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HomeMy WebLinkAboutWEL2025-00028 - WEL Application, Design, Letter - 5/15/2025 MASON COUNTY 415N6T"STREET,SHELTON,WA 99594 SHELTON 360-427-9670,EXT 400 9ELFAIR'.f 360-275-446 ,EXT 400 Public Health & Human Services ELMA 360-482-5269,EXT 400 FAX'360-427-7787 PARKER RICHARD B JR & TARA 3261 E HARSTINE ISLAND RD N SHELTON, WA 98584 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2025-00028 3261 E Harstine Island Rd N 221264400080 The 2-party water system, Parker Rawlins (221264400080/221264400080), 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 �� 2WWZo751 um9 MASON COUNTY Oa Received O . /$ 2O2 5. COMMUNITY SERVICES Ren.4 5_40 ReCaiVed a, , jPaulding,Planning Enma„mw,uldnb.cnm,m,n;nle<,IM JI5N.64 Strec:.(Bldg 8)-Shelton,WA 98584 WEB 204S Do02V Shelton 360-427-9070 x400 Ileltai(360-275-1467(.400 FlImo 160-482-5209 4400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICA.r PHONE 'ARA ?ARK6R -2sz-320-brµ8 3lb% �EE.ER, +IARsn..3e Sit-APb t7.D .J 54-iacrt' I iA 99fQ STREET.CITI.a FATE,ZIP 32491 E 4ARSTV44t SSt-Arf1) RD .d 5-el-TWA WA 98rb4 rI„ ISIAN%PARCEL Z2-0-6-NN`PI- 000S0 SI(O➢LIAR%PARCEL]I MBERI SAM L AS PRIM AR%IF I OCA I kU ON SAME PARL EL) ZZt7.lo- 4444 -000 SO AxeacRl I SOURCE-FA // PAR(FAAl1 I0I SCE(min I 1 . New YFxistin/ IE g N�tVeil Spring s,AL Near.. - Y+Imm lnr,o PROYOzrm warm SYSTEM NAME IREarnaem 7ni=kER RAIdLzaS D (.�E� [I(] r� YNO.ItOI UI:A NIPLI(rn le.¢,aeumM mr,nrcuinFM lnmiy,mtlemenimn¢m,memon,ncl C V II�111I ' New brrAcumskN ,acb paJ MAY 1 5 2 § 1 OIRrcrioNs do SITE COzammSM/CILIE000%L An LOCATION,FTC. By Site Plan: (may also be attached) roperty boundaries,structures,well site w1lUO'radius,driveways,roads.septic/sewer components and lines,water lines,property easements,etc) 5tL pkta..w-a Required Submittals Checklist: (additional information located on the first page of this packet) Satisfactory bacteriological test from within the last year Well report with well tag number,well tag secured to well casing,and capacity test showing 800 gal per day 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 if there is a lack of septic records on file) This form may be scanned and made mailable for public viewing on the Mason County website. Revised:01112025 Page I of 2 Staff Use Only Review Step I: Well Site Inspection: vle y75 YES NO NA t ❑ 0 Evidence of existing sources of contamination within a IOU-foot radius of the water source?(drainfields, tanks,buildings: indicate distance on plot plan) ❑ 0 ❑ Are there roads within a I 00-foot radius of the water source? / r Is the road Private,County,or State?(circle one) Distance to the road(s) _ ��.,,.,(p 0�❑ Does the ground slope away from the water source site? 0 0 Satisfactory well cap? ?ov{-of be/PSeit� , E ecinri( °mete. IY`� ❑ `1 ❑ Well cap screened and vented? qq.r 0 The well casing extends• "�'/ above level round manta . (circle one) ❑ ❑ Evidence of a surface seal? - &'Wrrcvc cent,'& C ? � LBf. ''Z 2-11Zt, 0 ❑ Adequate surface seal? Lon -02-et'$g( ❑ X ❑ Variance5ar neccessarr for well site approwaall1?S[µ'� {� /� /� (I Tag. lac tog Comments: /g/101$ ' Ie1V(tl'hL bolls 171/T4/Id `' (ci6T rcpoe Ci Pass it Inspector Date 6 7 / ZG Zc if/Ze7Zo7S1 Review Step 2: Two-Party Review: s NO NA U ' pl1, p+ PintT 4f II6/A0 lfOm, X ❑ ❑ Water ell report(well log)with a concurrent capacity test? D ctr ❑ ❑ Nonconcurrent/separate capacity(test? Capacity test information: Date ) 17(a,25 Driller y p *(Arj Pilibt, GPM If Duration(minutes) /gd Total Gal (ego 0 0 Satisfactory bacteriological analysis? Date of test 12(t(/(eat f7�( Q�.�� �Y-� im ❑ ❑ Signed notarized,and recorded noti to futur property o t AFN Z Z G 6//O n§v"s'e y ❑ 0 The system appears adequate to serve two connections based on the information provided? 4 "' An�' Comments: 4•s 4U(j A. 20 Approved ❑ Denied Reviewer Date V7a//Q, [ ;iT. bindings in this review reflect observed conditions as they existed on the day ofihe site inspection. .Ao claim is made. express or implied of the fuhve success or failure of this system Hen site approval does not constitute water system approval All proposed connections to new wells are.subject to water adequacy requirements at time of building permit per MCC 6.68. IItiterusage restrictions and iulditianalffe.s may apply to all new welly drilled after January 19ib, 2018 per ES.SB 609L Revised:02/04/2025 I his form may be scanned and made available for public stewing on the Mason County website. Pam:2 cr2 400 Water Well Report For An Existing Well ��N3 Your well must be properly tagged prior to submitting this form. RF o1.i Asterisks(*)indicate required fields. Mail completed original form to: CFyVF ECOLOGY DEPARTMENT OF WA State Department of Ecology, PO Box 47600, Olympia,WA 98504-7600 State of Washington — Use this form if an original Water Well Report was never filed or Is missing from Ecology records. `\ 1 `Current Use *Unique Ecology Well ID Tag Number: \1)Q C4-104 "'Domestic ❑Industrial :Municipal ❑Dewater 1 ['Irrigation Dies(Well ❑Other: 'Water Right: ❑Yes (if yes, attach a copy) ❑O No Dimensions `Property Owner Name: Tara Parker Diameter of well 6 in. 'Well Street Address: 3261 E Hemline IsInd Rd N Depth of completed well ft.(if known) Construction Details `City: Shelton *County: Mason Liner installed: DYes "'No ❑Unknown *Site Well ID: NA r. Type: UPVC "'Steel ['Concrete Liner k DUnknown ❑Other: 'Tax Parcel Number: 22126.44-00080 Perforations `Date Well Constructed: NA d Oyes ❑No DUnknown `Location (Township, Range, Section) ^• Size of perforations in.by_ _in. An accurate location of your well is very important. The E Number of perforations_ from_ ft.to_ 8. Section,Township, Range,and%,%can be found on your co Screens tax parcel legal description or through your county c Oyes QNo "'Unknown assessor's office. 9 Type: ❑Stainless Steel DPVC ❑Other: E Diameter Slot Size from ft.to ft. Township 21N Range 2W ❑EWM or OWWM o Gravel/Filter Pack Section 26 SE 1/4-1/4 SE 1/4 c ❑Yes alo ®Unknown 1,�.(� t `o Materials placed from ft.to ft. Comments' e .v -& f�L °c Surface Seal MO\I-,\ ,r�n��t r, 7f�i' S o Dyes If known,to what depth ft. 4JU ltii ft ALJ SolJ. e-a r 1A )). \1 o a o _ 'g ONO ®Unknown 0 e Materials used if known: _. 'inm.,rr ❑Bentonite ❑Cement "(of E.- Pump JU "'Yes ONo ❑Unknown N U o Type sub Horse Power 1 `i 70Z5-LatitudelLon itude 9 t — (Decimal Degrees recorded to 5 decimal - Water Land surface elevation above mean sea level IMO ft. (- ) Pk, Latitude(Example Casing stick-up *ft.below5 top of casingow land surface .52- Static Level 95 S top of Dale measured;5/9i2: Lonsitgle (Exam _le 118 345 o Artesian pressure no lbs. per square in.Date measured: - 1 i L r 53 ' L-� Well head has cap? Oyes❑No Shut off valve?Oyes"'No u Additional Information(If available, please attach) u Well Tests: 0 • Drawdown is amount water level is lowered below static level. ❑Location marked on topographic map Was a pump test made?®Yes(attach copy)❑No Unknown Yield: 11Was marked on air photo g _ gal/min.with 12 ft.drawdown after 3 hrs. ❑Consultant well report k. *Certification: The Information reported above is true to the best of my knowledge and belief. e ❑Consu ling Firm ❑�Driller ❑Engineer ['Properly Owner c Name:Mike Davis 6.g.cj L{ 1 _L Company:Davis Pumps Inc License Numb : 7 7 (r U 1- C Address of person completing this form: 340 NE Davis Farm Rd Signature: j ;4,,,,. 1 �r Date Signed: !J I((l-C() `'1/ City, State,Zip:Belfair,Wa 98528 1 f v iiai SVIn4`UIII .1ADA. I. i, u d riA-i Ial lui rlr G all. '.tpaii,1 .u'I Vn li..n IO2 .! 60-117- .,^. Pa¢ vIL.1..11i ,•.1nc..l Nt `+ ,u, ..I :II r-nmi r :e,JivuI 1 lr:.n. ' It.n:.II r Dada Runpa, Inc. 340WE Vaal'hum lid 7)elfair,'Wa 98528 (360)329-2399 ',1•1„ nr°/E60109y Project: iUN 03102$ Capacity Test TAG: n/a, none 3261 E Shelton, Watine Island Rd. N ���h� 'Ocoee pm8 ram Date 5/9/25 V Pump 1 H.P. Well Depth Unknown C S Static Water Level 95.5 Draw Down Recovery Time Water Level GPM 0 107.5' c 0 € 0 min 95.5' 0 1min 102.3' e E 5 min 106.1' 11 2 100' 0 `c_ 10 min 106.4' 11 3 99' 00 e 15 min 106.4' 11 4 98.4' 0 3 30 min 107.2' 11 5 98' 0 `. 1 hr 107.4' 11 10 97' 2 hr 107.5' 11 20 96.5' 3 hr 107.5' 11 30 96.1' 40 95.5' 0 _ —_- 0 0 ii u Capacity Notes: c 0 IR R. ii c c Vanguard Laboratory 2635 Parkmont late SW •a Olympia,WA 98502 360.967.7010 VANGUAlit ep) Report of Laboratory Analysis LABORATORY Collected by: A-Pro Home Inspections Matrix Drinking Water aprowa(acomcastnet Laboratory ID: V241216-3 Sampling Address: Date Sampled: 12/16/24 400 3261 E Ilarstinc Island Road North Date Received: 12/16/24 9:58 Shelton,WA 98584 Date Reported: 12/1921)24 Sample ID: 3261 E Harstine Island Road North Analysis Result SDRL MCL Units DF Date Analyzed Total Coliform&E.coli by SM 9223B(IDEXX) Batch 1D:V241216-3 Analyst:AF Coliform,Total Negative I I MPN/100 mL I 12/162418:00 E.coil Negative 1 1 MPN/100 mL I 12/16/24 18:00 Nitrate by Hach Method 10206 Batch ID:V24I216-3 Analyst:KS Nitrate(as N) ND 0.50 1090 mg/I. 1 12/I6/241455 Notes: MPN:Most Probable Number ppm:parts per million in] non-detect Reviewed by Dusan Newnan,laboratory Director on 12/192024 ma..not applicable .SDRL:State Detection Reporting Limit Approved by Ton Johnson,Operations Manager on 12/192024 OF.Dilution Factor �Ii 177025:2017 MCL-Maximum Contaminant lac! 1bar! ssaoanroav Samples were received in acceptable condition The msWgs)in this report relate only to the ponies of the sample(s)tested.All analyses were pedm Hod consistent with the Qualiry Assurance program of Vanguard Laboratory.Please contact the laboratory if you should have any questions about the results. 2635 Parkmont Lu SW,Suite A,Olympia WA 98502 I Office:360.967.70101 testing( vanguardlaboratory.com I www.vanguardlaboratory.com 1 of I 2226198 MASON CO WA 0S/0212025 12:45 PM NDIGE PARKER E210316 Rec Fee. $304 50 Pages 2 IIIIII IIIIII III(III HIII IN III(III ill IIIII IIIII EIII III I I I All(III(Ill Reim„To _f2f4 )Se)TO: I ( �/ ?IL(0 ) 1� rLGeSw✓.L c.lN.S \2 .1 J04/ n G lnnror(s): (I) ,c.ra. rtoAfS , (2) 12 Ic..4-u-e l-wdcstT Grantee(s): (I)PUBLIC Legal Description 1 I) T?. `( LF St2. sr 5 L(e 12I zZ (dbbrevimedfan, i.e lot block.plat or.section,rovnship,range) Assessor's Tax Parcel: (I) 2211( 0 -4`1- PODE(-), NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM I (We)the undersigned erautor(s)_certify dial the water source located on the above-described real estate tinder 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) ZZIZr(p-:.(y - 000b0 Tax Parcel:(Connection 2) 2t(tio - 444 - at:nA° The system owner is responsible for keeping this system in compliance. The name of the water system is: PPc2(C'E\ _ _ ic,RW 1--Tn1S This system is designed to provide for two service connections. Planning and design approvals must be ohrained from the department prior to expanding beyond this number of services. Additionally,a water right,obtained fit in the Department of Ecology,is required if the water system exceeds exemption standards. This system(has/has not)been granted one or mare waivers from specific provisions of the regulations. Dated on this 2 day of 1‘.. R A) . 20.c.. Signature of Granroi{s): Page I of 2 State of W ashinaton County ofSgii � (5` \ I, the undersigned. a Notary Public in and for We above named County and State,do hereby ceitify that on this (. a^O( p day of ,20ac. li0.)(iA.P( CkptfC- richaJCi Isar f personally appeared before me,who is known to be signer of the above instrument.and acknowledged that he(she)(they)signed iL GIVEN under my hand and official seal the day and year last above written. Notary c in and for the State of Washington I residing at3117 'ab -t , Oel`rkork.,1 KAYTPMAKOWSKI My commission expires: in Notary Public 7J�, State of Washington Commission k 24016484 My Comm. Expires Jul 3, 2028 Page 2 of 2 60'0" 50'0" r-" "PbpoiedAOII i - N 15'a60' I 900 eQ.it. 1 Nam„ '02'�* pi ;Tanks ice.Septic 2 A . 31 P� A9 ma's Existing D F • P ;` '14A6tinD OW, O 0 Septic Tanks v • mi 2�• e ro l _ _ 0 _ �• ,� Existing sFR 24'D"- o zr+afi' c �tfi0'296 q.fth) (�..t 1296sV-C o 1� kx;1. /� • -� � b '1 New D.F. went -' ,.}314 1 b • �✓ 1+ • J. 0 SQ, N ti rat E Hars6ne Island Rd N �,� ..I �° tz A''TEST tkOLE 5 OS Control Panel wIth Autlio-Visoel Alum " ^ fre'\ a. - .f. ," -µ�Eece•s O Cwvwt � Nc * t -4 : 0- 12 � ( o 1-o 2-Compartment ha3rdiC.� canon septic/Aeration sh- lA0-4".. ` `/T re- cSitt o 1.000 Gaon clvisc/Pomp Ta' VA^cS-F I -v'C in s-compartment j/�y�&• wIli© OSCAR X02 Mound bnia0ela 'j a i " r.: Ol N. -- ,:7,_" 51049 -PAUTA JOYJJOHNSI t%41. sire • � \ 47 \ \ `5 Etrst-w r, ,4? \\ ' P. 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