HomeMy WebLinkAboutWEL2025-00009 - WEL Application, Design, Letter - 1/13/2025 584
MASON COUNTY 415N6 SHELTON: , 0427-97 ,EXT 400
SH STREET,
,SHEL-ON,W EXT 400
9ELFAIR:360-2754467,EXT 400
Public Health & Human Services ELMA:3604825269,EXT 400
FAX:360427-7767
UPSON NORM R & MELISSA A
390 W GREEN FOREST DR
SHELTON, WA98584
RE: WATER SYSTEM PERMIT., TWO-PARTY
WEL2025-00009
391 W Green Forest Dr
520097590187
The 2-party water system, UPSON COMMUNITY WELL (52009759018715200975901187), 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
Since
David Anderson
Environmental Health Specialist
Mason County Environmental Health
2 / I$/U175
MASON COUNTY -
COMMUNITY SERVICES
YuLYnp lTn,iM,EU W mM WN.rMYY(n,TUO W N W M
415 N.6"Sbut.(Bldg S)-Shdtoa.WA 98594 WEL Qoc�,5 : octoc)c (
Shclton: 360.427-9610x400 Mi 360-275i 7x4U0 EIArs3604a5269 x4W \
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLLAMi LpNECtL Fhtal P� • fS-8073
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HECONMRYPARCU NUMBER I9AME AS PPoMARY F LCCATEO nN SAME PARCEu
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PAwEL1LCTBl�b%n a) PARCELYLCT 92EdM,1 wy
❑New*VExistiag Well ❑ Spring
PROPOHFp WATER9YeTFl1 XPMEIREpdREdY
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Site Plan: (may also be attached)
(p�rtyboundaries,s,$tNCtU ,,yw.e115fts 100'mdiW,drNeweys,roads,sepdcheweroomporrenbendlines,%star fines,propedyeasements,etc.) y
By,.�,
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Required Submittals Checklist: (additional information located on the first page of this packet)
1iJ Satisfactory bacteriological test from within the last year(this may be deferred if the well has not been drilled yet)
tl Well log and/or capacity test performed by a well driller(this may be defamed if the well has not been drilled yet)
L'Notice to Future Property Owners of Private Two-Party Water System recorded with Mason County Auditors Office
rd Septic Records(additional locating requirements may apply if there is a lack of septic records on file)
Thisform msy be Scorned and asaaable for public Slew on the Mason Ceunty Web she. Revised;12/17/2024
Page L of 2
Staff Use only —_._.._----------
Review Step 1: Well Site Inspection:
YES NO NA ffArSe ^-YO
(� ❑ ❑ 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 va ounty or State.
What Is distance to ROW? ^W
�i ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan)
❑ ( ❑ Is fine well cap satisfactory? Y ovf 01 y twee
❑ ❑ Screened and vented? P r r
❑ The well casing extends I above level ground/concrete slab?(circle one)
❑ ❑ Is there evidence of a surface seal? .. Let: q?-2)1 bT
7 ❑ ❑ Does the seal appear adequate? - Lon: "fZJ 710Of
r❑c ( ❑ Is a variance necessary for well site approval? Ta9 �1(.L j
Comments tWZ Aa41` h u*V,Ly -
it ktftwd by havrzov rm z-//y/20tr g '`
® Pass ❑ Fail Inspector Date
Review Step Y: Two-Psrty Review:
S NO NA
❑ ❑ Water Well Report with adequate pump test on fie? An4dI9 OfYl(rt1.f onI1/3Rapl w/20 Bladder`
If NO,date of Capacity Test Driller_ J GPM -'Tr
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test
❑ ❑ Received Signed, Notarized,and Recorded Notice? AFN 2zZo$N
[ r ❑ ❑ System appears adequate to serve 2 single-family residences based on information providel ww
Comments AN_
W SOd�OG f G4
❑
Approved Denied Reviewer Date Z Ilk Ohs
F'l7
ilk
Findings in this review reflect obsery c,ndluom as they ertsted on the day of the site hupection No claim is made,express ��y
or implied of the fundre success or failure ofthis system. Well site approval does not constitute water system approval. Water
System approval is a two-part process.
All Droposed mrmectiow to new wills are subJect to water adequacy requirements at time ofbudding permit per MCC 6.68.
Water usage restrictions and additional fees may apply to all new wells drilled Oa January 19i°,2018 per FSSB 6091.
Revised: 12/17/2024
This Pnmm y be scanned and av,liabiefor publicA enthe Meson County Web eke.
Page 2 of 2
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WATER WELL REPORT CURRENT
OdeaJa Pmpr-Rmmv,Ymn-- .nd"mn-enum Notice oflatent No wl92rn
y CoostrMclion/Decommission("X"in Circle) Unique Ecolo�We111D Tag No. ALL31s
DConstmmion Water Right Permit No.EXEbBf WELL
Decommission ORIGINAL RWSTALL47TONNotice Property 05vnm Name CHAD a SRAVNA COEBY
`0 1 5757D oflNmtN m6e Well Street Address W REEVES FULL DRIVE (TRACT 4)
C PROVIDGEa USE: mnammd. ❑Iaa:miJ Mmidp.I City SHELTON County MASON
Q On,,.m ❑I,^e.em OTeuwa Ober
a Location NFIXI/4 SE 1/4 Sec 9 T,MI R eve 0..
q ,,roFwDSE: Oa.ere:m,hvofw jgm=nMEN)TRA(7T4
E ®.—well ❑Rmoadiemmd Mn go, OB.M ODD— Lnt/LO WWM
B. ommme CAW O,wm ❑lmee ng(a,4 r Let Deg Lm M alSec
DIMENSIONS: Oia .fo l l ima...... . m a StiII REQUIRED) Long D g Long MiNSec
C Depoorwvp well 80 a
tp CONSTRIH711M DETAILS Tan Parcel No.SRD97590I ST
L c.Jn ®wddre fi Dlw ft.._ft.m so
A lnwlp: L—sNEN - u.m.6vm am a CONSTRUCTION OR DECOMMISSION PROCEDURE
L �rS,eeed ' Dim:.nvmanft ro:m.um.numM b/mbr.abusmr.Jx Nm.viY Wmucove.daeMmme
OPerfonfi.:u: Ye.
ype No weaftlu mumJmemam.mmpeeeeuea wiaulaM:mvySaarh vhmae ar
Tofpm —J mh:m.uw. USE ADDITIONAL SHEETS IF NECESSARY.
WSME ofpeN u by_is mdm.a(pna_fiw_ftb_a RATERIAL FROM TO
Bvemn: Tm ON. ❑K-Ps Lamm RED SILTY CLAY,GRAVQ 0 IB
Mrarm..r.rvve BROWN SILTY SAND.GRAVEL 18 51
O drm Muds aem Model Na. am 6 RED SILT BOUND SAND,GRAVEL 51 68
W Due. Rmds eve 6m n. BROWN SILT,GRAVEL fib 76
.s OnrJThm pmbM: Y. No bsmc rip MM GRAVEL,SOME SAND,WATER 74 RI
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� Yield: W./mia..io REnwMwn Nv hL
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d BIeM1DJe 112I5 Cpmpblae Dam IIOgS
L
H WELL CONSTRUCTION mzKW CAmanal used
the mdrenacceprported above for Due So
ion aseia lodgc an its elief. cewiN ell
Washmgme well mnatructrw SlalldMdi. MMerials usN and Me infomladon reported above R true m my base Imow4ege end belief.
auuD OEvaivmr.D Tmbm. )EDNELSON Orera campmy ARCADIA DRILLING INC,
war./Eva�rmrtmbm 5ignume Addrtm POBOX IT90
nNlmmumee Liana No ISM cW.SmN,mp SHISLTON WA 99594
efTMmEL CmvsV I
Drimr.uem.M n. RV dm No ARCADDINBKI ON,1IMS
Ddllrr;sku.:.n EmlavamEnmlovpmnmin Emplmm.
ECY05al-m(F-Ml) The Deparlmentof Ecology does NOTwarramythe Data andlorinformation on this Well Report.
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285- 11710
2220748 MASON CO WA
01,1712026 03 46 PM NOTCE
Retum To up M X20560] Rec Fss 30X.60 Pap r 2
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meu&s�_ Job ih
310 to EireoH ewes+ t� .
Sl1ea� l,�>g 995b�F
Grantor(s): (1) N (�. sex/ (2) /yELiSSASo.`l
Grantee(s): (1)PUBLIC
Legal Description (1) 0 5�'+�1'1'7l 'PI'N 74- Ib S i3/`1l S 27lttoo
(Abbremated form:i.e.loq block,plat w section, townsh/p,range)
Assessor's Tax Parcel: (1)------------------- 52Ztl97S9O/B7
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) ----------------- 520O9759O187
Tax Parcel: (Connection 2) -----------------------
The system owner is responsible for keeping this system in compliance.
The name of the water system is: j4e aN comm"AJAZ4 WC b
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. ��-�f�(
Dated on this�r=day of(J —, 20
Signature of Gralntor(s : J
Page 1 of 2
State of Washington )
County of Mason ) -
I,the undersigned, a tary Public in and for the above npm�d County and Stale, do hereby
qq�artity that on this day of �+1NUFI5e 20L_J
{Vo6m U/IoN �j B UPI personally appeared before me,who is known to be
signer of the above instrument, and acknowledged that he(she)(they) signed ft.
GIVEN under my hand and official seal the day and year last above written.
otary Public in and f r the State of ashington,
ppy residing at -A1,1A, ti
� ,iySzS'fJ My'commisslon expires: 0 2Y— 2
r _C
( NOTARY E S
PUBLIC ,,�;•_
Sri91F s�oxE ......:�'G'�.:'�
WASMN='•
Page 2 of 2
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cwMy (gar f-I-AOt- (51 zE vn1 W 1Wa.I)
s W IGL;eA,10JT �x�
MASON CpUiv RecordDrawinn
��, Parcel: $2 ool - 75 -`TO/$7
Public Health Owner: Cog 81
Always working for a safer healthier Mason County Date: 7 t 7
Page: Z of 2-.
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UP50N RESIOENCE
301 W CvIRF-F-N FOREST 1)P-
5HELTON, WA 98584 ADAM LANEER DESIGN
a,cFitect,re I con—It,