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HomeMy WebLinkAboutwel2025-00017 - WEL Application - 3/25/2025 ON, 584 MASON COUNTY 415 NB THELTON: ,SHELT967 ,EXT 400 SHELTON:360<27-4467,EXT 400 BELFAIR:380-275-0467,E%T 400 Public Health & Human Services ELMA:360482-5269,EXT 400 FAX:360427-7787 FRAHM CODY & BRITTNEY 872 EAST DANIELS RD SHELTON, WA 98584 RE: WATER SYSTEM PERMIT. TWO-PARTY WEL2025-00017 872 E Daniels Rd 320112290014 The 2-party water system, 870 + 872 2 Party Well (320112290014/320112290013), 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 D MAR 0 3 2025 ® MASON CO y COMMUNITY S CES YiigPamgEmrvvn,n,Nl NdMCamm�MXetla 415 N.6•Sua (Bldg 8)-ShO.,WA 985M WEL Z025 - 0o�l l-1 ShLl 36 27-%N x4W Bclnki 360-375-4467 x400 Elma:3W482-520 xH)0 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION gpRlL/,BE PIXINE -/ - MRM1Xa/�gnar ORE99 BrREEr.Cn1.8r/,TE3a' aaE gowEaa-srREET,arr,rtgTe,aP PIaMMY PMCEL X V MEER HELL 8nE1 ZO l �ZR c7O1 aECONOMY PMLEL N V NME0.pF gPPIIOJLE) 320 N\ 2z 00 3 WgiER aOURCE 9aIlaCE TYPE P/,IICELI LOT aIiE P4iLELILUTI ❑New ' Ezisting Well O Spring a Ll NO PROPOSED W1TF0.5YarEM X.WEIREWIRE01 1r el �12 2 Y w6ti` PROTECT DEacrlvrwx �1 *0 Got— o L aREclwxe To ertEicanoalDxa la.a L, k S L UUYttSD s&126 U tp"e I U —SttE S S76h Y.N SV— Site Plan: (may also be attached) (propeny bourltlanes,slmclur n,well see w/100''retlius,driveways,marls,septidsewer ca nents and lines,easements,etc...) 5 00 s 0 ' = 6AssnEvr Submittals Checklist: (these additional items will be required for approval) 6 Satisfactory Bacteriological sample(this may be defened if well is not yet drilled) 91 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) jff Septic Records(additional locating requirements may apply if there is a lack of septic records on file) T is form may be scanned and available for public view an the Mason County Web site. Revised: 10/13/2021 Pape 1 of 2 -----_------_----- Staff Use Only -- Route Step 1: Well Site Inspection: ' 1-k&AC ( M YES NO NA (lv I' �] ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water scurce? (dminfields,tanks, buildings; indicate distance on plot plan) ❑ t ❑ Are there roads within the 100 foot radius of the water source?If so, is road private,County or State. What is distance to ROW? 1,./] ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan) ICf ❑ ❑ Is the well cep satisfactory? ISR ❑ ❑ Screened and vented? (� t r ❑ The well casing extends Z I r, above level ground/concrete slab? (circle one) ❑ ❑ Is there evidence of a surface seal? ts{•, 4?.Z4ltV r� ❑ ❑ Does the seal appear adequate? tot:. - al-012f Z vR ❑ Is a variance necessary for well site approval? 1'65 ?0151 4. Comments 4f4(t' war • laakd 8 . fro" 1+ /kya &iI kag ,r br danreawrtU'• vfMa � , Pass ❑ Fail Inspector Dale Review Step 2: Two-Party Review: YES NO NA �ry"( ❑ ❑ Water Well Report with adequate pump test on file?q/((r(/i o M(Mg Oq d(l0(2014 V1 ZO Gitry fie.(,Orr If NO,date of Capacity Test Driller GPM (t1Dd)<() ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 3 e ❑ ❑ Received Signed, Notarized,and Recorded Notice? AFN ❑ ❑ System appears adequate to serve 2 single-family residences based on information prole Ad7�©� Comments t Ccet' 2-1261X fP�rAc�fYd �/t y�7a)S' d1gSON` . MqA �(` 0 NM IA.Approved ❑ Denied Reviewer Date 3ZZw? 2 5 `4 l _Firdings in this review reflect observed conditions as they existed on the day oftbe site inspection. No clam is made,express or implied of the future success orfailure ofthis system. Well site approval does not constitute water system approval. Water System approval is a two-pan process. All proposed connections to new wells are subject to water adequacy requirements at time ofluilding permit perMCC 6.68. Water usage restrictions and additional fees may apply to all new wells drilled after January 19', 1018 per ESSB 6091. Revised: 10/13/2021 nb Nrm may be scanned and available for Public view on tiro Mason County Weblike. Page 2 of 2 RFCEIVFD: WATER WELL REPORT 9EPARTMENT of Nolircc ofudmt No. WE39678 ECOLOGY thtigw colop Wk1IDTkgNo.SM5128 TrPadwwk Mawof wRSM1mglm Sirc TVell Neme(iFmmeUmone xeRh�T�o em km ❑ M'ssion .� OdymlvakLLamN01 Na WebT Righ[RrmiVCertiRgm No. Rgmk Urc, mDw Olnd.oirl ❑mokipN Properly"w rNa Bdtlmpa Codv Frehm ❑Ibe.'alr:iq abnW o 13Trxwm 30ho, Well3lml Addren 872 E Dmdtle Rd m ht hmrype: Me1RW mxew—xeu nAhenlbv ❑Odwn ❑IrM ❑CONeTkol CilY 9lMam County Moran ❑Deapemq OWv ❑Dq MAk- nhW-buy Tm1w4No. Ml i-22-90014 m.e t Diamruor6wy 6 b,.238 R. WMevelienceepprovN For Uie xxIlT OYo 13No Jkya:afm:gkw.0 230 A (:.uk.Rm Dewik: WM IFYM,x9M xv the verie:Ra fef? 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P.O.Box 1790 Shelton,WA.98584 Customer: Brittney 8 Cody Frahm Well Tag#:BMS126 Phone: 360-970-3248 Depth: 238' Well Site Address: 872 E Daniels Rd,Shelton Pump Set:220' Date of Test:Oil 2120 Static: 183' TIME GPM LEVEL 1 Min 6 183.4 2 Min 6 183.6 3 Min 6 183.5 4 Min 6 183.5 5 Min 6 183.5 6 Min 6 183.5 7 Min 6 183.5 8 Min 6 183.5 9 Min 8 183.5 10 Min 10 183.5 15 Min 10 183.8 20 Min 10 183.8 25Min 10 183.8 30 Min 10 183.8 35 Min 10 183.8 40 Min 10 183.8 45 Min 10 183.8 50 Min 10 183.8 55 Min 10 183.8 1 Hr 10 183.6 TotW CQ\ICnS?0MPe6 �u C�Q��GnS WGLA�7-5 -060« Thurston County Environmental Health 412 Lilly Rd NE•Olympia,WA 95506 360867-2631 COLIFORM BACTERIA ANALYSIS Dab SWO-Cakded Tine Sa,pb Cbedr Cdb W Wm pry Ya TMdwawSydem ldbdaNyae bmQ ❑ pmmde NmwMld C�G� ❑DrbpA ❑Droops �(D �iI/6ecFrd.w• GMp Aend CM 8Sry0e-ProiM Web,FedINM mm,(WFI): MARpg1p15 1Dd - - - - - - RECEIVED sy�Nam: cmbdva®n: Day PhDM:( ) cal nieb:Ipmm��..�aw.anDmm a.no+.mwl vy TCFm+r"� G. tV6-cat SAMPLE INFORMAIWN Smrybm9xbdby(.): r-4*14M S bcetlon araMMeMmm smnDb mpxied: SpemimWD mmmmMnis: �1Z E •DAwLEd.S ¢o SNE�-laN�Wk �'F$5 fl4 TWbd6mpblmtds 00DMbmdR1dwupNR4bledtelm) 1.❑RDutlMde0lbNon Bempb �.RepplSmpk l.kr uadtmwM) fiMy.ya—ND_ ❑Disbibu9Dn Slsbm CNmMRq"W:Tdal_FM_ Chbnne*d:Yes—ND_ d.RdNWdmSDemeSempk abdne Residual.Tdel_FM_ ❑E.and-GWRWF) ❑Paul-sido.IXllM9l�1 Umekledo,YrouBWleb MrtLr FIwM:Ym_No_ ____— ❑MswMMMrki'uglA� DreekfekrY mdbe mkddeb: ❑aver _1-1— S d. 4mnPle WYcbd rorldomnlDD troy __ Cmmuckn lRepeis— Otler_ LAB USE ONLY DRINKING WATER RESULTS lAB USE ONLY ❑Une.&FctWW Tdd CDpbm Presd and sow-dry ❑Eta4 pmxnt ❑Ealetmnt colibDn eebme ReplRMmed Sampk RK.Ind: ❑SaNb boaN l»p haul) ❑TNTC ❑ BedMd DensYY RaMk:TDW Cddam n9Gn1. EmA ndbu. Fmeltp111am naaml EnbMnDd n99m. IANd Cade: SId9Yl9B ❑8149= ubad Tom Pawwd:0753 W92158 ❑Enb*WW - ab T Mtryd - OebMpaledas' sam.xere.Iopxmwrw DW IabUr aY 0 8 0 • —. _-- nmy tl A n eanl' U 2223116 MASON CO WA 0312"2021 01 4B "F.NOTCE FRP Nlllhlllllhgllllllllllllllll IIIIIIIIII!11111i1ul� lllMIA Return To cony Ti u MOVE D g�� 'ppatc.-L_S Rn S�tc�r�, q 9f24 MAR 2 4 2 5 sy Granlor(s): (1) nntn PMA'FIm . (2) 7_LTTN�n_j �Y�.1"KM Grantee(s): (1)PUBLIC Legal Description (1) LOT- y or SP4 Ztait{ 1>rN w i�2 N ur A_i W (Abbreviated form:La. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) Sit -71 20 — R3 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 l)� -Z— O ��-�Z•1 UQ Tax Parcel: (Connection 2)!-1:- U 1 --2=_q'_- q The system owner is responsible for keeping this system in compliance. The name of the water system is:Rj 0 �LZ kiii CJ`. 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 (ha as been granted one or more waivers from specific provisions of the regulations. Dated on this day of A141UH .20 'Zf Signatur Grantor(s (1) (2) Page 1 of 2 State of Washington ) County of Mason ) I, the undersigned, a Nqtary Public in and for the above named County and State, do hereby certify that on this 2ACP day of 20LS-- EEBIW personally 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 dayand-yW last above written. `;��Q``�GE,.n � ota Public f and for a State of Washington, Q: F �6-Ze2ei�;L ry 9 y'UoF,�ti :•,. residing arD rA tSA NpTAflY _ c �,� ,�; ❑ My commission expires: yc Der- 9G�ZS3' :[. Pl/wr oft= �i��iFOF1WA5kN`t�\� Page 2 of 2 .Jy\Ipp q 5a. 3 BR FFou S[ roa. OAudio-Visual Alarm ® © Cieanout © 1200 Gall— SePtic Tank 2.Compartment with lJ1.0 O E81umt Filter 4 J cc0 D(1-22-9noi4 Oa loco Gallon Fume charm gTZ I�.v el5 Rd 3 Valve Control Box _Shelton vJl4 98584 1� i (5)-5, YV rr�w,aru D.F. Trey,-tn e s w' Fh` Izo Resew�¢ ',n be-twe� N s O N 9 APPROVED ` OCT 15 2021 . ENSEPAu_A:�r�C"NSGN MASON COUNTYEM1iliONMENTALHEALTH 4 LSLiOCm"- ff_, RET m>ix o.,._ �vs ewrrts 5i,3r�'L. q- y,2- 21 322' �SQ15 Rcad - Scdh ,• = (a0r _ r � 0 '60 CID 9C 12D