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Home My WebLink AboutWEL2024-00052 - WEL Application, Design, Letter - 11/25/2024 MASON COUNTY 415 NB THELTON: ,SHELT967 ,EXT 404 SH STREET, ,SHEL ON, E%T584 BELFAIR:360-2754467,EXT 400 Public Health & Human Services ELMA:360482-5269,E%T400 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, Jce David Anderson Environmental Health Specialist Mason County Environmental Health 21131lei y ® MASON COUNTY °`� Was a COMMUNITY SERVICES RpaMed: RSYIwe 9YacP�YRnumm�.rwxuMhraYY��n�wE C1� �(�^ �j 415 N.6•Sfte (Bldg a)-Sbebw,WA 085M WEL oe(•�— & Mwiton: 36042/A670 x400 Belli 360-2754/67 x400 Elmo:360482-SM x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION wpxE 032 Y,uuxo sooReas-mneeT,rnr, TE,a 1 W WE ESS-araeeT.Cm',SrAT4a pRl PMC 11YBET IWFLL 8IIE) 2 - s- 9aas aecoxo,wvP NVYKR(Yxnuc.aLEl WATER SOURCE am1RCETYPe PM iLZale: VMCELI LOTS �New ❑Existing B Well 0 Spring . 2 !.81 PRO W/,TER ereTEY X/,ME IaEOY 0 PRPIER OE9CPoPfNM! Zwzo - -Yoaso aaecnoue Tosrtu co i s fo a -7 S-7 -:U Site Plan: (may also be attached) (property boundaries,structures,well site wit DO'radius,driveways,roads,aeptirlsewer Components and lines,easements.etc..J Submittals Checklist: (these additional items will be required for approval) 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(this may be deferred if well is not yet drilled) 1 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) Thy form may,be scanned one•vallable for public view on Me Mason County Web see. Revised: 10/13/2021 Pape I Of 2 -------- ---Staff Use Only Review Stop 1: Well Site Inspection: YES NO NA ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfrekis, tanks, buildings; indicate distance on plot plan) ❑ ❑ Are there roads within the 100 foot radius of the water source?If so, is roa prival ,County or State. What is distance to ROW? 6 /p DJ ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan) 0 ❑ ❑ Is the well cap satisfactory? ❑ ❑ Screened and vented? 1 r ❑ The well casing extends___ 3 above level ground I concrete slab? (circle one) ❑ ❑ Is there evidence of a surface seal? ✓Af: y j,ZGOy I ❑ ❑ Does the seal appear adequate? 191h. -(2 2. P 6 rb Z ❑ P" ❑ Is a variance necessary for well site approval? Tay: gQCBSY Comments RI Pass [IFai Inspector DateZ/�2! vZ(�f,.^ Review Step 2: Two-Party Review: YES NO NA ] ❑ ❑ Water Well Report with adequate pump test on file?AKad-b YrM/rYi p9 9/owy W �Vvpl fa 60*4(tpio If NO, date of Capacity Test Driller / GPM �pJ ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 10 1� RJ YJ ❑ ❑ Received Signed, Notarized,and Recorded Notice? AFN t ❑ ❑ System appears adequate to serve 2 single-family residences based on informatlo ) ? Comments , O d,C F ? Approved ❑ Denied ReWewer Data 11 2 G N�FNI W( Findings in this review reflect observed conditions as they existed on the day ofthe site inspection. No claim is made,express or implied ofthefulure success orfailure ofthis system. Well site approval does not constitute water system approval. Water System approwt is a twopart process. All proposed connections to new"Its are subject to water adequocy requirements at time ofbuilding permit per MCC 6.68. Water usage restrictions and addinamiI fees may apply to all new wells drilled ajferJanuary 190,1018 perESSB 6091. Revised: 10/132021 This form my be warmed and avallatle for patine view on the Mesen County wee eke. page 2 of 2 Puad 0tmba wne a11120)24 WATER WELL REPORT aDEPARTMENTOF Not.od tN0. WE56165 ECOLOGY Unique Ecolo,,Well ID Tag No 000069 TTp.awam sm.a wafnhtgfm m Cmm:w+ka Site Well Name(ifmam tl.n art Wql): ❑ lkmoa:d.bn o Od®.Iinwllnim NDl No Wua Rigb,PemtivtcoifN No. Pr,p we 0Do— ❑Inmmkl ❑M:r.,w Nopaty Owkr Name Darrel Be ❑Dex..ba ❑"wion ❑T.,ww ❑Og Wdl Sail Address 410 SE Sea Der Hok Ln Crasie TYR: MCM1si: ON .9 ❑Ah.an. OOm. OIwW ❑ch Tool City Shegm calmly Mum D D� OOm. ODte ffi� ❑Moaga.y Tax Paml No.4 22020.3}DDp50 Ol.mia.e lkwarofk:m.8 m.,m 220 R. Wasevariuweapprmdfor0isnkell? OY. IBM Dgmafmogbud wea 219 L w,el Ilya;wfiu Waz Ih varielwe far ca I.m Oatr Fmm Ta lkkam SW PVC WY land W 10 a in. a 215 .25 u 0 I ❑ M 10 Lookm(neinstmli on 2): OWWMa❑EWM ❑ 1 ❑ —in ❑ I ❑ O I ❑ NlN v y.Ofdm NW %;Saint 29 Tawnahip 2014 R. ZN ❑ 1 ❑ n. n ❑ 1 ❑ ❑ I ❑ ❑limtle(FxemWe:47.1234a)47.19976 ❑ 1 ❑ _m. — _ _n. ❑ 1 ❑ ❑ 1 ❑ Longiludc(Pxemple:-120.12M5) -122.D6837 I fi.: ❑Y. wXo Typeofpmb and Drilke,L4l/Cp.lractlpa or De.mNWns Praha. No.ofpnfo.dcm� Si ofpufwu by_u inv.lion:Da bhYmbr.drfne.fveofmalvblW Waenve,®dlYYmdn1 Pakniaf W Y. 0 No _abebw innm usu veEvvofine m.mtiY ei.ohk>vpe^en+rd,wuhftkm fs mlrY fuuhel.YnM Sreeu: OK-Prkc b Cega 212 g mi>®lim. Un Mdimul m<etf if�.ty. Menu xtmn:r vette Nloy ggprila Waks Mdo ial I. To T, Stainimsiow h lNo. Brown sftygndg navel 0 21 ! Gamete, 5= SW.m e14 n mmt 214 R.m 21D g Gao:nm_ Slueue_nam _ft._L Brown BarW CIeV 21 32 haWPnnr i.a:O Y. Bh.dlay K INRN. S-dMk0tmkl_ii GrW sft ,veal 1W 16 M.e:ials ge<edb®_fl.w_a. Gmy siRysartl 182 167 snrna Se.l: ov<. ON. Tawh.d.mY1a 4 Gray siRy satl0..sma gueel 187 190 M.mkl wed n. i Be 1 0 ch" Gray sard. v21u 190 220 1Tdey sow msam tmuabb well ❑Y. ONe rypeafwmen Dfphaf..e Metkdpfaealka.e.o6 Puy: htmmmkuvr'a Name Type: NP._ PumPinleN<degh:_9. Dcsi®xd aow'rw:_Qm Wakr Leveh: Land swfn«d<vatm ho"t ea level 110 g Slkk-upnftop of well nsittp 15 n.eMve paved amince Stub wean level 9a fl.helaw mpnlwell mvirv5 Unn W3024 Anevian w.,., ,,01,d px sgiurt ircL 0Ye pMfiao wem,e<mtmllad 6Y (ey,vdre amJ Wea T.k: Wuapmpiaeaop<rm:mN?wNo OY. O hywln:n! Yield_a wim_Ld:axdownaGr_bn Ywld_Wm whh_B dnxdowe aBm_M1n. Ykw_ppmwim_L maxdw'n ahn_M. Remrkydw Uine-mmwbtpuap uaxW oD-wmkwl nnuuW fiam wee kpmwner ktell T. W.n lzveJ Tim Wy.lnuel Titm WfWIeM One ofpumpina na yik,I<et_pnoxA:_g.DO Iml a ea9a_ha l Ab nk ppnwith wm w. 180 .br 1 bt F Om R'3021 i! Tn so w_Idxn J Teml.etmeafw.a 50 •F w.aarakde.y,kt.nn ❑Y. ENe Stan Due B2624 Campided Dam 9Id024 WELL CONSI'RUCYION CERTIFICATION: Icon.nm[ed atlN.emeppo onnbility far c:awmuon ofthu xell,.d ns mmpiume With all WMinglm uell !, C mdpn aI ndiodi.MMalek Ys[d Btld the Infi,n i.Rpm Ol above ae Irae to IIIY b.f kt odl atd bolRf ! E Driikr❑Tmmce❑PE-P' 'f a JOM Koepp Loin Cmn laeadia D61knq lm S m Addresv PO Box 1790 L' No 2574 City S Zip Sfe6on WA DR904 IFTRAfNEE'Spaua' arm No Cuotmoxa Slh.s.' Sig.sue R gislmme No ARCADDl0 l Dam D 4 ECY050-1-20(ReYOw1S) Ifymt dtlJadrcunuuinmallemamfOmcpleamcallthe Water Resou sPmgmmat36 07-m72. Perronatrirh peanrq;bss knn mil Jllfor Waahingan Relay Sereice. Perawa xithaapeeeh AmhiliN mn mllgJl-833-6341. V mguar(i Laboratory 2635 Parkmont Lane SW,Suite A Olympia WA 98502 O fEa ffl) 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM beta Saw"Cdecad Tire Bade county Cobaed 10/11/2024 . . . . am MASON ta.w De, Yaa _:_ON Tyre of wear Sysan(dad mM one blu) ❑GmpA 13Gmp8 ®Odter GapA am Gmup B Syearm-Pm.ide ban Waar Faciaies In enlory(WFI) Do _ _ — — _ — System Nare: LOGAN SPEAR ConlslPenon:An edict DnI t9,Inc Gay Pllote:(3B0 )426-3395 cetPlutxl 1 Ent Ere.Phata( ) Sad taelnb'.(Pnnt WI nary atdmss end zip mde aem 11 edela�ertn]Ixddlllni.can AND MlndQer<adaddEbp Cpn SAMPLE INFORMATION San*co" adWlnamel'SHAD Speak badem stare son le mlatl $pedaliabucporaammretm: 410 BE Sea Der Hok Ln,Shelton Counts Please Type otSupple O*do*one,4Wof W"fium bpest be*5bobn) 1.❑Routine sal bXbn Son"(AIP) 2.❑ RpaetB.pleluP) Chbaaaa:Yea_No_ Ihp.ambumn'nNeo4'name. Unastaaday ratite tab rubber CNaire RreiGmi:Total Ftce_ 3.Graund Wear Rule Scum)I San" Unseesaear/mlarembdbb' CnbnneaE:Yea_Np_ ❑Tn9Sered(AP) Chlorine Resauel:Total_Fere ❑Asseamaol(AR) 4. Surauor GWl Raw Soum WMr Sanpa(Enlmeralan) ' _ t ❑E cob Cl FecW ana Yn_ru_ s.�sargbCdixud a aarrnwen tab: IAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Umarisacoory Taal CaBmm Present and Saveame y ❑Enoli Present ❑E.cdiatoant BoaaNd Demky Rwab:ToW Cdihrm Jt0W E.Cop I1Wml FeralCdifam /10dd. HPC and RpleuaaK8atpa RqukiG ❑TNrC ❑Samdn weld ❑ Sarea Yeanle ❑Gaadvad Cor4MRr ❑ WnyeO. IS Rerrrem Numpr O 11 Rmep Tenor 1.0 " Code: SM9223B WIe Reltanada DDR IapWOy. W La SannWt 285- 01110 4 2219725 MASON CO WA ORRRELL015NERRIE B RNFSEtp04T40 Rec Fe. 1304 55 Pages 1 Jill II1I1 Return To�a.rel4IT 4\O .SF �onber Nnk lane pl+nn LEA 2K5%A Grantor(s): (1) t/QrreI F 'F�arnet� , (2) Sherrie C Vc�rne5 . . Grantee(s): (1)PUBLIC LDt ' Legal Description (1) I.o >r:P,0 - (Abbreviatedtomr i.e. lot, block,plat orsection, township, range) Assessor's Tax Parcel: (1) Q,4_0--33-A012 Q 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(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) D 0 3 0 - 3 3 -gG O O Tax Parcel: (Connection 2)�� 1U -a3--� U —L-0 The system owner is responsible for keeping this system in compliance. / The name of the water system is: Rer rnit 'd d / L J .24 -000 5;l Bar c This system is designed to provide for two service connections. Planning an rises gn a 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. Dated on this 19 day of e Signature of Granto (C): (1) . (2) �Q � � � �� 0W✓1-�'B-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 D3nQ nbCV✓ 20 Dinric k 12art.L*ersonally appeared before me,who is known to be signer of the above instrument, and acknowledged that he(she) (they) signed ft. GIVEN under my hand and official seal the day andyear last above wrMen. LL��. N , otary Public in an or the State of Washington, �F•'F'�3i za residing at My commission expires: :a PUBLIC N�ohm Si':02: mb Page 2 of 2 i HAMMERSLEY INLET APPROX. SHORELINE I II vozo-3:5-soosu ]2010-3i-A]D50 I .y�a NVWATER& I 1 PVMP TANK& HEADWORK$ 1 / I i II FUTURE TRANSPORT& HOME' LOCATION RETURN LINE Apon I I fv FUTURE WELL J j I Nov 1 �� i I 5 2023 I c vn"fkNRO•V1i- - �� DJA tNt41 _ PRIMARY AREA (1080 SOFT) I APPROX. RESERVEAREA I DRIVEWAY 1— — I (14405OFT) I I ———————————— �T SEA DER HOK LN TIN AN ASBUILTI INSTALL SIGNGFF FEE WILL WC GED AT TIME OF IWTA TM PIONEERPIONEER DIGGINQINC CIbTOA1FR: DARRII BARNFS 0RI(Nm T TN^41 ("3 . PARCEL.*2202P339WSO p4,1.\) 0 Ux).Nl. U231.LNI L4\1.\1 2M L1.11 2b i lAl 'IK DI.. ADDRES� 905E SEA DER HOKIN A, R\lb RLVI,23 30S3 E�t�.��v NI�4��ao <,a v Fvl[w.wn wt515 DFSIGNFR: RDURT N PAYS5E r® .OFFICE-W42(+-1803 F�\ 3aT4n2353 SHEEI: $REPLAN SUIE P=7Y �.'+�"^•'�.+'. "'°'�°'�" r lawrPUraY 22CUM Z7 In 00 M �H-, M ar m k � rr` v"Qu.. w Y 9�