HomeMy WebLinkAboutWEL2024-00053 - WEL Application, Design, Letter - 12/16/2025 SHELTON,WA
584
MASON COUNTY 415NBTHELTON: , 0427-97 ,EXT 400
SHELTON:360-2759 70,EXT 400
9ELFAIR:360-275-0487,E%T 400
Public Health & Human Services ELMA:360482-5269,EXT 400
FAX:360-427-7787
CLAIR JUSTIN D
751 E MASON BENSON RD
GRAPEVIEW, WA 98546
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2024-00053
751 E Mason Benson Rd
221103290023
The 2-party water system, Clair Residence Well (221103290023/221103290023), 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,
X/
David Anderson
Environmental Health Specialist
Mason County Environmental Health
� lr?o7S
MASON COUNTY
COMMUNITY SERVICES Al An,Rgrvtl: 5d5 R m B 6
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415 R 6A Sheet,(Bldg 8)-Shal ,WA 995M WEB ?0Z11 - 6M66
Rehr: 360427-9670 x400 Bi,f ,360-2954469 x400 Etna:360482-5269 x4W
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
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PRIRARYPARCELNUNBERmELLenE1
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9ECONpMY PARCEL NUMBER(IF APPLICARLE)alE1
N/A
WATERSpUn. eWRCE TYPE
❑New '�1 Existing
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Site Plan:(may also be attached)
(property boundaries,stmetures,well site w/100'radius,driveways,roads,septid ewer comppnents and lines,easements,etc...)
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Submittals Checklist: (these additional items will be required for approval)
Satisfactory Bacteriological sample(this may be deferred if well is not yet drilled)
Well Log with pump test or 4-hour capacity lest 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 farm 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:
-ri)rfrlaf-v4 oaved "it !teed CaltIon 4afd W Ovid d itt'i0i
YES NO NA - LV fbarkd JO frov! laptf
I ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
r (drainfields,tanks, buildings; indicate distance on plot plan)
❑ Lr] ❑ 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?
❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan)
❑ Is the well cap satisfactoryl l aot e{Y well e*M "ON' 60l$ lease
1l61
❑ ❑ Screened and vented?
❑ The well casing extends y above level u /concrete slab? (circle one)
❑ ❑ Is there evidence of a surface seal? Let: YNNYY
❑ ❑ Does the seal appear adequate? Lon:-f 22•q2V I
❑ F ❑ Is a variance necessary for well site approval? Tag: Allil
Comments
- " Pass XFail Inspector Date /tIZI Z01j
Review Step 2: Two?any Review:
YES NO NA
❑ ❑ Water Well Report with adequate pump test on file?TWAY vvw,t or? ZI7;1&a7 w y0 b/e7 fw 0^w �2ya'1�
If NO,date of Capacity Test Driller // GPM
C}� ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test tVzopr
(c ❑ ❑ Received Signed, Notarized,and Recorded Notice? AFN
,LrJ� ❑ ❑ System appears adequate to serve 2 single-family residences based on infomratloB�y
n provided? �q
(Comments COG
�n-
Approved El❑ Denied Reviewer Date '9!
Findings in this review reflect observed conditions as they existed on the day of the site inspection. No claim is made.express
or implied of the future success or failure of this system. Well site approval does not constitute water system approval. Water
System approval is a twopan process.
All proposed connections to new wells are subject to water adequacy requirements at time of building 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: 12/17/2024
Thisform may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
�Em' """ WATER WELL REPORT Nuance '"" '"��'+5
O NI0UEWELLLD.O APQS�
p^ Second,Cap,-Owneh copy �¢� STATE OF WASHINGTON
Thum Opp,-DAlefampy ��SLITILJ Warr Right Permit No. N/A
(1)0WNER: Name BRAD TROUT Ardrr
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(2a)STREET ADDRESS OF WELL(or nearest a lavess) 751 E MASON BENSON RD
N TAX PARCEL NO. 221103290023...
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Thurston County Environmental Health
412 Lilly Rd NE•Olympia,WA 98506
360 867-2631
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2223564 MASON CO WA
0410312025 09:52 Rn NOTCE
CLAIRryI0s�20as0 7 RAw�wNF *'I 30��Cm50 P r 2t1■
Return To
/ Ial� uYl�s� lW
RF�Fy� 1015
Fp
Grantor(s): (1)
Grantee(s): (1) PUBLIC
Legal Description (1) S r/r. S '(c #U SW t✓ .r' MY "t:3 04� 8P 4663 E 4'/oaf
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) a )L 1 1 O _ 3 2 __I O 0 2 3
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: hereln described:
Tax Parcel: (Connection 1) ;L z l 1 0 _ 3 2. - H 0 0 2 3
Tax Parcel: (Connection 2) Z Z l 1 0 _ 'N Z _ q 8 0 Z 3
The system owner is responsible for keeping this system in compliance.
The name of the water system is: U.a, mrid.,c, ya\I
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 (hast has not) been granted one or more waivers from specific provisions of the
regulations.
Dated on this day of'G P 204.
Signature of rantor(s):
Page 1 of 2
State of Washington )
County of Mason )
I, the undersigned, a Kojary Public'n and or the above named County and State,do hereby
Acerti tha on this�_ ay of jC , 20�
� uw ���,�}� personally appeared before me,who is known to be
signer of the above instrument, and acknowledged that he(s (they)signed it.
GIVEN under my hand and official seal the day and r last ve�wten
w.Nnan.Y'n
toafjPuiillc't nd a to of Washington,
p �o+ NOTARY '�^;;• residing at _
': 23038426 : My commissW expires:
's o+�,• PUBLIC ii;;i�3
g49J::!erylrl�.
h4 mil`W�Q"M
NVYYIYNMNN
Page 2 of 2
2223564 Page 2 of 2 04/03/2025 09:52:05 AM Mason County, WA
I 1 �
i
I EXIST. HOME
1
I i
EXIST. TANKS
3RD SURVEY PIN ,
FROM SE CORNER -2
I I
I I I I I
PROPOSEDADU
SEPTICSY5TEM
E%P ES
I I r --- --I EXIST. ATTN.
L- - J I I1 ZONE
PROPO5EDADU yl I�
I I I
I I EXIST. PRIMARY
BE5TGUESS WATERLINE EXIST. RESERVE..
LOCATION: INSTALLER
TO VERIFY PRIOR
TO INSTALLATION
EXISTING HOME
AND SEPTIC SYSTEM
` I AREAPPROX.
LOCATIONS BASED
ON FIELD "SIT, GIS,
� F A�D��ioC�VsED
MC PI IRI Ir HFALTH
1 ��\ NOV 1 7 Z015
EXIST. WELL
`CEW
`oFss
I 7 -
1` SE CORNER
CUSTOMER: JUSIIN CLAI ,
PIONEEP, DIGGING, INC PARcEi.t ZWO-3290023 FST HOCEF TFS HOU2
I ADDRESS: 751 MASON BEIISON RD 1&7o LS cL5 tr¢a5
SEPTIC DESIGNS &67 12-70
30R3 E M N Bw NW caAVE W,WA 9fl DESIGNER: ROBERT PATSSEE
lJF U-3b0-0 IW)3 FA%-%P427-M DESIGN PAGE OF
1