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HomeMy WebLinkAboutWEL2025-00016 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION - WEL Application, Design, Letter - 6/18/2025 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 A BELFAIR:360-275-4467,EXT 400 • Public Health & Human Services ELMA:360-482-5269,EXT400 FAX:360-427-7787 Riley Pollard 2380 W Deegan Rd SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2025-00016 2380 W Deegan Rd W 420352400060 The 2-party water system, WELL-Potable water (420352400060/420352400060), 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 6(l Se( Za ZS :4001"14.14&.. MASON COUNTY Date Received: 0 4 - /'t /f ' noz5 L COMMUNITY SERVICES Amount Recevedey: t. 5l� � Building.Planning.Environmental Health,Community Health (� rvti 415N.6'"Street,(Bldg 8)—Shelton,WA98584 rYEL 2025- 00I Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO—PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE RILEY POLLARD 360-580-1735 rt,„ [_ _Th MAILING ADDRESS-STREET,CITY,STATE,ZIP 1r 2380 W DEEGAN RD SHELTON WA 98584 SITE ADDRESS-STREET,CITY,STATE,ZP MAR 0 3 2025 2380 W DEEGAN RD SHELTON WA 98584 PRIMARY PARCEL NUMBER(WELL SITE) 420352400060 By SECONDARY PARCEL NUMBER(SAME AS PRIMARY IF LOCATED ON SAME PARCEL) SAME AS PRIMARY WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE(mini acre) PARCEL 2 LOT SIZE(min 1 acre) ❑New I Existing i Well 0 Spring 5.70 N/A PROPOSED WATER SYSTEM NAME(REQUIRED). WELL-Potable water PROJECT DESCRIPTION(e.g.,detached ADU,new single-family residence,existing connection,etc.) Adding detached ADU manufactured home. DIRECTIONS TO SITE I CONDITIONS I GATE CODE I KEY LOCATION/ETC. W ! 4r�rt� r fc/3 f T d!� i�C �,{� J'- , 2,5 M,1C° � , ©rePeilT y oil rlbk) L Ito er'-) . Site Plan: (may also be attached) (property boundaries,structures,well site w/1 00'radius,driveways,roads,septic/sewer components and lines,water lines,property easements,etc.) e-7 cZ T-Ncoed, Required Submittals Checklist: (additional information located on the first page of this packet) Satisfactory bacteriological test from within the last year(this may be deferred 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) li Notice to Future Property Owners of Private Two-Party Water System recorded with Mason County Auditor's Office a Septic Records(additional locating requirements may apply if there is a lack of septic records on file) This form may be scanned and available for public view on the Mason County Web site. Revised: 12/17/2024 Page 1 of 2 ------- Staff Use Only -- — ---- --- ----- ---- ------ Review Step 1: Well Site Inspection: , (+WPC- 35 YES NO NA f ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) 9 ❑ ElAre there roads within the 100 foot radius of the water source? If so, is road private, Cor State. What is distance to ROW? 'to Z ❑ ❑ Does the ground slope away from the water source site?(show slope on plot plan) oa 5(Ztl2'tt 1- ❑ Is the well cap satisfactory? LAW 144n9 fserqh /O. ❑ Ef ❑ Screened and vented? I. ❑ The well casing extends 10 above level ground/concrete slab? (circle one) r4 ❑ ❑ Is there evidence of a surface seal? Lat: v. I vtr.6 pi ❑ ❑ Does the seal appear adequate? Lon: -123•I s�lff ❑ [ ❑ Is a variance necessary for well site approval? Tag: 06 1$) Comments L e(I ap (catty, (va*rot, . iVo vc.,(1 y.C, , " coffekk. /(/gins or OL-- ass tyl Fail Inspector Date 3/2 rl G 0Z f a\ ----- q 1 ni 7o7,Sr „,- Review Step 2: Two-Party Review: YES NO NA [1 ❑ ❑ Water Well Report with adequate pump test on file?Je(('Pr:(My GI 516(1Q76 b( /S 6/0)fee 60001(9er✓/pp1) If NO, date of Capacity Test l?/ l Y Driller !fC /et Odithic GPM 16 ( 165a' if- in ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 10ll87 t o 7 Y. ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN 7Z 2 7 2.0 7 ))1 ❑ ❑ System appears adequate to serve 2 single-family residences based on information prbvldeed? ��? Comments #_ 4 Approved ❑ Denied Reviewer Date 6 q 4 Findings in this review reflect observed conditions as they existed on the day of the site inspection. No claim is made,ex JJs or implied of the future success or.failure of this system. Well site approval does not constitute water system approval. Watr', System approval is a two-part process. All proposed connections to new wells are subject to water adequacy requirements at time of building permit per MCC 6.68. Water usage restrictions and additional fees may apply to all new wells drilled after January 19'r', 2018 per ESSB 6091. Revised: 12/17/2024 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 1 Figure A-2. Example Water Well Report for an Existing Well Water Well Report For An Existing Well WILYour well must be properly tagged prior to submitting this form. vrrfrrr.rat or Asterisks(')indicate required Gelds Mail completed original form to ECOLOGY WA State Department of Ecology.PO Box 47600.Olympia,WA 98504-7600 Stan o'N•,w.te•tt Use this form It an original Water Well Report was never filed or is missing from Ecology records.// (',��'ent Use 'Unique Ecology Well ID Tag Number 6�xv 155 ,L3Domestic ❑Industnal ❑Muntopal DDewater ❑trrtgatan ❑Test Wer ❑other '1h'ater Rght ❑Yes(if yes,attach a soppy)` No Dimensions 'Property Owner Name i�l�G2� \ �YY1 Vl Diameter d wen ((J in 'Well Street Address Lb SO` �1�. DQv��1�(,ynw�v�� rd•W Depth of completed weD IU ft (if known) ,C�Sh el � 'County �v 1 a S 1 Construction Details Liner instated ❑Yes ENo ❑Unknown 'Site Well ID Type ❑PVC ❑Steel ❑Concrete Liner 'Tax Parcel Number #W T—24—Q j DUnknoan ❑Other Perforavons 60 'Date Well Constructed 19 I , ❑Yes ZN ['Unknown 'Location(Township.Range,Section) 3 S, Tam t4U Sae d perforators in M n An accurate location of your well is very important The Mintier of perforations from ff to tt Section,Township,Range,and'/.,V.can be found on your Screens tax parcel legal descnption or through your county ❑Yes f2No ❑Unknown assessor's office Type ❑Stainless Steel ❑PVC Dottier_ �(( ,{ Diameter_Slot Size from_f to_fl Towrnhipa7/" Range 4W DEWM or 'M Gravel fitt�er Section 5 G 1/4-1/4 Mid 114 ❑Yes pl"o ['Unknown Matenats placed from f to ft Comments. a Seal A.Yes known,known,t Yes tf k ,to venal depth is ff ❑No ❑Unk.nown Mltertats used rf known ❑Bentorxte ❑Cement rJr� ❑No known Type et, Ar�YYY, Ili lase Power Ili Latitude/Longitude (Decimal Degrees recorded to 5 decimal places) Water Levels Land surtace elewa shove mean sea level PO rt Latitude Example 4 12345) Casing sticke-up above/below.land surface I 4 i- (,2 S Static Level4.J° below top of casing Date measuredS,1 t-L I Longitude Exampj118 12345 Artesian pressure ttws per square n Date measured Z . I "]444 Weil head has cap 0es❑No Shut off valve/❑Yes ONo Additional Information(If available,please attach) Well Tests: Drawdown is amount water)evet is lowered below static level ❑Location marked on topographic map Was a pyrr test mace'jMYp(attach copy)❑No 9 Unknown ❑Location marked on air photo Yield in wilt ftdrawdown after firs ❑Consuttant well report 'Certification:The rnfomtation reported above is true to the best of my knowledge and belief ❑Consulting FM Antler ❑Engineer ❑Property Owner Name A r)L. 1 e.o cr.r. Company. License Number Z 1 q Address of person completing this form Sgnat re� /, �y i Date Signed C- Li- Cdy,State,Zip i f !! 1.(..1 L'v!r:i[C:Ole.i To wont ADA a:cosxadamo m:hdta;ma.•etal.to•bi at ner th.tttxain;.waved all Ecolor Nate f wor:es Rogra 360.10' WI Ponac rid tmpund heaamg u•cat d'i Amide P./tar smrca at r i i Posen,nth tp.ch d:taha1a mar caD TTY at t"-1331341 EA.P08I,Version 1.2 Page 20 Uncontrolled copy when printed Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Mike Mclrvin Well Tag#: None Site Address: 2380 W Deegan Road, Shelton Depth: Unknown Date of Test: 8/7/2024 Static: 4.5' TIME GPM LEVEL RECOVERY 1 Min 10 7.6 TIME LEVEL 2 Min 10 8 1 Min 8.5 3 Min 10 8.1 2 Min 7.3 4 Min 10 8.5 3 Min 6.9 5 Min 16 8.9 4 Min 6.4 6 Min 16 11 5 Min 6 7 Min 16 11.9 6 Min 5.9 8 Min 16 12.1 7 Min 5.7 9 Min 16 12.3 8 Min 5.5 10 Min 16 12.5 9 Min 5.3 15 Min 16 13.7 10 Min 5.2 20 Min 16 13.9 25 Min 16 14.4 30 Min 16 14.3 35 Min 16 14.2 40 Min 16 14.7 ' 45 Min 16 14.6 50 Min 16 14.5 55 Min 16 14.3 1 Hr 16 14.7 Total Gallons Pumped = 936 V N dl V I Vanguard Laboratory 2635 Parkmont Lane SW,Suite A Olympia WA 98502 yaas eD 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Tine Semple County Collected 1 C' 12-1 12`1 t I �A� n b Dry Tow Type of Water System(check only one boot) ❑Group A ❑Group B Grail A aid Group BSystem-Provide from Mier fiver ocy•(WTI) I System Name: C«,tactPersa,: VC11 LLk 1("-1 -- 4'U trl DayPhone:( ) Col PAonec( ) A 4.3 t.i Emtet V U\1T1t~._`I/cr.:Ap'll_ be Monet( ) . Send remits b:(Print All nag,{CNN a codr or 1 jCl'�( 2i< (s C Lck 4-12-5W Iiv- , kr) r ck. titi C,ht (tQn, . SAMPLE INFORMATION Sample collected by(name): 1�I (ii n Specific location where sample collected: Special instructions or connects bCkt poin s in t - l7o! !t' alifirgf,aapp(efnmg'p .q15.P,or!) 1 0 Routine Distribution Sample(AIP) 2 Q Repeat Sample(A/P) Chlorinated:Yes No ( system ate treat ro,.v,e) Chlorine Residual:Total Free Ursai sfactory rare lab numtxr. 3.Ground Water Rule Source Sample —--` —--—--- S I Unsatisfactory r utne collect date: l -- r / Chlorrated:Yes No ❑Triggered(AP) Chlorine Residua Total Free, 0 Assessment (AP) 4. Surface or GWI Raw Source Water Sample(Enumeration) ❑Eco! ❑Fec�J ) S FNaW Yat_No• i k L m aacnc6e �krinb YtCrcv:y: LAB USE ONLY DRINKING WATER RESULTSLAB U.SE ONLY ❑Unsatisfactory Total Calrform Pre ent and Egl❑E col`present Satisfactory ❑Epaf absent Bacterial Density Results:Total C i;brn Feet C^+ifomn '---lt00ml. EcaS /SCCm:!. , J10Qm1 FiPCii ml. Replacement Sample Required: ❑TNTC 0 Sample too Old 11 ❑ Sample Volume 0 Damaged Container [) y 0 Ite4t�-1c1 Temp C: Metod Code: 7.0 SM9223B Date Reported to DOH lap Use Only: DOH LabSa---- 285- 02819 .tic,- raglanr onne„ d„ ? g701J1ASON2220 CO ILIA 03/2025 PERMIT ASSISTANCE CENTER #206961 Rec Fee $304.50 Pages 2 IIII II I III III IIII IIIIIII ill IIIII IIIII Illll IIIIIII III IIIII IIIII II IIII Return To tss istan € Ce_,ni-e-V 15 Iry, p�tfAe.v S}re e_-+ Sh-e.►+or)1 1,r\1 N ci8 1 Grantor(s): (1) /�//Gt � 14G1-11/1/14 , (2) /-1l4e/1-e. Grantee(s): (1) PUBLIC Legal Description (1)SE NW OF RNV&E OF CREEK PCL 3 OF BLA#98-33#666113 S 40/221 S 46/169.(4W 20N 35) (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1)--d2o- 5246aZ- 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) -92-'k35 2'if.C)C° 60 Tax Parcel: (Connection 2) 4 2c352 1/Q0O The system owner is responsible for keeping this system in compliance. The name of the water system is: Wei) - PCTcP/c t,Jya 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. eit- Dated on this day of ,rli f , 20 Signature of Gra r(s):: (1) .' ��. , (2) t7'..'\ r4A1(\k/c,,,2)0/Vt,, Page 1 of 2 State of Washington County of Mason I, the undersigned, a Notary Public in and for the above named County and State, do hereby certifythat on this q day of�.N ck,r\v�cc , 20 6.4S 1,`10. 119. �r x.R6tIi ) As personally appeared before me, who is known to be signer of the above instrument, and acknowledged that he (s.e) (they) signed it. GIVEN under my hand and official seal the da and la bove wri en. Wie IA— otary Public ' n thq to of Washington, l residing at Notary Public } My commission expires: -�.44-.141 State of Washington r T LOVEJOY SCHAEFER MY COMMISSION EXPIRES APRIL 24,2027 G Page 2 of 2 1.nsimtsg • • D &rilnf icld& layout pri itat n ATraiddbeddimansic.is I within*oat • • goptic.tpumptnk pinewood. - . . - .. .,g{ •..ocadon o[btdldingo. • ;, Obsorvadanpod tt dew- - y - _ • • out k;oad on- j_.____ - - •\?1) 7 a A Location of wells& y G�p J Undisturbed native roll . �� �,..:, - � l -; \.1-- :1 :....., tc_ \\ b- — itsa,it. _ - • __ • W i t_c• ti . ' ! - ardie rot o ol&bloddreaea Ibei i!etfoi tar*Me�lta6oPtSeaotm�s.1 is ama� in.l.Btki..uloo +t auto mut'o installer Chock slam from Row"A"ard•$",fib?and disiraedolestiae - .' =' - . - l4. AZ: I Ant Ibmtslled the system ❑ I oadify that sit dsdations mo stamped de, frostthetL dna b7 MCEIBEI ate Amp skate. MCA - 1 • to Wyo.bemoan�e B; Ic$�Iceadaded�dos and k8tk'° D- Iddnot � spoken open far inspectionupb 4E bprior* G baaniirittakat- carves. _ Y four ow:*that all infouantion codaioid eta l is fond is a win,-I andatstaud feat Klan heed mistimed herein is not _wombs,there/alba:odcausefor afaa4 e. _ 8 f - ut Hain Ca a on beihs1fo[�tsca�Y ' •' ,'se••- .• Barvicoss. . Iho.�+tpPt „jail"- 41 14ki 3'• - IJr 1 - . .. 1 .t)rs P4' ell 1 •�- Ut-- --(,.... ,.../ ' '1, 1 7----- r w 1 00 • i---.."\..--\ p8 8l l Ul 99 6/ •�# / �. 3 �k ` y r� 1 / ` i \ 11 L N / CO I r o ; / \ KD \ \ y\2 ._ 'C\/ I / Z.- ° I I I / / (43 P �`------.___ (:)______ ____--._---Ht----' -------, ,....... ...." 9 ! yC � NN L , `n r`I ru lA \o,-- chi; rb rn z Io • \ oCo rnN cr1. A m r a ; ru N Il ` N x 1 s�. bpi A e ‘‘. Z �qSk'�a, `1 ,�, (n m �1 m Cq Cm s Ark, ,9 • fr c c A Lo,2 y,.j ��' Sg£Sz m 1 • % i s