HomeMy WebLinkAboutwel2025-00004 - SWG Application / Design - 10/17/2027 WA
584
MASON COUNTY 416NBTHELTON: , 0427-97 ,EXT 400
6HSTREE SHEL ON, EXT 400
BELFAIR:360-276 67,EXT 400
Public Health & Human Services ELMA:3604825269,EXT 400
FAX:360427-7787
MCTURNAL WILLIAM B & JANET F
PO BOX 12048
OLYMPIA, WA 98508
RE: WATER SYSTEM PERMIT., TWO-PARTY
WEL2025-00004
1057 E Crestview Or
320227790011
The 2-party water system, MCTURNAL 2 PARTY (3202277900111320227790022), 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 360427-9670 Ext.353 or email at
danderson@masoncountywa.gov
Sincerely,
a-
David Anderson
Environmental Health Specialist
Mason County Environmental Health
2/'/91/2025-
AA
MASON COUNTY
COMMUNITY SERVICES _R_eAAr R¢Ire ay
Surdp P6mAg Emimrnrul H W IA CommunMy X W M
IISN.6m Sn«t,(Bldg B)—SIIeltov,WA9R5R4 WEL 20Z5_000 q
Shelton: 360427-9670 x400 Hdfalr 360-2054467 x400 Elme:160JR2-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPl1LANT PRONE
e«4, fT.taCi i KW L u
MAILI AWR SE-STREET,CITY. .SIP ` I_ 7�
$n A RESS-R EFT,LIryr.PYl�YfI� YfJ W Shelton w,4 *QSIS.d oz
PRIMARY PARCEL NVMSERIWELL 611[ItjU
' Zu2z -4�- 9oe�.1
$ECONOARY ARC �O... PLICASLEI - V
WATFR9WRCE Z S°°RCE TYPF PARCELIL°T e¢E l PARCEL3LOTme
ew ❑Existing eg O Spring Z S' z.J
PROPOSE°WATER SYSTEM NAMEIREOUIREOI
u��
PROJECTARRUMPTION
DIRECTORS TO m V ConoITMNS �✓�i _
Site Plan: (may also be attached)
(property boundaries.
structures,well site w1100'radius,dnveways,wads,septitlsexer components and lines,easements,etc...)
Submittals Checklist: (these additional items will be required for approval)
19 Satisfactory Bacteriological sample(this may be defamed 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)
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 view on the Mason County Web site. Revised: 10/13/2021
Page 1 of 2
- ------------------------------------------.--Staff Use Only—
Review Step 1: Well Site Inspection:
Ikr✓18 1 j� 4wc1y
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 private, County or State.
- --- - -......rrr- -- -- - What is distance to ROW?-
❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan)
❑ ❑ Is the well cap satisfactory?
❑ ❑ Screened and vented? /III
❑ The well casing extends a above level ground/concrete slab? (circle one)
❑ ❑ Is there evidence of a surface seal? 1.01f. jV 12 91
❑ ❑ Does the seal appear adequate? Loe)., -121.0149G
❑ 06 ❑ Is a variance necessary for well site approval? 1 p0! $pip 06l-
Comments J
Pass ❑ Fail Inspector Date
Review Step 2: Two-Party Review:
YES NO NA ��"�
I� ❑ ❑ Water Well Report with adequate pump test on file?AdrwcYA Dr"(J'H 1U�f i�iyt�/ ZI ^pr z40Mv1J
r t (> 5��
If NO, date of Capacity Test Driller GPM
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 10 i 2
❑ ❑ Received Signed, Notarized,and Recorded Notice? AFN 2 Z 17 ZL
❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments /
Approved ❑ Denied Reviewer Date 7 7(�/GQ l5-
Findings in this review reflect observed conditions as they existed on the day of the site inspection No claim is made,express
or implied ofthe future 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 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 FSSB 6091.
Revised: 10/13/2021
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
RECEIVED
OCT 24 2024
WATER WELL REPORT iNDLPARTMLNI Dr Rm;cc oflnN•nl No. WE57M WA State Depart7Net;t
ECOLOGY unyner ulmywall nTag No. BpN087 of EoolM (SWRO)
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bm9a 9eok aYa ❑Nu To whm dm? 19 A, GRAY CLAY AND GIUVEL 140
UWNTONIIECRAPDiexwomm<mmmumabkwaxrr �Ym MNo GRAVEL SAND WS 150
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WELLCONSTRUCTIONCERTIFICATION: InmirvclN nnd/m naepl wspmaiM1ilityf cunslvaim ol'lhiscell,aM iu nmplNme wishell Weahinglm well
mnirvnim sNrdmN.Metmiels Ined mld the imfommtiom rrponed oboe man live to my bat kuuwlc-0gc arW bvlicf.
71Mlla❑Tnkm C FE-Print Nolan ROBERT LAYMON Drilling cmwmny ADVANCED DRILLING LLC
Sipoomm, ,...e.i+.i Addmsv 11530 SCHOOL LAND RD SW
Lkm a No. 2588 City.St.,/Ji a ROCHESTER WA M?9
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Thurston County Environmental Health
412 Lilly Rd NE ♦Olympia,WA 98506
x'nunamweoalvrr
360 867-2631
COLIFORM BACTERIA ANALYSIS
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412 Lilly Rd NE•Olympia,WA 98506 l
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Return To _ 217322 MASON CO WA
1 /21/2024 02:61 PM
NDTCE
�`«('`` ur304GUW� IITAIIIIIqnIIIIIIII7IIIII�IIIW�IIIIIIIIk�III�I911111N
/�L`�iuOM wrt 48ab� _
Grantor(s): (1) 1ul' v , (2) �aa� IGf4A�iLJL�
Grantee(s): (1) PUBLIC
Legal Description (1) - /1,4LT
(Abbreviated rm:i.e. lot, block,plat or section, township,range)
Assessor's Tax Parcel: ��_0_ s!.-��-�
Se.i_ 2� `P 2 L) fL3
NOTICE TO FUTURE PROPERTY OWN IRS OF PRIVATE TWO-PARTY WATER SYSTEM
I (We)the undersigned grantor(s), certify th t the water source located on the above-described
real estate under Legal Description (1)an Assessors Tax Parcel (1) situated in Mason
County, State of Washington, has been de ignated to serve a source of water to the following
parcels situated in Mason County, State of ashington; herein described:
Tax Parcel: (Connection 1) .?.,,, V -� -�1L d L
Tax Parcel: (Connection 2) ? S �.-�- - 9 —/ 2Z
The system owner is responsible for keepin this sys m in compliagce.
The name of the water system is: �' LC/
This system is designed to provide for two ervice connections. Planning an design approvals
must be obtained from the department prio to expanding beyond this number of services.
Additionally, a water right, obtained from th Department of Ecology, is required if the water
system exceeds exemption standards.
This system (has/f no been granted on i or more waivers from specific provisions of the
regulations.
Dated on this_jLday of , 204
Signature G or
(1) (2)
Page 1 of 2
State of Washington )
County of Mason
I,the undersigned, a Nq�ry Publ' in n for the above n ed County and State, do hereby
certify at on t _da of , 20 ,
L rsonaily appeared before me,who is known to be
signer of the above instrument, and ackn Wedged that he(she) (they) signed it.
GIVEN under my hand and official seal th day and ye H st a e wriIt
...nmHH....�.
o_•o�ggR SEta'
yg10H F;z . �4 No Publi and f the State of W shington,
NOTPRY gym; ; residing at °
0 2303&126 = My commission expires:
PUBLIC '2
%%6Hrx��MW,J
Page 2 of 2
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