dolling I. Si®e 4 -f Adtlress EOBox1T90 ''i Liceonttio,2 4 City sunnI,,zip ShNon WA OMM IF 1RAINFE It mxta's SpwD_'s Si®:wirc R4wation No ARCADDIO90K1 UUe 913024 ECY050-1-20(Revtl9llg) 1/3oorreed eM.rAaumea lnm alremarefamor,pfaaae mOrhe Warer Remurtea progeom of 3611d02E812. Persona wieA Aeorirg bu wn call)11/o.Waahirgbn RelnY service. Pereauwitharyexh&.Ntity.antlg774334341. vanguard LaDoratory 2635 Parkmont Lane SW,Suite A Olympia WA 98502 VtjffAmD 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM D&saigle Goww remsmpe Courty 10/11/2024 , a ❑. MASON unn ar ym _.—■w Type a W abr Sysbm(Mm&arty ore Ea) Cmup A art Gmup B Syaam-Pmv ham Wabr Feciaes W*w"(WFI): ma SysOm Nana: LOGAN SPEAR Canaat Pa rA *a 01",IM Day Pama(360 )426-3395 Cm Pnae:l ) Emit, SW saidR(Prtl M1tll nare,aeemss die vpmee aernaY) erewlwm.m�ww-mm use wm®.�wiwmsm.mm SAMPLE INFORMATION Sam&wlecba by(rams):SHAD Speak baalm om serape CAKW: specw kwhuptipm ammmia: 410 BE Sea Der Hok Ln,Sneaon Counts Please Tywof&w Nlsebdo*o %eof amCn San lypn 1#=*5bow) 1.0Roud%DWWWdon SMyY(#JP) 2❑ RBPwd&w 4PUP) CNoirom Yes No man eemwuongatan snaruma mums( UmaklaAxy mutlne w mmaer. Chbrcw Resbual:Toll_Free_ 6O�wndw��br Rule Source Smgb Utaeasfedory�auFneNbab� ChWwffW:Yea_No_ ❑TrIggerM(M+) Chbaw R98"Tael_fl% ❑Assessment(A((P) 4. 8wfmor GWl Raw Soum We Saap4((Erwnwtlm) ❑E w ❑Fetal Famw Ya_ao_ 5.�SwPb Ctlnebe br Monnwlan ay: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑UneUm gTaal Cafiam Pimento �SNshFbry ❑Ea*pmsent ❑E.W81A t BwW"Daway R"u*&TaWCd6mn____J160ai. E.cay /Md F"Cdifam HDDrnt HPC npt RWummot Smmpb Requmse: ❑TNTC ❑SW"bold ❑ Saawle YW.mw ❑DamapWUC um ❑ Rscawf. lee RMsenw Numna O 11 4 R aN TkP C•: Mepq°Cv°''l•0 SM9223B ode Pepamemron Lmuwalr 285- 01110 k 2219725 MASON CO WA 12120,2024 11 59 PN NOi CE llnll�!9�II�IWWIIIIIb��IIII111�11,,1141 ! s9°a 50 Pa9ea 2 Return To OEM barrel tSherne Barnes D OE V � D y\O .SF �ocaber 00k Lane DEC 2 2 4 �I+nn I,OA 9KSK� By Grantor(s): (1) arr1el E _'Rarne<, , (2) 5her(' e C VarTrn@S . . Grantee(s): (1)PUBLIC LDt Legal Description (1) LO-F•:• .)0 (Abbreviated form:i e. lot, block,plat or section, township,range) Assessor's Tax Parcel: (1) ;Z aj__0 ,j_0 NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM I (We)the undersigned granlor(s), certify that the water source located on the above-described real estate under Legal Description(,)and Assessors Tax Parcel (,) situated in Mason County, State of Washington, has been designated to serve a source of water to the following parcels situated in Mason County, Slate of Washington; herein described: Tax Parcel: (Connection t) a o a o -33-g 0 0 3_S2 Tax Parcel: (Connection 2) O sL CJ -a -2---a O 0-L 0 The system owner is responsible for keeping this system in compliance. The name of the water system is: fermt 21 k/E L2f7-2r1-DO05P-1 5' rn ec SC0.�r This system is designed to provide for two service connections. Planning an design appro als 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. q 1 Dated on this IL day of ge-eml er , 20_2,�. Signature of Granto•(s): (,) (2) C � 7 � 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 day of Q1ftaA be V- . 2()�, j7pW\ �— 2j vv(2 2011'ersonally appeared before me, who is known to be signer of the above instrument, and acknowledged that he(she) (they) signed h. GIVEN under my hand and official seal the day and yy�eeaarrlast taaabboo(1ve'fEen. 1P�fMf � ry ,ota Public in an or the State of Washington, �'F a i 2 1e O�ti residingat'.Qvo M13 p9 O••cfi __� Np7Agy a•.n,_ My commission expires: N� �'UBL1 fi•2� i� �•7A N•�O` N�moe�M1;:RC�~ Infl, an Page 2 of 2 I HAMMER5LEY INLET I APPROX. SHORELINE I I II I uo2o-a-sunro I �-. uo2o-33-sooso I I xoe.61O"wrs.e I I NUWATER& I I PUMPTANK& `J 1 I FUTURE TRAN5PORT& HOMEi� LOCATION \ RETURN LINE 4 I IJ I R100 41i I App,© I I � C®V I J FUTURE WELL i I Nov / MASO,YCOU.YryENVlc57Z3 1 i 0„q i PRIMARY AREA (1080 SQFT) I RESERVE AREA I \_ APPROX. I (1",0 SOFT) DRIVEWAY 1100Z I 1 - - - t ---- — ——————— _ �T SEA DER HOK LN 1V. — -L �_ AN ASBNETI INSTALL SIGNOFF FEE WILL W C MGFA AT TSE OF INSTALLATION CLLCTOMFA: DARRII.BARAFS u61VFll.F O%c.'t' AL SI/91.3: PIONEERPIONEER DIGGNQ ENC PARCEL.t.2207b3390050 A. L\ ±a. kl i3 2 i SEPTIC DESIGNS ADDRE�> +a SE SF^DEx NOR LN Ra 1.3" .a)ts a..,. .�..�....�.oNw 3083EAIAxXJSPiJIV RD. GRAPEVIEW.WA9S516 DLqGNER: RDBEATHPAr%E JFTK'F-W426NR13 FAX 272353 I:HEEf: gm PLN1 scAE P=70 0�..,�..'cr..Rvw°oraw.mo.Air�awa.s mm �� �ti r � / �s�o����� �, ,. m�� � ' �� � ffi wk � �: . - � "' �- ,� �'-° � � � �' — — — — — — — . , .