The URL can be used to link to this page

Home My WebLink AboutWEL2025-00015 - WEL Application, Design, Letter - 2/28/2025 MASON COUNTY 415NBTHELTON:STREET,SHELT967 ,EXT 400 SB ELTON:360-027-4467.EXT 400 BELFAIR:360.2754467,EXT 400 Public Health & Human Services ELMA:360482-5269.EXT 400 FAX 360427-7787 VANGELDER KARMA M 2940 E Grapeview Loop GRAPEVIEW, WA 98546 RE: WATER SYSTEM PERMIT. TWO-PARTY WEL2025-00015 2940 E Grapeview Loop Rd 121077700130 The 2-party water system, Existing Well (1 21 0777001 30/1 21 0777001 30), 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 3l`Zol tazs MASON COUNTY ° °R""° COMMUNITY SERVICES q�� W INy%mnip.Ermmmn4l H W N Cwnnwlry XeaIN 415N.bm Sfto L(Bldg 8)-Shelron,WA 985M WEL 2025 - OQOI "j Shelton: 360421-9610 xQO Belfair:560-2754 7x900 Elmo:3W482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION MPLN:LN! MpXE dc 1� c 6o v 7010 uuLwG Aoo ss- Er, ,STNE.W Zg E c e r2e1 loop EIiE ADORES$-STREET,LRY,$iRTE.ID Flo � Cnr ev;e� loo PRI NARY PMCEL XIIYSER IW ELL 91E1 SECDMDMY PARLELNIIYSE ( _EASPRIM4EYn LMATEDONSAME PARCEL) 2l oll o PMCEL1Loi SfflnN Il PARCEL2LM5U(mn1Kn) ❑New Inxisting D&Wcll ❑ Spring S. Z0 PROPOSED WATER SYSTEM NAPE IREWeIE PR ECTOEacRI (e EM}AW nW NqI LMCB.gJMna[Om°ctlm.Mc.1 MA lull OIRECTIONS TO SREICONDMONS(GATE CODEINEY LOCAMN I M. ey Site Plan:(may also be attached) (property boundaries,stmdures,well site wIl DW radius,dnveways,roads,sepbdsewer components and lines,water lines,property easements,etc.) A}kid Required Submittals Checklist: (additional information located on the first page of this packet) , l rSafisfactory bacteriological test from within the last year(this may be deferred ff the well has not been drilled yet) Well log and/or capacity lest performed by a well driller(this may be defened if the well has not been drilled yet) Notice to Future Property Owners of Private Two-Party Water System recorded with Mason County Auditor's Office Septic Records(additional locating requirements may apply if there is a lack of septic records on file) Thisform may be scanned and made available for public viewing on the Mason County websits. Revised:01/10/2025 Page 1 of 2 ------ Staff Use Only -- -- Review Step 1: Well Site inspection: YES NO NA ElElEvidence of existing sources of contamination within a 100-foot radius of the water source? (drainfields,tanks, buildings; indicate distance on plot plan) - ❑ ❑ Are there roads within 0-foot radius of the water source? 4 • Is the road Private, u or State?(circle one) Distance to the road(s) ❑ ❑ Does the ground slope away from the water source site? ✓✓✓ ❑ ❑ Satisfactory well cap? ❑ ❑ Well cap screened and vented? r ❑ The well casing extends _above level ground I concrete slab?(circle one) ❑ ❑ Evidence of a surface seal? Lat: 4p•)f6Jt �] ❑ ❑ Adequate surface seal? Lon: 'f ii,•QS94y ❑ ❑ Variance necessary for well site approval? Tag:A%9X6 ,Comments: Ly Pass ❑ Fail Inspector Data lvl.� Review Step 2: Two-Party Review: YES NO NA E] ❑ Water well report(well log)with a concurrent capacity test? ❑ Nonconcurrent/separate capacity test? �1 Capacity test information: Date IM Z-d 11 Driller �CQ 1.w GPM Duration(minutes)�r. GPD p•I ❑ ❑ Satisfactory bacteriological analysis? Date of test Z/14�Zc S I[ ❑ ❑ Signed, notarized,and recorded notice to future property owners?AFN ZZ IF❑1e ❑ ❑ The system appears adequate to serve two connections based on the information provided? % n Comments: A I vUIIII$ Approved ❑ Denied Reviewer Date Findings in this review reflect observed conditions as they existed on the day ofthe site inspection No claim is made,express or implied ofthe future success or failure ofthis system Well site approval does not constitute water system approval All proposed connections to new wells are subject to water adequacy requirements m time of buildiag permit per MCC 6.68. Water usage restrictions and additional fees may apply to all new wells dniledafler January 19`^, 1018 per F-SSB 6091. Revised:01/10/2025 This form may be scanned and made available for public viewing on the Mason County website. Page 2 of 2 Please print,sign and realm to the Department of Ecology • CLd,mt Water Well Report Ploticearfbm a. WIN31Tetx orlpaa-[mw.E+mbd- .Ad eaq-mm. i'!1•l't i� Uvique Ecology Weg ID TegNo. A1LB'1M cc,lhactloa/Dacommisdaa Water Right Permit No.IDrm6PD WHLL 0Coutmctioo ❑DecommiasiOD ORLOINAL MTALLATLONAb&M pmpaty Owoe Name NARILh VANGff D OJlnfeorMunbar Well street Address MOE 13RAVEVIEWLCWROAD taoposID ude: MD. B ivemea eibua0r City DMAPBVWW Canty ❑oew.m ❑mpsm Tmwat oer Lund.S11,14M SWUd See? Two 1g R1W aw rues rt'womc: D®e(.vmbaefwal(Hmedmmdj wwN a ❑De w pae®aamad :Oovme ®nasal 1 d A Dvg(a,t,r Let Deg_Lot Wm/sec ple¢nslons:name:bafwm 6 �—M IN A. dBIREQUDtID) L.SDaS.LODEMi1Aee_ Depb Pfampaw] tm M1 Tm Pelael No. 12V77100131 LTINSIIIIIClmX DETAILS ®twaw 6 Dam M1am}j�Am,]]�_M1 ��—�bo ;:D HDOTSONORIIHOOMMMONPADCPDUES Farmgratmd.maa.r®Pfaabeamemum.e,sm tlsloa6mG {4famboe YB No mar ,bI®ENWvmmtle'N,�l MAMRI .HOCK 0 1 btm:anme'r lhm T w — SILTYCGY-GaAVBL ^m� 1 6 _aa�__6® M1b t TS GHAY SLLTHOOND SAND AbID OAAVH. A v..,a:Farp_mL: Te__ Ib �p SbcofM__aA.aa BROW Ci.AV111.WEf Sa..... „ ...__._ .. SD.ITSALeD.QAVELHGVING WATER lls 165 >bfan SmE:mYe ❑Na To madamM M1 SAND oHAVFL AEID IMM 10 ISO Natal uelbaW••'•••••• OdmTNamavemaNewlr(f ❑Tw mW TyprefWt! D:4bofYm 1Aa .feaammYPR 1111@:EeoJmedellm RP. lypc WATHRLBTm.0 LrN ,uwamee.eePam.mlwa M1 9eYcmd 65 M1baawbpofwS D+C I1I1601 An®P:� b.R.WmaVerA Wc— M owiaiemmabdby w U,xSPY:daWo h-.-wwtwduloavNW.&Aclna YASe Pbp>m°• Oy. Olio Vdm,bywb aaA ml,laa wb M1aeammwlb W Yldd mlAm.r A WbW n+mama � amnarapc.lab:mteo wYegarnrdPdJ dads lawisss�edfod ybw<W fl¢ Warlwa l:m YAdwlaaa Ifine 5lalaLara hbefbe — elaw_W/mart Adnadem Yw�:A Nam>p_yAmwWmraa l6fl Dft bm .Ndmeaa m�+ impvdveefwaa_Wbe detlm rWTare•06 0Tb mNP 11Od'Nd 81rt 011e 11113101 Oonpmea We WELL CONHTRDCIPON C,,X=CATION: I eooamcled md/m emeptnapoaubaily fm cOndn"m ard'swdL mdib eompbmae 5rilh ell Wediaatov well eomWSEm amdmk. Matmelsused mdthe ivfo fioerepaded&bow m buetov bestlmowkINe svdbeEet p TaRogarmlwaee Nme(PadD FDA GN Cneiagcmpm➢ oaabgaa:aapDsbe:na.mc � Aamv 1790 caamaarl wmfaB M. HydnY®lb..nr.nnmoo¢l Dtla I1 TDI aay.aa.rm Emlmbmrqul GPpadufg-Plea. WY am.I.ID QIn Aan =76T+etve _—�- T"IaNW �c AA " SPECTRA LAboraterics Kitsw mw (s6WTro s161 COLWORM BACTERIA ANALYSIS FORM DO Bomb caYaa6 rms.Wa carp al l ! caY ? a ou o, o� !no sir G WAr G6WBSptl -P*Na Wlr .w DYAs 106 ce Canl6tl Pais �' Dry Plw CN FMre: Eeai .__ Eve PM.: E,uq��li7aa-e� '(�eahmcvd- SAMPLE NFGRYATNNI SWA,NmNr6rha W. d S a� sP.ftEisfon.hae wpemk<ALL sPeaa6madbaaowwAc ktL.e n Si nk TSFrrlrpY laad66t/ala to +.�R.+.LLtaareB.Wt.LAq tOwFws6.P6W►1 Yn ❑ No$P LLYrLe�al�wwaW..r.rrp t6.awmrr".wn.e.r. CNRYrRolAmtroW_fm_ lOs�6WaYraYl'aro Ll.epa UnselkhrbynabMm,R1Mb: s I I I Ch aa6:Yn_Ro_ ❑Tqp vW) C eRcal6.el:ToW Fea_ ❑Awm'eM(A➢) IB�Ir+ar4Y11RslwuWtlr9wp(Enrtxiatiml a � � ❑ E WN ❑FUM r rn_ i •crwrrr..+r�o.y. LAD USE OILY MIMON WATER RESULTS LAB USE ONLY ❑LL..ws sryTaatCafAnn PA..ar ftbba r ❑EcofpYe6 ❑ENe0w6 Beelrld O�wAr BM6:TOY Co�aan_�Jt60al Ewf_aNrt 60mL fefJl Cafbnn._._ _o1W1sOM H'CatYa/. Lt pm.ABrWb Aw+� E17mc ❑s.Wr wo O Sm*Vole+ ❑Dawp6r 0 WrfwRYlwt \V�� tyr D IlwLTgyC �O`� aieaWvm,toWr A19IIA k I FES ...r. ._„�. �.. Y�YYInw.YYM�'in�.uw�� "L*a. bs 5- W� w�MW1rT�Y�Y�Ye�O 0 O� Y`M`ie1Me��iA�ly6iYY/Y� Spectra Labs -Sitsap,LLC (Poulsbo) SPECTRA Laboratories -Kitsap 26276 Twelve Trees Ln NW Ste.C where experience n ffe.s Poulsbo,WA 98370 Phone:(360)779-5141 www.spectra-lab.com Spectra Labs-Kitsap,LLC(Poulsbo)received samples for Evergreen Water Treatment on Tuesday, February 11, 2025 at 2:00 pm. Unless otherwise noted,all samples were received in good condition and were tested in accordance with the laboratory's quality control procedures.A summary of the samples received are outlined below. Sample No. Description Location Sampled 248517-01 Tyler Kitchen Sink 02/112025 8:00 This report package contains laboratory sample results and any attachments listed below. If you have any questions please call (360)779-5141 or email us at www.spectra-lab.com. Attachments 01) This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at 360-443-7945 and destroy Ibis report promptly. These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall net be reproduced except in full,without prior express written approval by Spectra Laboratories. 02n5am Page I of 1 2222905 MASON CO WA 03I1812025 02 00 PM NOTCE Return To r Nt CL,'K�t Eisk 5v `d MqH �� v eW �/A RF �O'?o Grantor(s): (1) IL4.✓ ",Rk Grantee(s): (1) PUBLIC Legal Description(1)_57i 172__I i R1 (Abbrevietedform:i.e. lot, block,platorsection, township,range) Assessor's Tax Parcel: (1) 1110 77-7 - Wl_-',O 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) 0-1(0 Zl-7- On 1 '�O Tax Parcel: (Connection 2) Q_\0 l=f -1- On 13n The system owner is responsible for keeping this system in compliance. The name of the water system is: w e l l 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. th Dated on this��day of Aumn 20 . Signature of Grantor(s): Page 1 of 2 State of Washington County of Mason I,the undersigned, a r�ry Public ' and for he above named County and State, do hereby certi that on this r"r7ay of , 20-0±�, A personally appeared before me,who is known to be signer of the above instmment, and acknowledged that he (she) (they) signed it. GIVEN under my hand and official seal the day and y last ve wr'Ka . O u ic ' for I ate of Washington, a+ NOTARY mN; siding at 23038426 _ My commission expires: =; N+., PUBLIC •'�2, '•'��FQF WAu �wo. Page 2 of 2 Nov 22 04 09: 54a //Bob 6 Patty Payaaa 360-427-2353 p•4 • fC ail M0 Ll4N frl'i Dfi2 tOL10 Do 30 Z0 t O (rQ• t qG fG U j=as; ✓N%"f j KO O -p1Zi U vi sit `/ i • V C dC H W .I • 7 G X i.+ U Z _Q 3 O vNi a0 L a+ W a V) _� C LLI I O = y m J O o a r p d = N O a� 00 a Ns W � xo S� i:F;