HomeMy WebLinkAboutWEL2025-00013 - WEL Application, Design, Letter - 2/14/2025 MASON COUNTY 415NB SHELTON: ,SHELTO70,EXT 400
SHELTON:3fi0-027-9670,E%T 400
BELFAIR:360-275- 467,E%T 400
Public Health & Human Services ELMA:360482-5269,EXT 400
FAX:360-027-7787
BROOKS JARED A & BRITTNEY L
4260 W SHELTON MATLOCK RD
SHELTON, WA 98534
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2025-00013
4260 W Shelton Matlock Rd
420221300020
The 2-party water system, Brooks Farm Well (420221300020/420221300020), 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
/W10 ?5
u� FEB 1 IJ
MASON COUN Rmow°' Q2- IV- 2625
TT COMMUNY �m MR d.x 560 RWW�6
aJaJtliq M°mina ervrnneMd xa°INt Comminity HmXM1
415 N.6"SaceL(Bids 8)-SWton,WA 985" WEL 2025 • Ooo -5
Saeltm: 36P427-9670 AW Belfeir:360-275-0 67 x400 Elm 360482-5269 x400
TWO-PARTY
�P PRIVATE WATER SYSTEM APPLICATION
APPISRM fir 1'-1���(% P E -
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Site Plan: (may also be attached)
(properly bouroaries,sbudures,well site WIDO'radius,ddseways,roads,septlGaewer compenem and Imes,water lines,property easements.etc.)
Required Submittals Checklist: (additional information located on the first page of this packet)
� Satisfactory bacteriological test from within the last year(this may be deferred if the well has not been drilled yet)
,H'Well log and/or capacity test performed by a well driller(this may be deferred if the well has not been drilled yet)
0 Notice to Future Property Owners of Private Two-Party Water System recorded with Mason County Auditor's Office
SL,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: 12/17/2024
Page 1 of 2
Staff Use Only
Review Step 1: Well Site Inspection:
YES NO NA
❑ ❑ Evidence of existing sources of contamination within a 100-foot radius of the water source?
(drainfelds, tanks, buildings; indicate distance on plot plan)
❑ f ❑ Are there roads within a 100-foot radius of the water source?
r Is the road Private, County, or State?(circle one) Distance to the road(s)
❑ ❑ Does the ground slope away from the water source site?
❑ ❑ Satisfactory well rap?
❑ ❑ Well cap screened and vented?., ,
[I The well casing extends �O above level ground 1 concrete slab?(circle one)
❑ ❑ Evidence of a surface seal? Let: 4i.IOM
[� ❑ ❑ Adequate surface seal? Lon: -I V.(III;
❑ F ❑ Variance necessary for well site approval? Tag: 6 MIS(}8
Comments:
pJ Pass ❑ Fail Inspector Date Zr[rJT
Review Step 2: Two-Party Review:
YES NO NA
❑ ❑ Water well report(well log)with a conwrrem capacity test?
4R'ur ❑ Nonconcument/separate capacity test? �t
Capacity test information: Date 1 Z d NO Driller fi Ort'I�t�S
i
GPM 30 Duration (minutes)/Toottal Gal
/
2r Satisfactory bacteriological analysis? Date of test ,
�rlVVV ❑ ❑❑ ❑ Signed, notarized, and recorded notice to future property owners?AFN ZZZ
I(J`y,•, ❑ ❑ The system appears adequate to serve two connections based on the information provi
Comments: d/gsoNeCli 'y.4 vy�
Approved ❑ Denied Reviewer Date 11�1Zcr
A�
Findings in this review,reflect observed conditions as they existed on the day of the site inspection. No claim it made, expr /�'
or implied ofthe future success orfadure ofthis system Well site approval does not constitute water system approval
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 drilled after January 19*,, 2018 per ESSB 6091.
Revised:02/04/2025
This farm may be scanned and made available for public voting on the Meson County weMits.
Page 2 M 2
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Thurston County Environmental Health
412 Lilly Rd NE ♦Olympia,WA 98506
360867-2631
TNl]nfiIUN CAIMfY ,
COLIFORM BACTERIA ANALYSIS
Dale Sample Co1WWd Time Sample County
eall
rmw ors Year :
Typeof Waarr Systam(cmx*cnlyone box) ❑ Pnvele HousehoN�9.
❑Group A ❑GroupB
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
D#
System Name:
Contact Person:Jvt ✓e/C rC vle 'r t
D :(3EG1 cell Phone n (2-
mPn Eve.Rmne:(
Sendmeulbb(P.J�lul am,aMaesemvP Wtlewmalemmul
SAMPLE INFORMATION
Sample collected by(name):
Spelift location or address where sample coileced: Special instructions or warrants:
roc Zy'Z'WJ ,1746
-Type of Sample(mustcheclr ony one box of#1 NmWh#41is4M bebw)
t Rou#rw Distnbullon Semple / 2.Rawl Sample(after urea[routine)
Chbmaled:Yes_Nc_ ❑nisNbulion System
Chlonne Residual.Total_Fame_ Chlorinated:Yes_No
3.Raw Water Source,Sample Chbnne Residual:Total_Free_
❑E cold-GWR(AP)
❑Fecal-s�,awl,a m,,lnu.l Unsatisfactory retina lab number.
Flared.Yea Na
❑Assessment Monibnrm(AIP) Unsabslaclory rose.colbc[dam:
❑Orher 11
s
4. Sample Cogeo for tuormation Only
Investigative Construction/Repabs ✓ Otaer j
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsedehetory Total Conform Present and ❑$atsfacbry
❑E cofipresent ❑Egli absent No Cablandetecded
Repkcemerd Sample Required:
❑Sample be ob(>30 hours) ❑TNTC ❑
Bacterial Density Resulls'.Tota'Colifmti 1100m1. Ecob 1100.1.
Fecal Collorm I10Uml Enterocoma H00 mi.
Method!Gede:JASM 9223E ❑SM9222D oaluacd Tlme Rerevu
❑SM 92158 ❑Entend.0
DaeanLT'me Analymd: Dare Repodedl
sempbuumbrm]I nunapnlu�lrveeigire) Lab/ lyp y:
0 8 0
IXMI rpm WLT9lnrr]11rza1
2221708 MASON CO WA
02/14/2026 91 49 PM NOTCE
BROOKS F3C6493 ReC Fee $304.50 Pages. 2
1I11111IIINIII II11111IIIIIII1IIIIIIIIIIIIIIIIIIII1IIIIIIIIIIIIIIII
Return To
9� f+�rco%d
r11 / 2ct
'AaHon W t 96T,;&
Grantor(s): (1) 1 7avY Z 4- (2) "Irl frl Cif G,
Grantse(s): (1)PUBLIC ,50�68�— S7wrYey 1517"/
Legal DeS iption (1)�[�fnF
PLfy9f2/6H6613 (Abbreviated TOM!.9 lot, block,platorsecbon, township, rangy ,
Assessor's Tax Parcel: (1)-1?1-=&-- - - - 417-02-7-J3o-60 Z p
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) ------------------------------- ��2-Z13 L5Tt0 Zl7
Tax Parcel: (Connection 2)-------------------------- ���
The system owner is responsible for keeping this system in compliance.
The name of the water system is: '-T�k-I (/VaIll
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. �}{/� ��'y,,/�'',�,,',r{�J-
Dated on this ` ' clay of J��D` ( 20-Lr
Si re of Grant ^s (2
Page 1 of 2
i
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 Zday of a 20,LG ,
.\Aral A.VArQ0I52 lVAkTW1L.IkcoY4persona 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.
KAENLI E MCAULEY Not ry Public in and for the State of Washington,
otary Public residing at 6Z& w L cr E srfen u-t%RFiSffi(
state of Washington
License Number 22037380 My commission expires: AarkAnl 20, o-&�
My Commission Expires
January 20,2027
Page 2 of 2
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