HomeMy WebLinkAboutWEL2024-00021 - WEL Application - 4/3/2024 (2) 415 N 6TH STREET,SHELTON,WA 98584
® MASON COUNTY SHELTON360427-9670,EXT 400
fiEL 360-275�67,EXT 400
Public Health & Human Services ELMA:360< M289,EXT 400
FM 360 27J787
ISLAND LAKE ENTERPRISES LLC
P O BOX 1473
SHELTON, WA 98564
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2024-00021
1052 E Island Lake Dr
420014190042
The 2-party water system, Two Party Well (420014190042/420014190043), 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@masonoountywa.gov
Sincerely,�
David Anderson
Environmental Health Specialist
Mason County Environmental Health
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TyMASON COUN 0e1eR �1VBtl - Z
COMMUNITY SERVICES
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® 415N.61°Street,(Bldg 9)—Shelton,WA985M WEL 'yp
Shelton: 360427-9670 x4D0 Bdfeir:360-275-0 7 x400 Elmo:360482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
AXONE
APPucANT 360.490.7843
Island Lake Enterprises, LLC C 1w Qnt��
MRILMGADDRM STREET.CITY,STATE MF
PO Box 1473
S1W ADDREss-STREET,CITY,STATE,MP A�
Shelton, WA 98584
PRIMARY PARCEL NUMBFRIWELLSnE)
4200141-90042 O
$ECONDRRY PARCEL NUMBER RF MPLICRaLE)
42 001 41-9004 3 PARCELILOTM PARC8.2LOTSa
WATERSOURCE %OURCETYPE Well ❑Spring 1.59_v e3 aad
m New ❑Existing (�
PROPOSED WATER MTEM NAME IREOUIREDI A9, ZL I Z l
Two parry well
PROJECT DESCRMTION
Two parry well for two single family dwelling units
DIRECT1005TOWE eONOmONS
d
Site Plan: (may also be attached) easements,etc...)
(property,boundaries,structures,Well site W/100'radius,driveways,roads,septclsmer components and lines,
see attached
hWIC970
MAR 024 �UUJJ
BY:---- ------
Submittals Checklist: (these additional items will be required for approval)
® Satisfactory Bacteriological sample(this may be deferred if well is not yet drilled)
f3 Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
B 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)
This form may be scanned and available for public Wew on the Mason County Web site.
Revised: 10/13/2021
page 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)
❑ ❑ Are there roads within the 100 foot radius of the water source?If so, is road riv ,County or Slate.
T- What is distance to ROW? K
`�J ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan)
/ ❑ ❑ Is the well cap satisfactory?
❑ ❑ Screened and vented? t r
❑ The well casing extends above level ground/concrete slab?(circle one)
10 ❑ ❑ Is there evidence of a surface seal? t 4{-; Y?299`4
❑ ❑ Does the seal appear adequate? WV -14,1?O}y,
❑ ()g ❑ Is a variance necessary for well site approval? Tat 1PV$
Comments I
Pass ❑ Fail Inspector Date / ZIP_
Review Step 2: Two-Parry Review:
YES NO NA
IN ❑ ❑ Water Well Report with adequate pump test on file?ATs"I
/ _�r'IIIK >+ 6/f/bX / 30n/nfa`60w�y18ad5al�
If NO,date of Capacity Test N` 7ttw- Driller tk Mat GPM 21.
[D ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test l
W ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN IZo
❑ ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments U�l tot mi, 1"`rll kafh k1fJ-asZUZY -an?
Approved ❑ Denied Reviewer Date
Findings in this review reflect observedcodhions as they existed on the day ofthe 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.
ls are subject to water adeuacy
permit
All
Water geoestrrictions and addiltionalfees may apply to all requirements ew wells driled after January l9'"2018 per ESSB 6091.
_- -- Revised: 10/13/2021
This form may he scanned and available ter public view on the Mason county Web site. Page 2 of 2
WATER WELL REPORT DEPARTMENT of NotircoMNnt No. WE4?144
ECOLOGY Un;ga EaoIMWellmTn No BNV070
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WELL CONS ULTION CERTIFICATION: IcenaWcicd mNa amepl rapomailiWfor mrmry vmofNis x<II,and iummpliancc wth eII Wuhinatan xcll
ontog.ion pnouhu .M isalda uwd ad On inWmulim reposed above aR Uue to my Sea knoMINAW END belief
p UrDkr❑Tn oa 0 PE-P Nave ien 'll Cgm %01 pitlbq lnc
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Arcadia Drilling Inc.
P.O.Box 1790
Shelton,WA 985"
Customer: Jerry&Cynthia Radtke Well Tag#: BNV879
Phone: 360-490-7843 Depth: 78'
Well Site Address: 1052 E Island Lake Dr.,Shelton Pump Set: so,
Date of Test: 617I2022 Static 23.7'
TIME GPM LEVEL RECOVERY
1 Min 7.0 25.7 TIME LEVEL
2.in
7.0 28.5 1 Min i29.4
3 Min 7.0 26.7 2 Min 27.6
4 Min 7.0 27.0 3 Min 25.3
5 Min 7.0 27.0 4 Min I 2A.9
6 Min 7.0 27.0 5 Min 23.8
7 Min 10.0 27.1
e Min 10.0 20.0
9 Min 10.0 28.5
10 Min 10A 28.6
15 Min 15.0 29.0
20 Min 16.0 31.7
25 Min 21.0 32.0
30 Min 21.0 36.7
35 Min 21.0 37.1
40 Min 21.0 37A
45 Min 21.0 37A
Thurston County Environmental Health
412 Lilly Rd NE th .
Olympia,WA 98506 12
360-867-2631
'CflUP810N COUNIV
COLIFORM BACTERIA ANALYSIS
Dale Sample Cdlecled Tare Semple County
31 5 1 20{ -ap '1 m �n
1M, par Year _om
Type0fWmrSyslem(dm*waf0reb0x) ❑ Private Housftd
❑Gmup A ❑Gmw B Omer
Group A and Group B Syslems-PmMtle km Wabr Fables Imombry(WFI):
D#
System Name:
Q:nw: mon: to
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Emem E".Phore:( J
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t
QO kE l4'13
WA q'85`64
SAMPLE INFORMATION
Semple mlbcdd by(mare) wry
1P- L8bQ
Spl�eyck-�b�cemon oraddram� -"w_�he1m� ample wl SpecWbdnx1knaarcaments:
1l/.JZ �✓ko nµ L t'
V 1✓<
Typeof Sample(mud check oidy are box0f41 through#4 Waal Wma)
1tq Rmmne DhMbudon Semple 2.Repeat Simmer(after umat.mrtme)
Chbdnebd:Yee_No ❑Ueblbudw System
Chbdw RaeWM:Total_Free_ Chbdnmd:Yee_No
S.Raw Water Soume Sample ChWm,Reaiduel:Totd_Fme_
❑E.wh-GWR(ArP)
❑Feral-Sumo oWi.acnwa(nu�) Unsetefecbry roulne lab number
FinerW Y._No _
❑Assessment MonibiN(A(P) Unimmeladaymulnmwllectdme:
!, ❑01her
S
4.§(Sample Collwbd for lMomarkn only 1't rAt
Investgmwe— COnswclionlR �ej�I'\t7 a'Y
IAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Uneadehcbry total Coftm Present aW Sausbcamy
❑E.wg present Ewa absent Cobb.detxed
Raplaeement Sample Re"Ired:
❑Sample kwold(4m teum) ❑TNrC ❑
BwWWIl dty Remb.ToWColifom nOW Ecol H00mI.
Fecal C0100rm HOOmI Emamwd /l00w.
blamed Cod 8223B ❑SM9222D OweWTmyaZO
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0 8 0 If `IL
2209181 MASON CO WA
0312912024 02 27 PM NOICE
CYN7Mlil RWT`E N196261 Rec Foe $304 50 Pages: 2
aelum To IIIIII11111111�111111141111 III 111111111W1111IIWNN1111111Ili
6111 (1k15
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Grantor(s): (1) Island Lake Enterprises, LLC (2)
Grantee(s): (1) PUBLIC �1
Legal Description (1) 5Q1-7 7-0
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 42001-41-90042 ---------
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) 42001-40-90042 -__-
Tax Parcel: (Connection 2) 42001-41-90043 -__-___
The system owner is responsible for keeping this system in compliance.
The name of the water system is: Two Party Well
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. -A � �w C
Dated on this I day of -January , 20 24 .
Sign re of Grantor(s):
Page 1 of 2
State of Washington )
County of Mason )
I, the undersigned, a Notary Public in and for the above nay med County and State, do hereby
certi at thisa day of V&—c A., , 20QLA ,
18wt4..�. R•elAq personally appeared before me, who is known to be
signer of the above instrument, and acknowledged that he (she) (they) signed it.
GIVEN under my hand and official seal the day and year last
taabove
)written.
"pnuuuunuu � "
NR�SS"'�.,
, Not Public in and forthe State of Washington,
P 'ssion F Notary U
residing at
My commission expires: 1
T umbs,:•a
F'WASN\",,,
Page 2 of 2
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