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HomeMy WebLinkAboutWEL2025-00005 - WEL Application, Design, Letter - 1/21/2025 MASON COUNTY 415NBTHELTON: 60427-967 ,EXT40 SHSTREE STREET, ON, A985"BELFAIR:360-2754467,EXT 400 Public Health & Human Services ELMA:360482-5269,EXT 400 FAX 360427-7787 ZEPEDA ET lIX CESAR O 80 E El Fuego Dr SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2025-00005 151 E Hiawatha Blvd 320071490041 The 2-party water system, HiaWater(320071490041/320071490041), 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 ? 0 / 101S- MASON COUNTY 0 zxy S' COMMUNITY SERVICES MR mM4: R mM wanovsMlaBEM°Rn..M.Ix.I1ncMMRM�Mrwla 415 N.6A Sum,(Bldg 8)-Shelton,WA 98584 WEL2025 - 00005 Shchon: 3W427-9670x400 Belfalr.W-2754467x4W Elmo:3WA82-5261 141➢I TWO-PARTY PRIVATE WATER SYSTEM APPLICATION PPPMANT PHONE C�SAz ZEP412 MALINON)0REs5-3TREET,C1TV,ET.LTP cv 0 60 &- EL FQe&o DR—. 110MGM SnEAWRE55-STREET,1I1.STgTE.tV ^ e `� PRIMARY PARCEL NUMBER mELL SIMI 3aoo7- I - 9 CJ SECONDARY PARCEL NUMBER is APKICAB1El V WATER SOURCE ❑New Existing ETMWell OSpring P°0.LFL1Lm)aMx r PARCELELm S¢E PROPOSEDWATER5Y5W,%3MEIMEDVIREm N OYay PROJECT DESCRIPTION Ir f T7 .)1. LA) T U(th - hzaol,' A,)P DIREmI W s TosrrW coxDlTIOxs �f3M Q2CLEX CIL TU I PJ.}'rl U Sir w fP_r Site Plan: (may also be attached) (property boundaries,strunures,wall site w1100 radius,driveways,roads,septiclsewer components and lines,easements,etc...) (SCE_ / Trp'(_1 ) 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) Of Notice to Future Property Owners recording(record with Mason Co.Auditor, supply copy of recorded document) Or Septic Records(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 sift. Revised: 10/13/2021 Pape 1 of 2 Staff Use Only---------------------------- Review Step 1: Well Site Inspection: YES NO NA ❑ ❑ Evidence of existing sources of Contamination Within 100 foot radius of Water source? (drainfields,tanks, buildings; indicate distance on plot plan) IL ❑ ❑ Are there roads Within the 100 foot tlius of the water source?If so,is raa rival , County or State. T What is distance to ROW? t ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan) ❑ ❑ Is the well cap satisfactory? ❑ ❑ Screened and vented? l� vel q❑ The well casing extends I ` above I nd/concrete slab?(circle one) {` ❑ ❑ Is there evidence of a surface seal? �Qf; u7.�3 y 7 ❑ ❑ Does the seal appear adequate? on: C?O Z"). ❑ F ❑ Is a variance necessary for well site approval? r rll: Y7 A e V Comments L Ipass ❑ Fail Inspector Date //Review Step 2: Two-Parry Review: YES NO NA tv ❑ ❑ Water Well Report With adequate pump test on file? r}, —Iflq"ate of Capacity Test L Z Z 7 D e-riller ttr T!' 0 y GPM���Nh UQ�tq $0 ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 1 ❑ ❑ Received Signed, Notarized,and Recorded Notice? AFN❑ �...ssee ❑ System appears adequate to serve 2 single-family residences based on information p4¢Z Comments Ate_ 9pryCO F���� Approved ❑ Denied Reviewer Date ' 4 F Findings in this review reflect observed conditions as they existed on the day ofthe site inspection. No claim is made,express F9(�, or implied of the furore success or failure of this system. Well site approval does not constitute water system approval Water System approval is a two-part process All proposed connections to new wells are subject to water adequacy requirements at time ofbuilding permit per MCC 6.68. Water usage restrictions and additional fees may apply to all new wells drilled after January 19'^ 1018 per ESSB 6091. Revised: 10/13/2021 This form may be scanned and available far public view on the Mason County Web site. Page 2 of 2 WATER WELL REPORT 11PARTMENTOF NoNceofietem No. Mellll 4 ECOLOGY Unpoe Eemegy Well ID Tag Ne WIN" l}peanva.k Sememwdd'mn Site Well Now(if mac than one=11). CA cww bo ❑P.:mm;mkn =-> om,oumeWkdee NnINm Weler Right Pennit/Cerbricale No. lem'.dUse: RDem , ❑ledwukl ❑Mwpgn pmpert3'Osmtt Nome CaldwZ608da ulD .bele4 Ohn"im OTmwN ❑a Well Suce Address Hiawatha Blvd Cowmeeioe Type: Isfafb4r City SheRm County Masan Owe—ell ❑Abodes Dllriee O] OcableTwl Y O Dwpemo6 00wm OD, mAb- ❑m",;tany Tex Parcel No. 32007-14.90041 Dimew+ew:Eimemeafbud,R wleuesbn ,_ m<,m 70 t WayaavmmmaagmvNfmtNoaw elT ❑- Ye &No Oe'aa.f.epkMwl 70 M1 WB Ifm,Woa%wtNvanasafn Idn6 mecmlXmoe< fwm To md4xu Seed PVWNm mm.e I ❑ a N rP 0.25 in. O 1 ❑ 9 1 ❑ I.amim(uw imlmmia ,on aagei): BWWM me O EWh1 ❑ O _m. « ❑ ❑ —10' _a SE Y'/oflhe NE lk, aon ] TomhiP 2lN Range T ! . O 0 (1 I ❑ _ WNde(E.. Pe4T1N5)0.2090N ma ide-120.12343) -123.101]4W Perbaatlev: ORm ®No Typenfpa6:m wN Drllkr'a Log/Cooserumion de Deeommialmen Praeedure y$ No.ofperfml:wr_ g;mefpuWedma_iiN_-m F—ac-.—W by mbe,cfeen,n,siu M::uunalardaw'nue.sed:Mafed and Peebrned noel_R b_A W pa 1w6a ..17d,e. 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Thurston County Environmental Health 412 Ully Rd NE•Olympia,WA 98506 360867-2631 COLIFORM BACTERIA ANALYSIS Deb S-*Cokcbd Time Sempb Courts Colboktl If Ial Ids �a 3o�,a � N y_ Typsof Webr Syaleml odyMbW Rnale Hwedlpld ❑GmWA ❑GioWB ❑� CmW A wd GmW B SyBOmb_plova7eban Wier Faidi9ae Imadwy0yF7 SpbmNme Codwi ream: E ®OR DeyMwlw:l36O) g5_19' c.MrMna.( ) E.MW yMreWN b:lPm eme.atllw+aM uawdea emal etlM1eaM) . .- F 60x aycez a�a�u 6.rruz, JAiV13 TLN wk 955�9 RFci5jI, SAMPLE INFORMATION Sampleoa ww by(�): Sp.kw,admaetldleee elbre n pl k1d: SpedNinebwtiweoromnwda: Type of Semple(mntdwckadyom bw of#1 burgh A4 Baled bebw) 1. Ro0w0bblb"nS0mple 2.R.M,Sempb(efbr anal.raullne) ChbMMbd.Yee__No_. ❑IFehibuwn Syslem Chbdne ReWual:Tobl_Free_ Chbrinabd.Yes_W_ S,Rm Wa So...Semple Ghbrine Residual:Total_Free_ ❑E.m -GWR(Aml 0Feca1-1—,-1 q%4+ kelab nuwbw: Fftm ..YM_--NM__ _- -.— ❑eneeaementWnlbdng(MP) Wawd'j Urou9rw mkddam'. poma S 4.p 9empb Conecmd M hlimmatlon Only InwNge9,w_ Co�mcAonl Repein_ 01Mr_ LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Um ftkc yToolC *.Pmaent aM dellCbd ❑Ecok WWI ❑E.wl eb I Replsemeni Semple Rmubed: ❑Senpleboeld(130W e) ❑TNTC Cl— Be W DaWty Rewk'.TWIl jfomi___JjW E00 I100M Fecal Cokbnn__�,gOml Edemoxd nBO M. WftdCade: M8719B ❑SM 9222D "ed ❑SM 9215E ❑En*MWS ti3' mwme Tvnemek/md . 'L2- s.mexmbrtodNnwb.F,+ dpb) LebUm a,F/081�. 0 8 0 Cd1eU4+-FA` 'k+ ' us �- 2220783 MASON CO WA 01'2V2025 "' 22 0" 10TCE ZEPE00 CAR r205531 Rac Fg S304 5D Pages 2 Return To Grantor(s): (1) Granteti (1) PUBLIC n Legal Description (1) LOT 0c SV A(lo7y MF{db7873 PTA) CP SEND (Abbreviated/orm:i.e. /at, bock,plat or section, township,range) Assessor's Tax Parcel: 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) 3 a Q O - ! q Tax Parcel: (Connection 2) --�&L Q —7 - I q The system owner is responsible for keeping this syste'm i�tIn compliance. The name of the water system is: 2; W UL 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 speck provisions of the regulations. L (' Dated on this�T day 0?1 nJ lA - 20q[�. Signattuure of Grantor(s): _ Page t of 2 State of Washington ) County of Mason ) I, the undersigned, a N ry Public i and for the above Wmed County and State, do hereby certify that on this day of 20 , person ly appeared before me,who is known to be signer of the abovelristrument, and acknowledged that he( e)(they) sig ed it. GIVEN under my hand and official seal the day and r r I t bove w t 14 "��"66FJt SF„q , 11 ota Publi n To a Skate of Washington, NOTARY °my:. residing at 23038426 _ My commission expires: Nam:, PUBLIC so,97�y:a r7IlOZ�:a �• 'UP WASNv"r." Page 2 of 2 z o, y 9 40 m l_k5R2 apEm xxx E . I{ie��rrHquD . � Cs0. r Z[pRC10. VUM5 PrArc<I #F32o07-11- 9ooy� z� to'+ VGMS E $Cali:! 0 to ie qo �To am APPROVED •. F 1UN 16 2022 © �IIO1L E7 4YE5TA,EAi'r ® Caa ncw'hai` Q >too Gan m PMP I PUD I rn t ICI a S P < 0 S m s _ a � °�' Propo4td Lf iiOWY S;k Y i e 'ry i of ' \ well Drrv[w 19 / i J]i9 TnulA JOY JOYMSON T-i4.74