HomeMy WebLinkAboutWEL2025-00019 - WEL Application - 3/24/2025 MASON COUNTY 415NBTHELTON:30427-97 ,EXT 404
6HELTON:360-275-4467,EXT 400
BELFAIR:3fi0.275-0487,EXT 400
Public Health & Human Services ELMA:360482-5269,EXT 400
FAX 360427-7787
PHYTHIAN ROGERAY D & SCARLET
763 SE OLD ARCADIA RD
SHELTON, WA 98584
RE: WATER SYSTEM PERMIT., TWO-PARTY
WEL2025-00019
763 SE Old Arcadia Rd
320224690142
The 2-party water system, Roger Phythian (320224690142/320224690142), 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,"�/
e
David Anderson
Environmental Health Specialist
Mason County Environmental Health
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TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
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SECONDARY PARCEL NUMBER ISAMEA9 PRIMARY IF LOCATED ON SAME PARCEL)
SOURCE� bF��� PARCELLLOTS (eI 1wml PARCELS LOT
❑New V�Existing M.Wcll ❑ Spring
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Site Plan:(may also be attached)
(property boundaries,structures,well elew/100'radius,dnveways,roads,septidSewer components and Imes,water fires,property easements,etc.)
Required Submittals Checklist: (additional information located on the first page of this packet)
Satisfactory bacteriological test from within the last year(this may be defamed if the well has not been drilled yet)
Well log and/or capacity test performed by a well driller(this may be deferred 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 ifthere is a lack of septic records on file)
This form may be scanned and made available for public viewing on the Mason County website. Revised:01/10/2025 �
Page 1 of 2
—_----------------------------------------------------------- Staff Use Only --------------------------------—--------- _.
Review Step 1: Well Site Inspection: ca
YES NO NA �eT,-vim Syr
® ❑ ❑ Evidence of existing sources of contamination within a 100-foot radius of the water source?
(drainfelds,tanks, buildings; indicate distance on plot plan)
❑ 0 ❑ Are there roads within a 100-foot radius of the water source?
Is the road Private, County, or State?(circle one) Distance to the road(s)
F] ❑ ❑ Does the ground slope away from the water source site?
JH ❑ ❑ Satisfactory well cap?
❑ ❑ Well cap screened and vented?
N
[I The well casing extends I/p above level ground/concrete slab?(circle one)
�] ❑ ❑ Evidence of a surface seal? Y�•Zq
Lat:
❑ ❑ Adequate surface seal? Lon:41•DYOI�j
❑ ly ❑ Variance necessary for well site approval? Tag: pEA fir
Comments:
yMPass ❑ Fail Inspector Date
Review Step 2: Two-Parry Review:
YES NO NA
❑ ❑ Water well report(well log)with a concurrent capacity test?
❑ Nonconcurrent/separate capacity test?
Capacity test information: Date Z Driller
GPM Duration(minutes) ? YO
❑ ❑ Satisfactory bacteriological analysis? Date of test 7
El El Signed,Signed, notarized,and recorded notice to future property owners?AFN 7r K
❑ ❑ The system appears adequate to serve two connections based on the information provided?
Comments: r r } /�
Approved [I Denied Reviewer Date `( ( 7)
Findings in this review reflect observed conditions as they existed on the day of the site inspection No claim is made, express
or impliedofthefulure success orfailure ofthis system. Wellshe approval does not copstiture water system approval
A11 proposed connections to new wells are subject to water adequacy requirements at time ofbuil fang permit per MCC 6.68.
Water usage restrictions andadditional fees may apply to all new wells drilled after January 19a, 2018 per ESSB 6091,
This form maybe scanned and made available for public viewing on Me Mason County website. Revised:O1/10/2025
Page 2 of 2
DEC-08-2005 THII 11:35 PM FAX NO. P. 03
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2223544 MASON CO WA
04/0212025 03 24 PM NOTCE
R PHYTMM M8000 Rec Fee. $304.50 Paeee 2
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Return To
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76s s£ o�p dfLcq,Olb rio.0 fIIJnU(1Jf l�LS U LS
H£ttal ti.r} 9YS F l APR 0 2 2025
By
Grantor(s): (1) OZoafmy D IHy7H14,y (2)
Grantee(s): (1) PUBLIC
Legal Description (1) Sw 1w SE 1/1 SFr 2LI WA' 20r✓ 3�1
(Abbreviated form:i.e. lot, block,plat orsection, township, range)
Assessor's Tax Parcel: (1) 3102_ZNF, 90l N2
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) 3 Z 0.2 Zy 6 crpl g/z
Tax Parcel:(Connection 2) 3,2 O 1 Z y h 9014/2
The system owner is responsible for keeping this system in compliance.
The name of the water system is: Igo ltGAAY 0 1211 yT ifiy
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 API L , 20_2.!_.
Signature of Graptor(s):
Page 1 of 2
State of Washington
County of Mason
I,the undersigned, a Notary Public nin and for the above named County and State, do hereby
certify that on this /sh day of I Ad L 202�— ,
_Pncrr i P/i,. Ll< .�n personally appeared before me,who is known to be
sig er of k e above instribinent, and acknowledged that he (she) (they)signed it.
GIVEN under my hand and official seal the day and year last above
written.
Notary Public in and for the State of Washington,
residing at . S/V.110A
L PARKER My commission expires: i WZQ1.20drNotary Public
State of Washinston
Cmmission X 29421
[C.HRISTINA
mm. Expires Oct 10, 2026
Page 2 of 2
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