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HomeMy WebLinkAboutWEL2025-00003 - WEL Application, Design, Letter - 7/23/2025 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 YATES ET AL ALLISON NICOLE 733 NE BEAR CREEK DEWATTO RD BELFAIR, WA 98528 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2025-00003 733 NE Bear Creek Dewatto Rd 123093304020 The 2-party water system, 733737 (123093304020/123093304040), 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 7(Z)( 7o?f I I Date Received MASON COUNTY 4.P047 ZoZS COMMUNITY SERVICES Amount Received uw Received By • Building Planning Environmental Health,Community Health 415 N.6'h Street,(Bldg 8)--Shelton,WA 98584 WE L 2OZ5- 0000 3 Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Pima:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT MI \SI`� otsce,7 PHONE MAILING ADDRESS-STREET,CITY,STATE,ZIP / ' S 4Y, eKe sewo 4V ()4 WA(-0 Y/ V 0L/ S2 ci SITE ADDRESS-STREET, STATE, D PRIMARY PARCEL NUMBER(WELL SITE) JAN 1 0 2 2• y SECONDARY PARCEL UR(IF APPLICABLE) .. WATER SOURCE 0 33 VO'e g SOURCE TYPE PARCEL SLOT IZ By f AR ]L i1Z ❑ New 3 Existing Well 0 Spring (�/' � (� U PROPOSED WATER SYSTEM NAME(REQUIRED) v D 733737 PROJECT DESCRIPTION N& COOreel n C-3I V 'Fai,`1`;11 ParCel 410- 0-3 eq 33011 oaf DIRECTIONS TO SITE/CCIpNDI IONS ` �, ctirOn PId .�e IOU✓ �4te1 k ; G vt� 6.t�,cre' D 6wc4i *i. )rq 3 Pct,e5 3 oA 49 e ter Site Plan: (may also be attached) (property boundaries. structures.well site w/100' radius. driveways, roads,septic/sewer components and lines,easements,etc...) Submittals Checklist: (these additional items will be required for approval) Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled) q440e Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled) °Fewer 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 form may be scanned and available for public view on the Mason County Web site. Revised: 10/13/202I Page 1 of 2 Staff Use Only Review Step 1: Well Site Inspection: YES NO- NA ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings: indicate distance on plot plan) ❑ !slit Are there roads within the 100 foot radius of the water source? If so, is road private, County or State. l " What is distance to ROW'? ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) ❑ y ❑ Is the well cap satisfactory? ❑ St ❑ Screened and vented? If ❑ The well casing extends Li above level ground /concrete slab? (circle one) ❑ ❑ 6 Is there evidence of a surface seal? L Q# . y'7- 7 q-2 Y ❑ ❑ Does the seal appear adequate'? (,d4 ! l ❑ ❑ [] Is a variance necessary for w II site approval? �� Tay: $ (ICI 11 Comments L. sZl�� Pass ❑ Fail Inspector /4& Date r t 2 5 Review Step 2: Two-Party Review: YES NO NA . a� ❑ XI ❑ Water Well Report with adequate pump test on file? f�AtSkrf ��pNl�t�f °n S1$4�( q.Nb I" "p t•`rl If NO, date of Capacity Test S'/fp/mil y Driller ( ?wok" Prd IWr. GPM f ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 6�lTQ, y WeAlivoiFto qj a��� El ❑ Received Signed, Notarized, and Recorded Notice? AFN ZZ �3Q3 S elf5f Ot El El System appears adequate to serve 2 single-family residen t information provided? Comments j 0 1,Z.I..t M4SON 11� 23 �ooN7 2025 - — r IJ�gnN��NTq ig Approved ❑ Denied Reviewer Date /4 ?W70 7; 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 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 19'1', 2018 per ESSB 6091. Revised: 10/13/2021 This form may be scanned and available for public view on the Mason County Web site. Page 2 of 2 2228303 MASON CO WA 07/21/2025 03 56 PM NOTCE DRVIES CONSTRUCTION 14212076 Reycl Fee $II33''04 50 Pages 2 Return.To 1 1 11 1 I1 �1 III 11I111I 1Hil ���li� 11. 111 111111i 1 1E I j'.fl 15t13t Clcetr Crtc-G. IZdP r.J 1_1 t70,1,4Iseo Up, 90310 JUL 21 2025 By Grantor(s): (1) '‘\\6a l N V (2) n R I, c Grantee(s): (1) PUBLIC ,/ Legal Description (1) V 2- ut/'t- ul r�,. stv 3k1 l i G (Abbreviated form: i e lot. block, plat or section. township, range) Assessor's Tax Parcel: (1) \ '- 1) G a - '3- G (4 Q g 0 SmG -7Z3— t:l 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) \ . �j U L - 3 - Ott 0 1 O Tax Parcel: (Connection 2) ! }- 3 o q .- 3 .3 - C '-( 0 Z The system owner is responsible for keeping this system in compliance. The name of the water system is: 733 7 7 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. Dated on this 22' day of fiaveriNbe✓ , 20' . Signature of Grantor(s): (1) L!^LC%u't/�/(`16- , (2) 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 certify that on this VV wk* i r . 20 day of DVL z4 Aftsofrl Vat}t5 it,1'1Ctt� Irsonally 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 day and year last above written. `````,iiti{IIII�,,,I' .� ,,��K,Mp, Notary Public in and or the State of Washington. residing at S•�Yw -�a- WA' .My Comm.Eyokes - My commission expires' It fZZ/7-13 LC— November No.150116 :OZ` W ASS CNN ',,irri,i'N'.1 Page 2 of 2 N Cr 3 J �, ti tt is- t 3 1 i, x, V5-41 yk., I: r - F t 0'-t •` VT1 pp !O 'WO t k7r rt rr,,.;l► ate.3 `0° a .2 r� M .. gLJi �4 • �� r �� --.. i,..;.1x ; ' j f, paF '—' —.—_ o 1�Y Zw� (NI I= Z Q N> B J ZO " t LU 0p ma o • inp 2 " 'Y S i OQw.� O v' ... sZ pm _. ..�». 11 1Ozw ` - T U Z.,-w S dU I rS , t r, .........,. • �qt Yam.�'vyla i �.r�,t � � F S5P ` O:� fn �,t Cp. s � ' 3 t ix.ef` rxFin h �. 1.4 yPyy ,i/: i. C W U E a (.11 r ?. 1tlr-a .,„ 2r i .tT T O 2 t6 X N r .is rn. f '. •a I. ,.,T. ,yrvq ! CC F- OO U coU U c k .:,Lii cf �+ ..✓" i , . k {r .gal v> �;i f i a A g rC) WN 2, _ ba i' r n ,, � Lt zxar=fs 1At 'cZ ilk,W O VJ 157 7 M O_ Z Z O 0 0d ob U N Cl" t "k '• y .3,1-T'�ih ''•`+' 6 r f Z CO co .? L a h J4 u Q( m c O y p c v s ° �aFF4� iwsciyzF a Q H Z r•,,; CU @ O r N i d f1 tt !4. Z ,1 9 ;47fr'4 T4t ,,..y� m ¢ C Fa 5.ca a s art•• ��, r � �, : ,t,�, LUu- t. LL ec :n `+ J (A n.C ._ ... _.... _,.•.-•,... ; ' l '.�+?,a°+s --1'�Y i4 t.t '6 . y� 0_ : `i4, , - 'jy� •A3 rCF•4i t ,4M� 4 r• 3i r h' t ve rrr r. 1 *'. rrs}¢� Wlr_"CiY^ , .:,i4+r�'s;w> f (h r '- vrf`'. FIIIIIIM • E%eirigserves733NE Bear Creek Dewaao . X •173O9-3341O2O El+123' 325.47' El♦13Y�.......1 1 m 25' caaam.•M 100' °` 4 i I \ 60 �©A Jsc �� o N, - Proposed p9ea` c t,e\oQe 0:*: kT7-aci X ~ aSL // 1 t Envelope is>Ofto c f /,/,/, g X any surface waters •a I Lif 3 vC • /E NME MAR1g2021 \ COUNTYENVIRO APPROTNTALHEALTH I / \ cn w cn -OnA rn m d 4 7 I \ SL# 1 0"-64"Sand Loam&Gravel 65" Compacted Sand&Gravel SL#2 0"-62"Sand Loam&Gravel 4 63" Compacted Sand&Gravel SL# 3 0"-66"Sand Loam&Gravel 4 67" Compacted Sand&Gravel 0 s1,, coo El+0' 326.63' El+17' ir►►1 On-Site Septic Design Name:Hemece LLC Tax Parcel:12309-33-04040 ��, o '.!Jc. ►►i / 1 ; ,�?.r-> Scale= I"= 50' Address: ' NE Beer Creek Dewetta Rd.Belfair,WA 1,4 �� 11M..allprrpa,tysr.s/r...•^s1a.cCe:rBnmtt-atitt,te%merit)ni/rnerAger•;s) /vi 201O0609 1„t) 0. r On-Site Septic Design I Allied Septic Design and Excavating Fronk A.AAerctnko fr e, LICENSED DESIGNER ► . Xi!ifCS 0./* anion Appliutuxt Nall.o. pas OrlRnel and First COPY with WATER WELL REPORT colo socontm�'rtt of Owner's Copy Penult No .. cosy-Drillers Copy STATE Of WARRINGTON r L9rzq.....MCI Addr _SteRt.w Bo-ZI�SQ 311 fni -- (1) OWNER Name ��( Si .�JL111e See x T �1sr R1fai yr M 10 (2) LOCATION OF WELL County_.. . �•�•�!)Al CBearing and distance from action or subdivision corner - (10) WELL LOG: -- (3) PROPOSED USE: Domestic [A Industrial Q Munlclpal 0 porrtutlon:Describe by color,character,size of matenat and st rtarire,and Irritation 0 Test Well 0 Other ❑ those tAteknett of aqui//art and the kind sisal rtatsre of 1Ae�eue lormattiocn d shotum penetrated, w.igh i least one d.r for tags cAanO 1 f (4) TYPE OF WORK: pwner's number of well MATERIAL FROM TO . Ut more than onel ... .. ...... ... _. . ? 1 New well Method: Diu 0 Bored 0 Jar-W - T ical--- - -_ 0 t opened ❑ Cable je Driven ❑ ! "- Reconditioned ❑ Rotary 0 Jetted ❑ 2 30 i pA nlrA d---- • ' C (5) DIMENSIONS: Diameter of well 6, `nchee• -- - - _ .. O Drilled....._..._36. n• Depth of completed well -•••»• R 3 36 - E (6) CONSTRUCTION DETAILS: - i Casing installed:. 6.. Diem. from ........0... ft.to ...31.-ft. ___ O _••Dfam. from n. to ..- -•• n• --- vC Threaded 0 Welded •. Diem. from _......_..... tt. to ._._.._...... tt. -`— Perforations: ye.OWV No �G� Type of perforator used.»...____... .». in. SIZE of perforations-_ �+ _— .----_.. periorattona from _».--.....__..... ft.to ._...._._._ ft. , 11111C''' .-..__-_..e perforation' froms-ea .....__.._._...-..perforation'from __......_- n. to ..__ ...._.....fRR .., __ Screens: yes(i. No❑ iQ Manufactaret a Naz1e___..II - Tfl n_noll»..»-__._.._..___.- TYPe 4- iD11aaa--st Model No._._...—..._..._-_.. --s D ._-_Slot aiu.__0 from . 33.---ft.to .._...36•ft. Slot elre ...._._.from , .,_c Gravel packed: Yes❑ No le Sire of gravel:__..._._._-_-.--. - ------r—.: ,pp / �iSurface seal: Yes a. No❑ To what depth? __..1,ti...•-.- ft. �1 UN •) , Material used 1n seal...._-] j'jl.O<- i.te -._...... .....-_-_..�-- 79Did any strata contain unusable water? Yes❑ No❑ • IType of•rater?_____.._..._... _Depth of strata._.._.--..------- _;— C (7) PUIiP: Manufacturers Name_.-OW e ----�•$`3tal.liT>$•.•...•- .Typec HP......_._..__._..... -- ..(8) WATER LEVELS: Land-surface etewapon . above mean sea level-.. .._._..__...._.._.fit. Static level .................21 .....-_..-...it. below top of well Date..5/29/79 0 Artesian pressure ............ _.._ lbs. per square lath Date......._....__.- 0 Artesian water is controlled by......_....... . . ....._._..._._ .. .... IIJ (Cap.valve, etc.)w - _It- — O (9) WELL TESTS: lowered is amount water level s ,l lowered below static level Work started._..M$F a...._. j..9 Completed....Ma,r-- g CWas a pump test made? Yes 0 N* If yes, by whom?. - w Yield: gal./min. with ft. drawdown after hrs. WELL DRILLER'S STATEMENT: _ - This well was drilled under my jurisdiction and this report is i •• ••• _ true to the best of my knowledge and belief. QRecovery data (time taken as zero when pump turned off) (water level measured from well top to water level) a Time Water Level Time Water Level Time Water Level NAME rlran441$.... eii.niOn, ... lilg a► Star Routa' °c , ox 79 `T print) r I I. Address...Bremer.ton,....Wa.ab... 9.8314 Date of teat .... _ ,. _. _.............._.».. /( [signed]..,......k44,21 .sr• ............. t .__ .,.. Boller test........4 .., gallmin. with»..»._7..._..lt, drawdowa attar....... .._....b a. IWef Driller) Artesian !>ow.... »_.._.__............. _.....Y.p n. Data...... ....._....._.._........ .».. »». Temperature of water............ Was a chemical analysis madee Yea❑ No 0 License No........O......... Date....5/3© —......., 9.••v. (USE ADDITIONAL MELTS IF NECESSARY) S.F.No.13$ -IJtev.4-7J)• 111104 COOLWATER DRILLING, INC. 10921 HOLLY RD NW BREMERTON, WA 98312 360-830-9005 COOLWDI941QM CUSTOMER NAME DATE: 30 August 2024 Davies Construction CUSTOMER ADDRESS 737 NE BearCreek Dewato RD TIME STATIC GPM TIME STATIC GPM 22 05 25 8 120 10 32 8 135 15 35 8 150 20 35 8 165 25 35 8 180 30 35 8 205 45 35 8 220 60 35 8 235 75 35 8 90 35 8 105 RECOVERY STATIC RECOVERY STATIC TIME TIME 05 32 30 10 28 45 15 25 60 20 22 75 25 90 i 26276 Twelve Trees Ln NW Ste.0 ;t SPECTRA Laboratories - Kit`ap Poulsbo,WA 48370 ...Where experience nsarters (360)779-5141 I COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected 6 18 2/ ,� nano, oav Yea �1 ." f�em ,+'Yt Asa/ Type of Water System(cheek only one box) 0 Group A ❑Group B Pr-Otter Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): iD# System Name: N..o EL. A �(t.Q?c l j�f Contact Person: cool,.to o/2-x'L4ysit Day Plane: C el $J 4. 5'00 S' Cell Phony 1-•Email: Eve.Phone: I Send restdts to:pint he mere.address andel)=Icor resit above tor electronic copy domes) COS L1„ai1l-ir-^ It.6(2.a;.tt #C e,_, tier`pif'I,t.c041 II SAMPLE INFORMATION Sample collected by{name): C oo C w/f f Specific location where sample collected: [Special Instructions or comments: ?37 f3. •4,e cR£4h lr 0ATr43 Type of Sample(chec(only one box) 1.❑Routine Distribution Sample(AMP) 2.❑Repeat Sample(A/P) Chlorinated:Yes ❑ No 0 (from distribution system after unsat.routine) Unsatisfactory routine lab number Chlorine Residual:Total_Free i 3.Ground Water Rule Source Sample —— — ! S i{ I I Unsatisfactory routine collect date: ! Chlorinated:Yes No I 0 Triggered (N') CI Assessment(A/P) Chlorine Residual:Total Free 4.Surface or GWI Raw Source Water Sample(Enumeration) ( S 1 ❑ E.col/ ❑Fecal Filtered Yes No 5.�Saeple Collected for information Only: 11 ilik3 USE ONLY DRINKING WATER RESULTS LAB USE ONLY 0 Unsatisfactory Total Cotiform Present and 1Satisfactory 11 ❑E.coli present 0 E.cotiabsent Bacterial Density Results:Total Colifomi mpN100m1.E.coli mon/100ml. .' Fecal Coliform_ cfu/100m1. HPC ctuflml. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume 0 Damaged Container ❑ A i • Datcll"une Received: \": Lab Reference Number Receipt Temp C°:--Lq., Afethod Code:l yy' OT-COUNT/SM92220 Dalrllelnel fqp� Date Out mrr.atnt�.,awr►x�`t.,e.atopinolaaQcayr, ( //./ . �/3/2 Cf redid eEes�odintwo.ap youher or recenlam datlar:codisbye* inlnndldr«pMibatro,ggmd.tyou hawnanwllnrapolu soar,please mlVhe xndxam,adeti& 1360.7788141 aw DOt$Lab-Sarclee °ahoy`moanr GTMee...tu aid,eery tothem wood and neseeatOlt}ee Allalxrakry.This V IQ- \ nr iAs , •;apart word by Swim.bare DON iamt931319(etegW 06'17)