HomeMy WebLinkAboutWEL2025-00007 - WEL Application, Design, Letter - 1/22/2025 MASON COUNTY 415N6TH ELTON 0427-9 , 400
SHSTREE ,SHEL ONN, EXT 400
584
BELFAIR:360-2754467:EXT 400
Public Health & Human Services ELMA1360482-5269,EXT 400
FAX 360427-7787
CLAFLIN ET AL ANTHONY R & ROLENE J
211 NE SANCTUARY LN
TAHUYA, WA 98588
RE: WATER SYSTEM PERMIT. TWO-PARTY
WEL2025-00007
211 NE Sanctuary Ln
322127600130
The 2-party water system, BBD Springs (322127600130/322127600130), 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,
/9'
David Anderson
Environmental Health Specialist
Mason County Environmental Health
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COMMUNITY SERVICES momRxMaa R�;W4s
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415 N.6A Sheet,(Bldg 8)-Shelton,WA 98584 WEL 2025- 00007
Shelton: 360427-9670 x4DO Beirut:360-2]5-446]x4W Elmo:3W4825269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
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PRIMARY PARCEL NUMBER fwhE SREI
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S ECOXnRRYP LEL FAIR ER is APPI�ABL
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WATE2WZRCE Z TZ6 aVll 80URCE TYPF PRRCFLILOT BnB P 18
❑New Existing Well ❑ Spring
PROPOSED WATER SYSTEM NAME IREOUWEO) N
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Site Plan: (may also be attached)
(property boundaries,structures,well site w1100'redius,driveways,roads,septic/sewer wmponents and lines,essemenr,ate...)
Submittals Checklist: (these additional items will be required for approval)
Satisfactory Bacteriological sample(this may be deferred if well is not yet drilled)
,I
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 fie)
This form may be scanned and available for public view on the Mason County Web RRa. Revised: 10/13/2021
Page 1 of 2
_.._------_---------------_----- Staff Use Only ----------- ._...------
Review Step 1: Well Site Inspection:
NfNSB S.S
YES NO NA RV 1,'1 (AV f[(HT. dvV
❑ ❑ Evidence of existing sources of contamination within a 100-Toot radius of the water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
❑ ❑ Are there roads within a 100-fool radius of the water source?
�q Is the road Private, County,or State?(circle one) Distance to the mad(s)
P ❑ ❑ Does the ground slope away from the water source site?
❑ ❑ Satisfactory well cap?
❑ ❑ Well cap screened and vented?
❑ The well casing extends 7T7—above level round oncrete slab?(circle one)
❑ f ❑ Evidence of a surface seal? Lat: 147.41671
❑ ❑ Adequate surface seal? Lon: -IL3.OI 11
❑ ❑ Variance necessary for well site approval? Tag: 6LN16%
Comments: -Well ►lof wM ty ocovil)
y S:M & le,cG/ 71Z'iItOZr P" yy �'ww� Ir
Ara
ss� Fail Inspector
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Review Step 2: Two-Party Review:
YES NO NA
J I�I���IIII ❑ Water well report(well log)with a concurrent capacity test?
❑ 0C1 ❑ Noncencument/separate capacity test?7777 Capacity test information: Date466Driller
GPM Duration (minutes)_G-P7D�/�/
Q0 ❑ Satisfactory bacteriological analysis? Date of test
/❑. ❑ Signed, notarized,and recorded notice to future property owners?AFN 2 Z Z)
❑ El The system appears adequate to serve two connections based on the information provid Ro
Comments: %ot FFBZ
Ly Approved [I Den ied Reviewer Date Z'Z (h
/ Findings in this review reflect observed conditions as they existed on the day of the site inspection. No claim is made,express H `
or implied ofthefuture success orfailum ofthis system. Well site approval does not constitute water system approval
Alt proposed connections to new wells are subject to water adequacy requirements at time ofbuilding permit perMCC 6.68.
Water usage restrictions and additional fees may apply to all new wells drilled after January 19a,2018 per ESSB 6091.
— Revised:01/10/2025
ThIsform may be scanned and made available for publievlewlrp m the Mews Countywebse e•
Page 2 of 2
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Thurston County Environmental Health
422 Lilly Rd NE•Olympia,WA 98506
360 867-2631
Txu Ncootany
COLIFORM RACTERIA ANALYSIS
DaWSamp"On"cted Tame iaoay Sample County
Collected ow
Mbnh one w a : ISM maset�
Type of Water System(chedc only one box) ❑ proper Household
❑Group A ❑Group B 00aau Lg18 ?X T(
Group A and Grow B Syslems-Provide hum Water Facilities Imenrory(wF):
ID# _
System Name:
Contact Person: Ti IA
Day None: 1 COD Phone:(1tX5 I Is I523
E-muL TCLR lic LARsawneaurato yn L, va.Plgne:( )
m�xt�n4 e aranalamrnsl
SAMPLE INFORMATION
Sample mpeded by(name):
otn -kly�'w ckGfk N
Spxificbwtian araddreaswheresample roll ed. Spacial inaW w CAons or mmen6
'LIl rd— SGrsCA-V.
'cake A WA CLi
Types Sample(tmal chakonlyaw box of#1 through#4listed below)
1.WRouNne geWbutlon Semple 2.Repeat Sample(after umat routine)
Chlodmted:Yes_No_ ❑Diabibulion System
Chbdne Residual:Tolel_Fro_ ChbMetad:Yes_No
S.Raw Were,Source Sample Chbdne Reudual.Tolal_Fme_
❑E mli-MR(AP)
❑Fecal-sane,Gwl,rpwge emmmwl Unsatstacbry routine lab number
FiawM:Yes Ng_
❑Aseaeament Moulam9(A�P) UnsaNefoolory rouble mIW dale:
❑Goer
S
AQ Sample Collected for Information Only
I...Igm._ ConebucDon/Repays_ Other_
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Umatlsfaday Total Coliform Ptewmand hcfery
0Ecc4 present ❑E.cobabsent o deYcled
Replacement Sample Required:
❑Samplebcobp30hmrs) ❑TNTC ❑
8actedal Density Rewlb:Tolel Coliloon HOOMI. E.co# /10Dm1.
Fecal Colifolm I1DQrl Entemmcri /100 ML
Method Code:tAM 9223E [ISM 9222D DataaMT to .
❑SM9215B ❑Enterotedb 9-n'74
Dalew memwyoad'. DaleP
u@mw Wndar( .a.'..cwl LabluOnly:
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2221983 MASON CO WA
C1WL/ 005 01 50 PS NOTCE
CLRFLIN t20fi]03 Ric Fee 3304 50 Pages 1
Return To 11111I1111IN11111ININ1111911111111111111111111111
`
� �1 1 cxry LC��tt°
T& 'i 01� 5ep' GCS! �vl D
�;� FEB 2 4 2025
Grantor(s): (1)
Grantee(s): (1)PUBLIC
Legal Description (1) r�
(Abbreviated to=:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) L 1 -Z b
NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM
I (We)the undersigned gramor(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 J, 2k,k Z- z b - O O 1 3 a
Tax Parcel: (Connection 2) 3 ,� -.;k— 1 ';L - '7 b - D O \ 3
The system owner is responsible for keeping this system in compliance.
The name of the water system is: 1'.:� 1 1 b T bl9 r-
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.
Dated on this �_'A day of 1'zb (' , 20,0.
Signature
(1) a4o�/ff Grantoorr(s): t`�t
m , (2)
Page 1 of 2
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 thisoZLOIA day of 20 r ; ,
An4mu R CaaFl n pe nally appeared before me,who is known to be
signer h�e instrument, and acknowledged that he(she) (they)signed it.
GIVEN under my hand and official seal the day and year last above written.
r,onnwu*
of cg-P r the State of Washington,
esidin at SbUJ/w U A C�R1
pOfARY ;: M mmission expires: O7�19-.;2 jx
209271 _
PUBUC .
k`7wyuW�N,M"
Page 2 of 2
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