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HomeMy WebLinkAboutWEL2025-00001 - WEL Application, Design, Letter - 1/7/2025 415N H MASON COUNTY fi SELTON: 427-96 ,EXT 40H STREET,BHEL ON,, EXT 400 BELFAIR'.360-275-0 67,EXT 400 Public Health & Human Services ELMA:360482-5269,EXT 400 FAX:360427-7787 LEITZ JOSEPH E 91 E LITTLE BEAR LN SHELTON, WA 98584 RE: WATER SYSTEM PERMIT, TWO-PARTY WEL2025-0000f 9f E Little Bear Ln 320057500060 The 2-party water system, Leitr (320057500060/320067500060), 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 ILL/MZf MASON COUNTY Deng Mtl. Dl- D7- ?015 COMMUNITY SERVICES m utlR AwE 5 e�Mss Pmnxaem�mw xre.cam,n.imw+M 615N.6°Sbmt.Bldg 8)—Shdtan,WA 98594 WEL Z01S'00(D01 Shelton: 360427-96/0aa00 aelfvv.360-115-0 77AW Elm.:3W-M-5269 xa00 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION pPPtKIWT G�f`�T ° I's �ss 92 svluw RBBtS rT. .6T/.T- ^ �D SREP RE PwLYRYPARL4L xeMBER O Jam) 7 r ^^N ^ JAN 0 7 0 SECOROARYPA Mx11MBERISSMERB—B 'fLIX..YTEDOMSAMEmM 'L) 01 PPRCELt LOT S¢EprYitsn) P ❑New VF dging [Well ❑Spring t PROPOSER WATER SMTEM.ME1REQaIIEOI. / PROJECT P110H 1e.0.J4tME nvYgls e .W noxsToaTsrwxonlaxsrw LrooEl xsr tncAnoxJ Erc. ° F� crecr, eff Site Plan: (may also be attached)(property bauxlades, ,,dums,wall site W1Or rsdlus,driveways,roads,sepoCrsewer componentswater and lines, ter lines,properly easemeids,etc) 5f-t 0-- 1%6ke-s-( Required Submittals Checklist: (additional information located on the first page of this packet) ,t:F Satisfactory bacteriological test from within the last year(this may be deferred rf the well has not been drilled yet) ,8r Well log and/or capacity test performed by a well driller(this may be deferred 0 the well has not been drilled yet) Notice to Future Property Owners of Private Two-Party Water System recorded with Mason County Auditors Office Septic Records(additional locating requirements may apply If there is a lack of septic records on file)ShIG dDX-00y5f This form may be scanned and available for public view on the Mason County Web arm. Revised: 12JI72024 Page 1 of 2 _----- -- Staff Use Only ----- —'---- Review Step l: Well Stte�gspec r(MP it* YES NO NA M ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfelds,tanks, buildings; indicate distance on plot plan)I�{ ❑ ❑ Are there roads within the 100 fool radius of the water source?If so,is road pr9a,County or State. 7M� What is distance to ROW? ^I Z • _ Illl ❑ ❑ Does the ground slope may from the water source site?(show slope on plot plan) �] ❑ ❑ Is the well cap satisfactory? I r� ❑ ❑ Screened and vented? r T ❑ The well casing extends above level ground/concrete slab?(circle one) ❑ ❑ Is there evidence of a surface seal? Lat: 47•Zfd$f f ❑ ❑ Does the seal appear adequate? Lon: -Itf.&Vto ❑ ❑ ❑ Is a variance necessary for well site approval? Tag: A(Q Z8l Comments dukkM Ca7p3 P/II �I � y�ldiif I//9/brtS / a�mr cG�i/ren !� �assF� Inspector Date III�I ZOLS' /A 1 Review Step 2: Two-Party Review: YES NO NA ❑ ❑ Water Well Report with adequate pump test on file? AfcaAr`a O+r UrrY o+ IZnurllF r+l zs riP►I�tl�pghl(fjQf� If NO, date of Capacity Test Driller / GPM ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test Z)Z /Z 10 b( ❑ ❑ Received Signed,Notarized,and Recorded Notice? APN 2J ❑ ❑ System appears adequate to serve 2 single-family residences based on inform A? Comments jv ��// Datel Ury � p•� �] Approved ❑ Den ied Reviewer1 7/�"1pU 'YTAt� �<Ty Findings in this review reflect observed conditions as they existed on the day of the site inspection No claim is made,express or implied ofihefdure success orfailure 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 water adequacy requirements at time of building permit per MCC 6.68. Water usage restrictions andadditional fees may apply to all new wells drilled after January 19a,2018 per ESSB 6091. Revised:12/17/2024 This farm may be scanned and available tar public view on the Mason County Web site. Page 2 of 2 N A T ¢ R N R L L R F. P 0 R T are late Po. t1G91199 Wi9,e Well I.D. R ACG219 STA19 OF NASXIW'ICM Water Right Fermat w. L .. ._ . ....... .......... . ............. . .................. .^ Q (:I 4Y116R: wme DRt]ml. OM s dra9a IfIDS i0Y19 0195 YfIVD D®.M. as 9ASSa- a ..........................._.........._....._............ ........................_............................._............. Df (31 [ACATIOM OF WELL: coun[y fPSINI . IQ 1/e lA 1/4 Dec 9 S ]dN N.. R 1N NN lial 9'IRRFT ADER¢EE OF WELL (of nes[eaE addreaa) 91 D 1,1ifLt fY! .. finned. _ ... ........................... ..................................^............................. .... N (3) PROPOSED USA: VAOIfTIC I (101 N¢LL . ----- .. .. . ...I . . . . IU,TxeE OF NORX: Owner's aRaza of cell I Fgtwtion: Describe by color, ihanccer, Bis. of Rut.riAl N_ (if mt twc one) And Rod .,gruef t�mAnne tUaaneaef equifreeenen[[aced,Aci[h t fp X6e AnDfUrr foe[ n eachI [fore . -,,.. . ....... e[ lean[ one rtntry --- each change in fo[M----- Lac C f CORFer ed Well S ft. -ME ' 191 ORffil3[INA: � ��� C Ort1IM Ial [c. ..... of ......... -11 ... ... samme, Al I PRpf I TO C .a_ .._^.a... . ..... s.:...... ....... psces (mazzaacoma Nx tlq adI I 0 13 0 :61 MMTR I..TOME. Dg1'AIL9: - - PA69D COOR¢B 9AND OGRAWW I 1 I as c+aa9 11d a. S •• Din. Loom .1 It to la P.e fe. oU.Y 6ax ANn aLACA awVO. I aS I a] E NdDm JD:NO dial tram ft. t fL I OYY dAY Sl 16a Ole. f[um LL t It. lA9et ['oORBf SAXO nRY I N Te L __________________ _ OV.Y tTAY I T6 fl tO Per`orations: eD DlnA1 afAva NASY 69ARIXG f9 >s C Ty 112 pe of perforator need ®.ty tILEY ff i 1t9 134 S1'LE of perforations in. by rn. DLAIt ®AV6L CtY dLY BIAD9x NR SPerforations from ft. to ft. wAY a+r 194 391 ♦.a Per Lurafawn [ram ft, to ft. aROR M. [ouss. sAND oxER i 331 lal i a- __perfore'lang ffree, fe, to ft. -----------..____--------------- ____I pScreens lm I C Wemeacturer's n.rD I A TYRA MMel ]Lem. Blot fife Crm ft, to It. I VOf.- .lot See form ft. to ft. I _ __e _______________________________________I O Gravel packed: W Size Of 9reeml LCnvnl Placed from t[. to L[ - i ^ y sur£.ce anal: Yf3 To at depth? 20 ft. I rWare cal .'ad I. Real DLP9O•L'LR J ! C Did any strata co ntain unu able -ter] W LD Type of cater? nepth of all.. ft. I ��• L Method Of sealing strata o[f I ................ ._____ .......I to ............ . pl FOXP: wm+Feeruxx'. Memo I. X.P. IS) MATRR WVSL4: Land-eu[6cA nie-Lion z ,bore wean WAR level ... it. II N ar. a- ?Waal 95 ft. beloa top e1 Wall Data 12/11/97 QI Artesian Pressure Inc.. per square inch to I artesian -ter controlled Dy I Nor! a[Ort.d 11/21/17 caa le[ed 11/1L/97 T .................................. I91 WELL TESTS: Oravdovn m ae is aount .ec level is I...red Ontov NEiy [ro1fsTRORRIR C¢RTIPIGTIOX: aca[lc level. i constructed and/dr Accent reapomIDility far rnn- Nae a pump [ea[ Panel M If yea' M +ism, atmetion of this all, and its cnglianee with All V Yield: gall/min Wi[h Ct dreWOm after hra. so, the in .11 forouticn reported Abovelare t Watt imy East d W Anowled9cnand deli.[= tYe 1 Reap�ery data I « Ti a ee 1-1 Time Wecer level Tim Nocar le-1 i NMf¢ ADCADL V1011L9ICI Ise.t o[a[ion) ITyps of print? Er+ AGDRESF R 3To suanve 9ARSf� 9➢ Wt. of tea[ / / I (f-cy..�M-"'- LSttnue Na. --I CU Ra ilex cast gat/mm. ft, draMeen after Intel ISICN®) a Air tmt 95 9allmin. A/ At, set at 3IS ft- for 1 arm.I Ql Artesian flow 9.P.m. Dace I oncn.L.V. Tesperacu[e of Water Nu a chemical. awlyei. Rude? R0 I Registration We alCA D-IRS1 Noe 12112/9, ___ _ ................... .. ......... ... ........... - ... ......... C Thurston County Environmental Health 422 Lilly Rd NE d Olympia,WA 98506 aRU0.4tON mr>rdrc 360867-2fi31 COLIFORM BACTERIA ANALYSIS Dab Semple Cokcbd'1 Time Semple Comb J Collected AyR Dry Y. .Typadwaer Sytian(ot"Onlyone bar) Private Nwcehod ❑Gmup A ❑Group B ❑Clear Gmup A and Group B System-Provide from Water Facliks Inrenbry(WFp: i IDk System Name: - COntwtPawn: Day Phe Phone: 99 d e.FFwne:(( )E- Z C ) SAMPLE INFORMATION - Sample wlledetl by(n�): 1 Ot b 1 Spank location or addresawhere sample wlbded: Special bshcoom Or mmmanta 9/ E ��fKr. SIuI Type of Sample(musidleck Only one bwof#1 tnough p4 least below) 1.❑Roetlna DlsVibution Sample P.Repe dSample(adm unsaL make) Chlomakd:Ym_No_ ❑Wbibution System Chlorine Residual:Total_Faro_ Chlednaed:Yes_No 3.Raw Water Source Sample Chbdna Residual:TOW_Free_ i ❑E.ca4-GWR(AR) ❑Fecal-swl®,O'm,pwy lnwwrml Unsatisfactory mdbe at wmber. Rbred Yes—NO_ _ ❑Aswssmmt Monkdn9(AR) -- -- DOmer Unsakfattrxy rooks wtiaddete: _ S i 4.❑Sample Collected forinfomullon Only In**ative_ Cmsbur5on/Remsm_ OW_ LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unvtiefectery Tool CDltimm PrewM and Satisfactory ❑EOoNpmawt ❑EcotiabseM No Coifoon detached RaplwemeM Sample Raqulmd: ❑Sample ion old(>30 hours) ❑TNTC ❑ RadetalDmedy Rmb:ToWCaMom 1100m1. Escd /10pril. Fecal 0ftmn /100m1 EnWwrxd n00m. WOW Code: SM 9923E ❑SM 9= Dee,and Tore Wsisd: SM 9215B ❑ brd EnarM I'j-1k14 O}98 DNsnd TheAreyred:ll- i Dee Re Z'�7-14 Sa�delNMrllapllunarW/'rrnlpltl ? lee Ue QYY 0 -7- . D 8 0 P S J 8 06saL% . 9 VQ � i U'L 1 2220314 MASON CO WA 01/07/2025 02.53 PM NOTCE LEITZ #205239 Rec Fee S304.50 Pager 2 IIII Return To lose=J� L t .tom tv F�6�,L it,0— 5A9 IAIA 916V Grantor(s): (1) TOsa-nh t-A-' :?) (2) Grantee(s): (1) PUBLIC r (� / QS-�a- Legal Description(1) �IJ✓��'� (` ( j (Abbreviatedfony,,.e, t bl ,plat orsechon, townsb P range) Assessor's Tax Parcel: (1)--- 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) --Sqw,--ZS-� � Tax Parcel:(Connection 2) — -- -3aoo5- 75- yoaoo The system owner is responsible for keeping this system in compliance. fG The name of the water system is: L- t�'r 2 �r yj 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. Dated on this=day of J"V 0"u Signature of Grantor s): 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 1*+ day of3 av\varu , 20?s, 2E"e h uci tz personalry before me,who is known to be signer of the above instrument, and acknowledged that he(she) (the i ned it. GIVEN under my hand and official seal the year a ove written. o Public in and fo the State of Washington, Wq 9B5$4 - CO y o0.. $ My commission expires: .5 �HOIARY U V' S gip` %�9jF !knnh�--N�l pgiy nm p o\o, Page 2 of 2 sand 1�LOT PLhN td�*f'rtSSur� / R_ 1 dfbed w�'i'H T O "��SEPh E-CZ / ( D+� �,q IQYhS rEStYvC a S 0.yo Jai. PaLfa vr 3205-15-000 V0 f/ r 9l E um g (TieAe L'tJ. /c / / 14•x4 f' � / / Fens• 3C73 Il' LS, 11-12i Gas /Ea5 eYtSY��q v..:.k`ad � y,cx+'�e toca yr— . Q Audio-visual Alarm j E 36R f- © Cleanout HOME © 1200 Gallon Septic Tsok \ 2-Compartment With Effluent Filter O4 1000 Gallon Pump Chamber ioo'M�ry To cF EX�571NG \ \ SHOP Q D V w W P r � y TQEES Arrow Septic Designs E. LITTLE t3Eh2 LANE ,Union Vygcre_. 2 (360)696-2�155 JUN 14 20U24