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HomeMy WebLinkAboutWEL2024-00021 - WEL Application - 4/3/2024 415 NBTH STREET SHELTON,WA98584 MASON COUNTY SHELTON:360<2]-9670.EXT 400 eELFAIR'.360-2]5-048].EXT 600 Public Health & Human Services ELM:360 82-5269,EXT 400 4 FAX:36042]-]]8] ISLAND LAKE ENTERPRISES LLC P O BOX 1473 SHELTON, WA 98584 RE: WATER SYSTEM PERMIT., TWO-PARTY WEL2024-00021 1052 E Island Lake Dr 420014190042 The 2-party water system, Two Party Well (4200141900421420014190043), 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 �rr�zo�y MASON COUNTY C.R..N.C620 - COMMUNITY SERVICES 415 N.6p Sinet(Bldg B)—Sblmn,WA 98594 WEL Sbelron: 360427-9670 x400 Heiner:360-2754461 x400 Elms 360482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION PHONE APPLICANT Island Lake Enterprises, LLC _6 n{' c' _ Qom[- 360.490.7843 MAILme ADORM-STREET,CITY,sTATE,9P PO Box 1473 SITE ADDRESS-STREET.CT',WATE.LP Pp Shelton,WA 98584 PRIMARY PARCEL NUMBER)WELL SIiEI !;< 4200141-90042 SECONDARY PARCEL NUMBER I F APPLICABLE) 4200141-90043 WATER SOURCE 90UROF TYPE PARCFIIL,TS, PARCEL SLOTS¢ ®New ❑Existing 13 Well ❑Spring T59Mm ea.eu PROPoBED WATER 5111 NAME IREUBIREDI u '1 Il Two party well /, CL. C T PROIECTD-1,11IN Two party well for two single family dwelling units DIRECTIONS TO me CONDITIONS p^ seg attached �r Site Plan: (may also be attached) (pmpedy boundaries,slructums,well site w1100'radius,driveways,roads,septiNsewer components and lines,easements,etc...) see attached �WIM71D M ..' BY---�--- Submittals Checklist: (these additional items will be required for approval) 13 Satisfactory Bacteriological sample(this may be deferred if well is not yet drilled) 3 Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled) E3 Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document) 131 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 site. Revised: 10/13/2021 Page 1 of 2 -------------__-----------________------------------------_---Staff Use Only ______....._.____.....___..._____......___._...______.._______..____ Review Step is 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) �IJ ❑ ❑ Are there roads within the 10O foot r pus of the water source?If so, is road riv , County or State. rr What is distance to ROW?- '�J ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan) / ❑ ❑ Is the well cap satisfactory? ❑ ❑ Screened and vented? 11 ❑ The well casing extends above level ground/concrete slab? (circle one) ❑ ❑ Is there evidence of a surface seal? Lg -: Y} " 4 ❑ ❑ Does the seal appear adequate? oil: -125,Wfg , ❑ N ❑ Is a variance necessary for well site approval? 7p ! gNv g Comments VPass ❑ Fail Inspector ,. Date Review Step 2: Two-Party Review: YES NO NA In ❑ ❑ Water Well Report with adequate plump test on file?An d/b Qr'2U e4 &%/&?z w/ 3oa1n fn 60«4 1866$�( If NO, date of Capacity Test G IOU- Driller GPM [� ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 7 G' Vo ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN ❑ ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments V4&1 gd lot Miopeel halve!' WAI&gL -agy3 Approved ❑ Denied Reviewer Date 7l(/7e zy Findings in this review reflect observed conditions as they existed on the day of the site inspection No claim is made, express or implied of the future success or failure ofthia 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 and additional fees may apply to all new wells drilledafier January l y,1018 per FSSB 6091. Revised: 10/13/2021 "is form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 WATER WELL REPORT DEPARTMENT Of NWoeofhecnt No. WE67144 ECOLOGY Unique Frobp Well tDTMNo BW879 TryeMwarlc Sbaaf WSfM1in(ton Ske Well Namee(ifmwe Nm one x 11) CmYm n ❑ W4er Rigla PemiUCedifime No. FmFmn ty ■oy OlnvmW a..W pop Owner None ) RaI. Odmmmba Ooi ❑Tm WN O(Na We1150ecrAmm. 1052E land Tabu Dd 6mmm6mTFSe: M :f NswA OAMeee ❑w— OJ.W ❑C Ted e City sl m Camh, Mpm ODM h, OO ODq UA Omtl cosy TexP No. 4200141-0 2 gms4m:py.�eflmy§__m,u T9 rt Wnevvimceeppwd PorlNevdl1 O Y. Dom D"&a0000. e]T8 6 Nyq whet vm.dw verimwe Poll Crdmpryr Wdl (a{ ELm Dicer Fin T. T 025 Svl 0 weSYa TYetl 0 I 0 a e, 24_ .025i! 0 1 O 0 1 a lSE lsa immeIE /, (e x): OWWMaOEWM O O _& —in O 1 O 0 1 O BE Y.� ple BE Y.-Sactiar 1 Towm.M1iO 101a Ruses O 1 O _b. _ _ laMpoAExvnde:l➢-120[ ) 5).214.12 O 1 0 _ _lu O I O O I O Loop�r(F pk:-120.Ill15) -123.120885W FmMM�r OYmwONe ry .flmbnmmel Driller'.lug/Camenetloea DewmmeaYalkmedme Nmerymb — ]mpfEMBmlle_4M_4 Finae'pmbeMmlm.eba ea.aaefmmirlWmrere..d0:YY1N FA�dEa_6m_lheM a'mmE�\m ®eofrtem:vN mwd MmRem.mlw9edlmam ver finerLAmFaI lloo I MY. ONo wp, d eII3 2 ! iW�ue^Ue ddtlomlaMurJmamY. hYedm'.N®MMV Mx ~u; 81YaiY Frain Te 13 Vw0Wralmd Mom No- Brawn Nob mMlum vel 0 11 1 4 SM.m.01] p 6em A!m Te! D'mmrr_ Sla.im :win _!m_n Brown drmbmMWm .eD Oasd, 11 m d B..wTB.m me6OVm ONo Siaefph rmi.l_i. MedB.me ravel box wel 28 aY M.aie1. _6u_rt MUMwbred rmdlMn ea eM 19 y my.�Ym ON. TawW �dg31 _6 ,oeo: h)OYm O me 88 oee�mpamm:wuvlbw W BlafX mIEIWIIS Sba rSKI. 0 T.Teef..mfl U.PlM� OsillaMa aram.bl:d' � Muhicol ravotl Blum m. .Wat epLhw wale 88 1p �•f'e�'x0Q Brown mvell mMium sarrd,wel M 79 Pow: Mmv6muaf.Nm TSy: xe._ e:q.leWudm4_6 pMyeeMac_mm w.mrlerA: IW+u4eelewioo.bon mew LM E19 B S:ieYnpar¢q e(weD miy 1_5 6A M000P S:.tie«merl.al 31 6%la.wp o!«dl u.i7 pw 8:9123 Meaunprt.me�la R•Ym:<'uh D.Y moelkdM tA.Mw.M) .0 rmu� wssop:wpFnem:rttdermW' DAu Oyes C M.'1mm1 Yiele_pp _P a .d—.em_b_ YieIE L.wtlawn_ppm«iN_ft aRr�b r.ae epm.;m_na... eauoimc-u<e uhnDump u:wod u6-wam<Y.a mm.weRamweu wp— uv io ua m.ep Tim< \Y.u<t<.<1 Tams Weer Lawl Time WuerleM o�orv=mrv.au.: n 30 «lm nm as:n 8p n.br 1 b. Dau NB/!x .fi— p remre:Nee or«min 51 •v wm..OemiN mdwh m.L? OYm Olb Bun Dale BMIx2 CamdmM ire BIB.R2 \YELL CONSTRUCTION CERTIFICATION: I eeeii,Nola oeeept rapasNlky fin eon5vuaim Of Us we14 W i%compliance wiN ei Wnhingbn well cmmrrr¢. ooWeos MB coed voW mformvisn mpuned shove up bue to mY 0ca browod,end bole 0 Driller O Treince O PE, Namr RI( len O 11 AmaO DriEalg S. 7 PO Add 1T s. Box 50 Ue.N 2053 ,.• Cry Soo Zjg S %w WA gMil U'TRADIF£S 1Lievm No — Camntw'S Spamai SI a Rego'^^N ARCADD1p86K1 Wre 8Ul2 ECY 0SDI-x0(Rar 09115) IJyou n.rd UladavmemMxolvewon/wool i+lrare roll tNr lVarer Reroveen l'ro]rmnm3dOJ01-0811 perromwifhhe MpmnmRTli PrillmhjVa,RekSmrc Renwnwlfho Wechdrmbdrge m11677431-0311. Arcedia Drilling Inc. P.O.Box 17" Shaft.,WA.98554 Customer: Jerry 6 Cynthia Radtke Well Tag M: BNV079 Phone: 330-490-7843 Depth: 78' Well Site Address: 1052 E Island Lake Dr.,Shelton Pump Set: 60' Date of Test: 6/7/2022 Static 23Y TIME GPM LEVEL RECOVERY 1 Min 7.0 25.7 TIME LEVEL 2 Min 7.0 26.6 1 Min 29.4 3 Min 7.0 26.7 2 Min 27.fi 4 Min 7.027.0 3 Min 25.3 5 Min 7.0 27.0 4 Min 24.9 6 Min 7.0 27.0 5 Min 23.8 7 Min 10.0 27.1 8 Min 10.0 28.0 9 Min 10.0 28.6 10 Min 10.0 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 37.4 45 Min 21.0 37A Thurston County Environmental Health 41.2 Lilly Rd NE th Olympia,WA 98506 )2 360-867-2631 T COLIFORM BACTERIA ANALYSIS Dam Semple CaSeclee TYro SarpN County 3 15 / zoo{ �� r� Mason WN on Yes k:—ore Type of Water Syemm(deticonly as box) ❑ Pdvate Hareehdtl ❑GmupA ❑Group B Voter— a- CrcupAend GmupBSyctam-PmvidekmWater Fedlmesim "(WFI): IDS System Name: Conrad Paten: 1A Oay Phone:() a1 Cal Pha s 1 E-mail: Eve.Pl—:( ) Smd ree to 'aml ems,etl aural amines) 1� Pis kE (4113 -5*V,LAY WA '115 WA SAMPLE INFORMATION Semple mllocmd by(neme) n ,�'y, Iv l�EdeSr� Spwftbo0onmaddmuwimmso*leoobc6d I Spedalimmucbmsorcommenm: Ql!k f-� -P 6, l LI�� pri 41 Typeof Semple(mwawkontyombox Ofglthr ah941istedWbw) T6j Rmsme Gubibution Sample L Repeat Semple later uma.mutim) Chlorinated:Yea_No ❑Distribution System Chlodne Resdual:Total_Fine_ Chbdnaled:Yea_No B.Raw Wafer Souma Sample Chbdne Residual:Total Frce_ ❑E soli-GWR(ArP) ❑Fecal-M� GWI.ai Nwnanl Unsatiemcbry routine let,number: Fiaered'.Yes_No_ ❑Amamment Monimdng(ASP) Unaalislacmry muflne collect dote: []Other 5 4.IRS.pte Collected for III Momretiononly il'1..,.aa,� y1t InvaeApaGYe_ ConetnmSon lR er yaU"v 1. LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Calbrm Premnt and Satisfactory ❑E.ad'pawd ❑E.coyabeaM Cddnrm detecfad ReplacernaM8smple Rsci lad: ❑Semple too ole(IN hours) ❑TNTC ❑ Bsterim Denary Remlte:TOW E.mli_J7WM. Fecal Cohbmi /I00ml Enteromad HOO mi. i Metlnd 82238 ❑SM9717D I1Me anti nm�e' �" ❑SM92156 ❑EnWrolerlD � ' /r.r oqob OaearMTaa An*7ed WleRepaded•. 6epeamexloarnmbr WaM �1 laEUm Qiy. 0 6�w11p6}�4V�IL 2209181 MASON CO WA 031?912024 02 27 PM NOTCE C111I1TT"pfj I TKE �*1111I112,,6Ipp111 Rae WWFee $��33�0H4 5©ttIIPItlaoes. 2 Return To � 241kiick W bay, 14,13 St'\el1yD!1 \Id A_ Grantor(s): (1) Island Lake Enterprises, LLC (2) Grantee(s): (1) PUBLIC Legal Description (1) (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) 420 01-41-90 042 ---____ 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 (11)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) 4200140-90042 ____ 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. o� �- Pc. Dated on this I day of '9 20 24 . Sign re of Grantor(s): (1) (2) Page 1 of 2 State of Washington ) County of Mason ) I, the undersigned, a Notary Public in and for the above harped County and State, do hereby certi at thisa4 day of V(S l ' , 20QLJ , TorjkW 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 above written. `� �NrR UST"/'�i, N�Publor the State of Washington, �`P, on residing at S W� �NDUay my commission expires: t "r PUBOC.16 g�2_ T• u� /. 41, pFrW�S %`\\\ Page 2 of 2 e9 "c! 9 gi� #g A �. Ytt S i 'q� �rpi �1► i � 6ii4665::5ccce�A lit .........?.... ° �GB Ba � �. 5 1°S `-. ° � \ ¢ @� aEC• '!.I pact°�sieai � €i YRA§ onn`1T, fg Ti______ 11 e9aG9Gaaa6aaea i `� g eICA3a � R5 xa. � ���� FYii iii65 y w'� 3 J61 a 'S @3 Jill NS1Jje jN i s all i� jj-- @5 §p9 § 9� E ai6A b Nil sE $ n