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HomeMy WebLinkAboutWEL2025-00103 - WEL Application, Design, Letter immisimi7ommuniimmm.......m. .......... ..---i_ CI) 0 rn 0 a a , -a a) p (o a) pc D U n3 > U c..) a) a C Q E C C O O O C C n'U _0d m a) c W c .c c n m -o z al a3 3 a c Q 0 E n L � a) I Z a) ca) - oc : a U .0 a) a) O0 a) CnL 'V (0 «� (Co) � -0O Esn co. U -a co u) o c� a) Z O _ (1) a) -0 0 0 I-0 3 E c a n -0 a W .. a C W (6 0 .O a) D O T _ c/) O co -0 a (6 01 03 i, L- no CL — 2 ° m a:, m cu U) > Q (n W N � o U > � Q �j M z Y U O Y -0 N 0 W c ': O g 0 .0 CO C 3 0 3 � o w .J - Q3c a) a) Z Earn z Z (a � co as as m O Z U W Z y - L Cp L y- d Qd O O L 4- . 0 o 'a 0 >W `n Co� a� a� m ) Ci Q M J > Q) C a C c .0 0).0 a 0 li III a) W O Q E Q1 _ ... O C O CO R a cn Z_ p a ;a) -O Q - U) a C cn a) N O Z 'O O N V Q O+ d' a _N a c)a as rn OM Q (U) CI o 0 z W 0 W = R. E . CI m can Z �,, r z a 2 co O W O j..y m O >, I— i u c) c) C J 'I Z U) CD C- O —IO 3 O U W 0. a W c) w ± Q O E (N W * * C L_ O L O R a) a a a (a a) < a O r ` ad 6L1 0,-ita ' tk t-ot,4 CNw l \ MAO COUN f. > COMMUNITY SERVICES AUG 2.9.2025 %yam_ 4\- Building,Planning,Environmental Health,Community Health ,., 415 N 6th Street, Bldg 8, B y • Shelton WA 98584 Shelton: (360)427-9670 ext 400 •3 Belfair: (360)275-4467 ext 400 ❖ Elma: (360)482-5269 ext 400 FAX: (360)427-7787 APPLICATION FOR WELL SITE INSPECTION Permit Number Payment Information Instructions 1. Complete Part 1. Incomplete applications will be rejected. WEL, Receipt Number Q.5)26 ' ❑ Cash 0149,,R7 2. Attach a detailed plot plan. 3. Clearly stake out or flag the well site. ,, ❑ Check rr 4. Submit application and appropriate fee to Mason County �U V� G��� S Public Health. Refer to Mason county Environmental Health Date of Payment Og'a-1-e Fee schedule for cost. PART 1: Applicant/ Parcel Identification Water System Name Panhandle Lake 4H Camp Site Address 370 W Panhandle Lake Rd. Shelton, WA 98584-8923 Applicant Panhandle Lake 4H Camp Phone (360) 470-4870 Mailing Address 370 W Panhandle Lake Rd I City Shelton State WA Zip 98584 Parcel Number 520354160000 i Directions to Site From W Shelton Matlock Rd, take W Highland Rd to W Panhandle Lake Rd. Turn left onto W Panhandle Lake Rd. Water Source is: ❑ New ® Existing System Type: ® Well ❑ Spring No. of Proposed Connections 6 PART 2: Health Department Review(Staff Use Only) YES NO NA t (}(' K,/n/� 4 I ad i S IP ❑ ❑ Evidence of exis ing sources c nt`minatlon wit 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) ❑ 71.) ❑ 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? g- ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) 04 t sk ` ._ ❑ Is the well cap satisfactory? ❑ yi ❑ Screened and vented? + y //__ ❑ The well casing extends !€ above level ground/concrete slab? (circle one) ❑ ❑ Is there evidence of a surface seal? ❑ ❑ Does the seal appear adequate? ❑ ❑ Is a variance necessary for well site approval? omments /Vefn151Ca1 hict( c 40 loose yew o peA Lute. ❑ Pass tNi. Fail Inspector (A Date �����—s This form may be s n,0 and available for public view on the Mason County Web site. Findings in this review reflect observed co dit ns 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 passage does not constitute water system approval.Water system approval is a two part process. 1)Passage of the well site.2)Approval of the water system design.Once the well site is passed the water system design may be submitted for review 1 J:\EH Forms\DRINKING WATER FORMS\Drinking Water Well Site Inspection App.docx Revised: 1/20/2017 i , .c WS Planning • Management • Engineering 444 Northwest Water Systems P.O. Box 123 Port Orchard, WA 98366 • 888-881-0958 • 360-876-0958 www.nwwatersystems.com August 26, 2025 Jeff Wilmoth jwilmoth@masoncountywa.gov Environmental Health Mason County Public Health 415 N 6th St Shelton WA, 98584 Subject: Panhandle Lake 4H Group B (ID# 65913F), Well Site Application Dear Mr. Wilmoth, A well site inspection application and supporting documents are enclosed for the Panhandle Lake 4H Camp Group B water system. The system is currently unapproved as a Group B water system and is seeking approval to become a Group A TNC water system. There are three existing wells on the parcel (No. 520354160000) as part of the water system. Prior to 2025, two of the wells did not have well logs and thus had no confirmation of an 18 ft bentonite seal on either well. Therefore, a new well (well tag BQC060) was drilled in September 2024 and deepened in December 2024. Pump testing conducted by NWS showed the well was not capable of sustainably producing sufficient capacity for the system. Due to the risk of drilling another unusable well, the system has instead chosen to pursue the approval of one of the existing wells. S01 has been the main water source of the water system for the past 60 years. SO2 has been primarily used by the caretaker home and will be disconnected from the water system to only serve the home as a private well. Through discussions with the Washington State Department of Health, it was determined that S01 could be a viable source if it was brought into compliance with current well construction standards. In June 2025, Arcadia Drilling retrofitted the well with an 18ft bentonite seal and generated a new well log and tag (BRG650) for the well. In July of 2025, Arcadia conducted a well cleaning and verified that the depth of the well was approximately 175' and the pump is set at 80'. 4 Although site specific soil information for the existing well is not available, these layers can be somewhat inferred using the well log of the new nearby well BQC060. With an elevation of 435', BQC060 was drilled to a depth of 181', while S01 at an elevation of 420' was drilled to a depth of 175'. BQC060 features brown sandy clay from 147' to 174', therefore it would be expected that S01 would also contain a similar restrictive layer at this depth. This well is located inside a wellhouse on the north side of Panhandle Camp's main parking lot. The parking lot is paved and slopes down toward storm drains located in the center of the parking lot. There is also a gravel parking area located just to the north of the well and a workshop located just east of the well house. There are several mitigations that could be completed to help protect the well. It is proposed that a curtain drain is installed at the south section of the gravel parking lot to capture and redirect any potential contaminated flow away from the well. It is also proposed that long-term V (overnight) parking is located outside of the 100' SCA. The parking within the 100' SCA would be for short-term use or as a last resort to serve overflow parking. In addition, the camp could also conduct more frequent VOC testing on the well to ensure that well maintains quality parameters below the maximum contaminant levels (MCL). Although recent testing from July 2025 shows that the well is non-detect for all VOC contaminants. Should you have any questions or require further information, please feel free to contact me. Sincerely, NORTHWEST WATER SYSTEMS, INC. 4egt&iL 0}AeiYii Allison Whittle allison(a�nwwatersystems.com (360) 876-0958 ext: 121 NOTES: SITE INFORMATION PROVIDED BY:THE CLIENT AND PARCEL BOUNDARY MASON COUNTY GIS EXISTING WATER LINE THIS IS NOT A SURVEY.PROPERTY LINES AND I I EXISTING SEPTIC COMPONENTS ELEVATIONS SHOWN ARE BASED UPON THE AVAILABLE — EXISTING ROAD INFORMATION AND ARE APPROXIMATE ONLY. PAVED PARKING AREA DISTURBANCE OF EXISTING SURVEY MONUMENTS IS A ��� GRAVEL PARKING AREA GROSS MISDEMEANOR UNDER RCW 58.04.015 100'SCA WATER LINE AND SEPTIC COMPONENT LOCATIONS I———-I SURFACE WATER PROVIDED BY THE SITE MANAGER AND MASON COUNTY .111=111NON-SERVICE BUILDINGS RECORDS.LOCATION IS APPROXIMATE. LEGEND 'P.O 44 1Np� 90 1. GING GOAD — — EMERGENCY GRAVEL WELL(B00060) iii PARKING LOT ELEV.435' CARETAKER HOME TO - '''. WELL 1 BE SERVED BY WELL 2 - - - - - ''�' (BRG650) ELEV.415' 'r.r�.� ; r ELEV. !:#:I�1Y�T..- WELL 2. f ;N TO BE DISCONNECTED FROM PUBLIC WATER SYSTEM - ' ELEV.415' EXISTING -EXISTING WELL 2 PARKING LOT A PPlir _/ PUMPHOUSE _ ELEV.415' EXISTING WELL 10 SERVICE 1 - - - PUMPHOUSE I �0 - -EXISTING LODGE _ - _ ELEV.415' - - ELEV.420' - ' SERVICE 3 EXISTING DORMITORY - ELEV.410' SERVICE 2 - I EXISTING KITCHEN -PANHANDLE LAKE - SERVICE 4 ELEV.415 - - EXISTING BATH HOUSE - ELEV.410' 7 - BOOSTER PUMPHOUSE urn SERVICE 5&6 EXISTING HOSE BIBS AT TPN 520354160000 BARN AND ARENA 38.85 ACRES ELEV.440' SYSTEM DRAWN BY.Allison Whittle PANHANDLE LAKE 4H CHECKED BY FILE NO. FINE NAME SHE ET NO REVISION 240102 SITE MAP SCALE DESCRIPTION DATE DATfJuly 22, 2024 1" =300' UPDATED SITE MAP 8?8/2S NORTHWEST WATER SYSTEMS, INC. DESIGN-CONSULTING-MANAGEMENT P.O.BOX 123 PORT ORCHARD.WA 98366 (360)876-0958 MASON COUNTY N° 910 GENERAL SERVICES DEPARTMENT ENVIRONMENTAL HEALTH SECTION 303 NORTH 4th STREET • SHELTON;WA 98584 • PHONE (208)42655,61 RECORD OF FINAL INSPECTION OF YOUR_SEWAGE DISPOSAL SYSTEM OWV - Q,ilnik �If y,} �A - ADDRESS Jl 9?D �.4A h,qn d LF 4) '. Rd THIS RECORD IS NOT A GUARANTEE OF PERFORMANCE. LEGAL 0: o/ Ne - i x St , NE •; -S E/ Se-e .5 5 A SEPTIC SYSTEM IS NOT A MUNICIPAL SEWER. HOWEVER DESCRIPTION �O!lJk..4lx,'P Q N. •.� /.� WITH PROPER MAINTENANCE AND CAREFUL USE OF WATER IT CAN GIVE MANY YEARS OF TROUBLE FREE SER- VICE. MANY PROBLEMS WITH SEPTIC TANKS ARE CAUSED SOIL BY FLUSHING EXCESSIVE AMOUNTS OF PAPER, CLOTH COMMENTS Q,e,¢(/ //C.� AND PLASTIC MATERIALS DOWN THE DRAIN, OR BY SITE J J FIELD x LARGE AMOUNTS OF WATER FROM LEAKY FAUCETS OR NO: O it L. SIZE FAULTY FIXTURES. DEPTH TO MONTH WATER TABLE OF YEAR THE SEPTIC TANK ITSELF SHOULD BE CLEANED EVERY 'INSTALLER TWO OR THREE YEARS DEPENDING ON THE HABITS OF THE FAMILY, THE NUMBER OF FIXTURES IN THE HOUSE, AND • SIZE THE AMOUNT THAT A GARBAGE DISPOSAL IS USED. CLEAN- SEPTIC TANK (S) DDD 'o1- ING AT THE RIGHT TIME WILL AVOID THE RISK OF INJUR- DRAINFIELD �l FEET ING OR DESTROYING THE DRAINFIELD DUE TO SOLIDS LENGTH O n/'JS. i<O-,/�- " . �6 5-0' -s4 10,14 CARRYING OVER INTO THE DRAINFIELD. CALL THE TRENCH AREA SOD. FT. MASON COUNTY HEALTH DEPARTMENT FOR A LIST OF LICENSED SEPTIC TANK CLEANERS IN YOUR AREA. THE - TILE CLEANER CAN SERVE YOU BEST IF YOU SHOW HIM THIS , . DEPTH at) �� ❑ CORRUGATED ❑ RIGID LJ CEMENT RECORD WHEN HE COMES. ROCK DEPTH TOTAL HEAVY TRUCKS OR EQUIPMENT SHOULD NEVER BE BELOW CU. YDS. PIPE DEPTH . DRIVEN OVER THE TANK OR DRAINFIELD. CONSULT THIS SPACE RESERVED FOR RECORD IN CASE OF ANY BUILDINGS, DRIVEWAYS, REPLACEMENT DISTRIBUTION FIELD: SQ. FT. SWIMMING POOLS, OR EXTENSIVE GRADING OR FILLING ' , ( I + • ' +-NORTH-t+{��-�-I'F-_) ( III ■■ ■ ■■ ■■ I ARE LATER CONTEMPLATED. i ,: - 24�t I I Rp�N`- 5��ti to ■•■ ■■�a SHRUBS OR TREES SHOULD NOT BE PLANTED CLOSE TO ■ � I ° '�-; ,_�i rd ■ THE SEPTIC TANK AS THEY WOULD INTERFERE WITH •t■_ _ ■�i�� III CLEANING OF THE TANK. THEY CAN BE PLANTED IN THElb 4 r 1 ■:51: w::.��"Y�O�■• ��� INFIELD AREA PROVIDING WILLOWS ARE NOT USED.. ■■ ■■■■■ s■■■■�■■U■■■■.■ 1 ■■■■ TH D GRADE IN THE DISPOSAL AREA SHOULD BE W■. n 43_ ■••■a■■.■ru.. ■i'■ SUCH TH TER_IS NOT POCKETED ON THE • ■ ■ ■■■ ■■■ ■W■I�■ DRAINFIELD. ANY SETTLING OF THE GROUND OVER THE NMI mommiltilr�= D_ _M■■1■ y6 ■■ .■■■■■w . 1■ TR E FILLED IN WITH SOIL. DO NOT EX- ■ :■ Y1■ ■11 -■�n���■`_` : if1-�J _ CE SI LAWN IN THE DRAINFIELD AREA.. ----I -p 1 + r + ■ A■ - + I p:�' WATER EVAPORATION FROM THE DRAINFIELD IS ABOUT �, lj ' EQ RAIN PER DAY. / Y } ; I 1 1 + # 1 1 tt1 .+ I ' , _ TING DRAINAGE, DOWNS'*UTS AND WATER-' -�_�`''" + ._J_■I����It■ - OFTENER RECHARGE WATER SHO 1 LD 1. •• ' f ■ >.C!■■��■■lti!■r a ' _ NECTED TO THE SEPTIC SYSTEM OR 01' H�1,0 ���, f -r �� _ H , u,O��I■1111d _� ( I1 DRAINFIELD AREA. t1 5V1�!� I t THE TYPES OF BACTERIA NEEDE I I. :: ' :►. A•: I 1 j II k , .1 1 I 1110111111 'z l ALWAYS FOUND IN SEWAGE. THE'E IS NO NEED TO ADD N■ } YEAST OR OTHER STARTERS TO A -Y5 t, . THE USE OF-RE- f ' . I . JUVENATORS OR CHEMICALS Ti' �1 ►�' A SEPTIC TANK ' ', HAVE NOT BEEN PROVEN TO BE ; ". • AL AND MAY:BE - i 1 HARMFUL BY FLUSHING SOLIDS OUT OF THE TANK OR:BY - CHANGING THE CHARACTERISTICS OF THE SOIL. THE NORMAL USE OF BOWL CLEANERS OR CLEANING C M- - POUNDS WILL NOT KILL THE BACT AL ACTIO S ,W,. '' 1 SOILJTH- 1 0 DOWN THE OPERATION OF THE SE C � 1L/"'! /` •: THIS IS AN IMPOR A DOCUMENT DATE � - APPROVE, KEEP IT WITH GEED ESSENTIAL PAPERS. DATE _ CERTIFIED BY . 0 S ,t/t l L /'L'S'AVCM CM o IS13-0S71 t •E'MIT • PERMIT NO.q 3 -/4- 'r � N MASON 6DUN EPARTMENT OF HEALTH SERVICES SITE EVA}UA11ON N AND WSTAI-ATION m ����, Date `ol. . - Date 5. N (�,ge. 4- - DAR/P.O.BOX 1666/SHELTON,WA 98584 Receipt No. .f�j� Receipt No. 7 N- �t/ PHONE(206)427-9670 Amount$ - A,/Jd Amount$ a pgpoP O ER: DATE: CHECK APPLICABLE ITEMS ✓ u m R 1 o ..; L 1 a�e-y'f1 (.ate J��,)Q3 INSTALLING NEW SYSTEM D� MAILING ADDRESS: DAYTIME P ONE: REPAIRING OLD SYSTEM / �� R.Q y:.6 4 5.23 LtJ 3 70 P�r�lrn� P ZIP: , EXPANDING SYSTEM a CITY: STATE: SINGLE FAMILY .—mow S lie it '�0. OTHER J"` � z PROPERTY ADDRESS SPECIFY: Xi • e- PRIVATE WELL p m SPECIFIC DIRECTIONS FOR LOCATE G SITE: PUB AC SYSTEM / ,Q o She 111/on1`PAafi o4-Pt full- Pa�fi Dold'on�� SYSTEM ID NUMBER �t b /PM pn POaYloxn1-!2 1k Nd I,-m;le> Oh ',eh- SYSTEMNAME t fV APPLICANT 5 2•e 6 /Sr S NAME 113. Name of 1 Lot R.x ft. MAILING ADDRESS 0 i�V Installer J p b J Size: 4-7•— aces TELEPHONE ( i I� ' N Name of Number of I/ O a,,r) X �REDesigner k ' in t Bedro ` ' PLOT PLAN Draw a dimensional plot plan, L e7.4q e- 0D j �, ,y" Q I(� 3 r- .• r� boiC !�r p.'. . ... ovation o ,.We S IO ',i ba-4 showing _ v' • //a • ` tan ..:� 1�, `b0 > �O r�j. . i;dar-I .� ` -Ps n N *acthdherlig*_ � so ,;s.p .r.. to Nq�!�4-,Tm 0D "N 1 NI 70 j Ai �,CC v�,T W . I�a�C r' FICIAL USE ONLY. DO NOT WRITE BELOW DOUBLE LINE. _ i' / / , SOIL LOGS r)1 Q-� 6-0G1 .'.i - �1 GUT ) ✓C7lf6+l �_ � 1��d7f9G' ✓l e; - 6'( m or s 6..Q 10, .g,7 rn0,410, -,, dJ _ )moo lab7rse 40,3 Q' / (Jn 'z t l Q /� w� Depth from Original VV (Q Grade to Restrictive ® . tA At4er rj/ Z/ 4 Layer or Water Table: In. DESIGNER DESIGNATION SCORES MINIMUM SYSTEM REQUIREMENTS 1 Finding I Score 1 Designer Level: ,One O Two Soil Type 3 al 1. I✓3 le Mr- le1900 gzllo n` 1 hs/NIL q Septic Tank Daily Vertical Separation Oj . __W' S7',e. Capacity: Gal. Flow: /f 3 D GPD ' Ur Slope " Appl. 52/,[I Wilt.Parcel Size yf'l 5 -5 Rate/i 9, GPD/FTZ (/ Area FT' Distance to Shoreline �S�L _ Total q > Date q �, / Jns for �'o �f�tsdr ���'I�,� i, COMMENTS/CONDITIONS FOR APPROVAL 0 WW 1,. (t,)1, , u," yive 0 ta.;u ?-6/`)9.1/1)F real -ia''cvvec) S 2-1'?�tion. m con.51 nd or13on- rlofe 3 4 v- YL\ - Or o2� et7b.0h ti 21, 2, r4/ 17 is a5 �'o - 9 QC 5h7. n'e I4r er r.e 1�2 d u,wi •er 1 Any'chang? 'the s dfi"ed"us a of the property orb,n this permit m8 affecting the sto the Health-Officer stem desig___ri may nvali 10 d y18 01 dental date. •This Permit expires 3 years tram date of site Inspection.Denial y be appealed SPE: Regtf¢ed l7Not .. • :• DESI rkve�d`� ONotAp v INST L Vkr. Hued UNotAppro,,v/61„ i BY: A� DATE:),jig' �•�,BY: � y!\111L�1 DATE:,a,1J BY �. DATE:y��7'! 7jl k rIl F•nocyjnvi..,-• lr nnv R"�C17TTr1M•AnnlicaM'c Cony I AS-k?t1ILT FORM - PAGE TWO Revised 07/12/93 I+. PARCEL IDENTIFICATION . f• Permit Number SWC9 3 - ) 4 (� Subdivision (Na,n./DJ.vl..lon/sleek/Lut) Installer' s Name Assessor's Parcel No. s,.:)035 // .60005 Designer' s Name AS-BUILT DRAWING - . . . • - c. sery \ CO ( 7 :- Is 9 pi �3 110 \-> la. ' Y 7 9r------Praia . Virc • • WI) • . CAUTION: Minor adjustments to septic tank location and drainfield orientation made in the field by the installer are generally ac- . ceptablo to both the department and the designer, but could in certain cases compromise the viability of the system. it is the in staller's responsibility to obtain prior written approval Croa either the health department or the designer before making any devi- ations from the design that affect system viability. Any deviations from the approved design bust be shown above. AS-BUILT CHECKLIST . © Drainfield orientation ® Observation port location a Undisturbed native- soil and layout • between trenches t LIE Cleanout location n 0 Trench/bed dimensions and U North arrow critical distances within Manifold placement a Mrs • . layout Scale of drawing shown 0 Orifice placement on scale bar • D-Box/"T"/"L" location a H, Lateral placement, with Additional Mound .Information Septic tank/pump chamber distances to edge of bed location Endslope width ElLocation of wells, roads CE Location of buildings Overall fill dimensions MASON C• OUltITYoEPARTMENT OF HEALTH SERVICES O , , plIMIONMINIMIIIIIIIMIOMMI&Mitri 5 S • M \ PERMIT NO. SWG q � � Date <. 0 426 W.CEDAR/P.O.BOX 1666/SHELTON,WA 98584 rn 9 PHONE(360)427-9670 Receipt No. ram' = N 9,_ V 01t - Amount$ m a DATE CHECK APPLICABLE ITEMS 6/ ms " 1/ 'iu G. /o __II.. -97 m NEW SYSTEM MAILING A DRESS: DAYTIME PHONE: m y0 P �(, _�/ �I REPAIR SYSTEM CITY:-�� 3/ I An"M"r STATE: 21P: MAINTENANCE REVIEW d C f I �Q, C��� ZIP: SINGLE FAMILY PROPERTY ADDRESS: OTHER z / �p f/ SPECIFY: 3 LUGS>f ] / nGI►f o!/N` /" PRIVATE WELL S K. ro C RE.5CT)-1 R?gN J /4 ' ,/fr ,v 3 f COMMUNITY WELUPUBUC SYSTEM. �� j/��/ i� j� L/ O f,��y��, SYSTEM WFI H K/s1 IN y /''",/i `2�/C�1/7,,n `k _/J/ " '" x� APPSYSTEM NAME M/. �e. / r. '7 11 As' 11 e 4—HC/r f • ,NAME . • ICI Nam ) G 1 Lot ft.x ft. MAIL�� f Insta r ?Size: /f6 acres TELLP ) G Name of / /- 17 Designl/7Lopr /I� i 7-/'}-f lik1BedrooemsJ6 j-h Vl .7:11 1 f (l ✓ 1 PLOT PLAN Draw a dimensional plot plan, jj • /V A C X® I; including: J 1r /�;id h� x 5 It\ 0 Precise location of test ?j /�, , c X holes,showing I. ..- — AO—� @ Ya measured distances to g it cc,,,,,p X property boundaries. III Q Entry road;other roads, FArxi Nq I' ,• driveways. J NOTE: DO NOT DRAW IN II it SYSTEM DESIGN^ i An IPA, J lit. a2ol. • OFFICIAL USE ONLY. DO NOT WRITE BELOW DOUBLE LINE. , 1_,. .�( G-35" s / SOIL LOGS q.n.,� / y 0-?S 39-y6 ii,�pr<ckd. eA 4- 703 ef - 1421 kam• $ ( 2E5E11 � 1Tj Sa.Y,�S C.(:I I) / S 2s3 .714h o • z%3'4.,L 1 tom. 30 9ideal •Zs 54i,L +;I OCT 3 0199T T1-!2 � � /°`� -yc 30-(3b 44Il Zs- 4. -7747 0 PERMIT ASSISTANCE CENTER cd� e,fi ,,q q „Q s -3`d rood ) 2Y '' 3s' yh All 0-3/scr•,*11 leue- 9iR,J 745 foaf., DESIGNER DESIGNATION SCORES MINIMUM SYSTEM REQUIREMENTS Finding Score Designer Level: D One Two Soil Type _ 1.- Soil Depth B in. ic Tank Dow —Ii--- Capacity: Gal. Flow: 16 GPD Slope /7 % APO. r Infilt. Parcel Size 40 Ac. S Rate D.(p GPD/FT2 Area FT' 0 Distance to Shoreline Z 0 Total 11,,, 1 ' for Date - '- COMMENTS/C DMONS FO' APPROVAL , 0 •All on-site sewage systems must be designed by a Mason County Certified Designer or a Professional Engrg. •All on-site sewage systems must be installed by a Mason County Certified Installer,unless prior approval is granted for a homeowner installation of a gravity system. In such cases a preliminary on-site meeting between health department staff end the homeowner is required. •On-site sewage system design approval does not imply other bulkding site requirements(i.e.PLC,Water Adequacy)have been met. •Any change from the specified use of the property or any site alteration affecting the system design may invalidate this permit. •This•=y-expires 2 years from the date of site review.Denial of this permit may be appealed to the Health Officer within 10 days of denial date. SITE'I; - DESIGN REVIEW Approved p Not Approved INSTALLATION4Approved 0 Not Approved BY: I / DATE: ((I,DiQq BY:�• 1)¢�' DATE:(.2l_g8 BY: a-�.� DATE:2_.22„ct9 'i TOP:Health Dept.Copy MIDDLE: Designer's Copy BOTTOM:Applicants Copy fi • . • 1 \ t MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX 1666 SHELTON, WA 98584 (360 .427--9670 FAX 427-7798 APPLICATION FOR RE-INSPECTION [ 11 - ON-SITE SEWAGE PROGRAM - NOV 1 9 1997 DIRECTIONS PERMIT ASSISTANCE CENTER 1. Complete Part 1-3 and submit to the Director of Health Services, PO Box 1666, Shelton, WA 98584. 2. The on-site lead will make a determination in Part 4 whether a re-inspection is justified. When a re- . inspection is made, the findings of the second Environmental Health Specialist are written in Part 5. A final determination by the lead is recorded in Part 6. 3. Applicants are billed $77 when a re-inspection is required, and are expected to pay for any necessary laboratory costs associated with soil tests, unless prior arrangements are made with the health depart- ment. 4. Findings and determinations of the lead may be appealed to the Mason County Health Officer at the ad- dress listed above. PART 1: REQUEST FOR RE-INSPECTION- (� ��fj� / �/� Applicant's Name: ),A.40 t ' L.A t`E ` — `1 " - ( WA-L7�Kt f► rr u rat �� • Address: W Z S k 1 �� 1 • Telephone: ( 71 { c l `.0 • • ABBEgsb�'-PaTceT Rumbler-- uoaivisTion Name and L t Number Health Department finding being disputed by applicant: 1--) Anticipated n Anticipated depth of watertable U Soil type/application rate U Depth or presence of mottling Mew drainfield area to evaluate tJ Othgr (please specify) ?5Le., ./ SoW Nam'—) ► -tTS I A+ I�4L Q — 'Ne-�'"r iv F-tH L c) Y ,EC , f pi 3as"f �L-- so i Imo+-�T'G� 9 e p&- PART 2: AUTHORIZATION APPLICANT DATE H:OW-SITSIRR-fiVAL.W Reviled 09/03/96 N 4 • PART 3: PLOT PLAN Use this space to draw a detailed plot plan, or attach one to this application. A detailed plot plan is one that shows the precise location of the test hole , existing septic systems, dimensions of the property, and location of any wells, roads, or other buildings on the proper � + 9157 N6lAj 4F1-1"' ;or ` la visrfmr_ CF.\ 4 q Nitta- >o PART 4: DETERMINATION OF LEAD r-i 1__1 Re-inspection is justified. n l__i Re-inspection is not justified, for the following reason(s) : On-Site Lead Date H:ON-SITEIRE-EVAL.N Revised 09/0J/96 • ' " . . 453cimill.1 .4":14461/4): ". • ../ 44 __,/f j t� ... tit _ . - •�VI,o d v Min :44111k ...---66' AP ry°eFt "6 rl ettn ttNa—.4-4 — %-- 42 I °V1S::D '-''' 0 0 : .. •i io• --�:_a al 9 , olio • I 14 ,C it �v of i w ) I. 1 1 1";. i . . , / Z i� � 4- et2 o � . 1 ' i- - y • m v a -- ‘5 - '1- I\ \ - ,.. " . . 1 IQ) i its .N) ;70 kil t lk 1 i i i i 6 " 4 "%ir 1 i 1 ; lt WELL #1, EXISTING WELL WATER WELL REPORT tw� DEPARTMENT OF Notice of Intent No. WE59443 ECO LOGY Unique Ecology Well ID Tag No. BRG650 Type of Work: state of Washington 17 Construction Site Well Name(if more than one well): Well#1 0 Decommission t' Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: I Domestic 0 Industrial O Municipal Property Owner Name Panhandle 4-H Association ❑Dewatering O Irrigation ❑Test Well ❑Other Well Street Address 370 W Panhandle Lake Rd Construction Type: Method: ❑New well al Alteration ❑Driven ❑Jetted O Cable Tool City Shelton County Mason ❑Deepening O Other 0 Dug O Air- 0 Mud-Rotary Tax Parcel No. 52035-41-60000 Dimensions: Diameter of boring 8 in.,to 175 ft. Was a variance approved for this well? 0 Ycs 0 No Depth of completed well 175 ft. If yes,what was the variance for? Construction Details: wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread p I 0 8 in. 0 175 .25 in. DI I 0 O I 0 Location(see instructions on page 2) 51 WWM or 0 EWM ❑ 1 ❑ in — — tn. ❑ 1 ❑ ❑ 1 ❑ NE '/.-'/.of the SE 'A;Section 35 Township 20N Range 5W ❑ I ❑ in. 1n ❑ 1 ❑ ❑ 1 ❑. ❑ I ❑ ❑ I ❑ p I ❑ in. in Latitude(Example:47.12345) 47.178089 N Longitude(Example:-I20.12345) -123.266809 W Perforations: ®Yes ❑No Type of perforator used Mills knife Driller's Log/Construction or Decommission Procedure No.of perforations 116 Size of perforations in.by 3 in. Formation:Describe by color,character,size of material and structure,and the kind and ll Perforated from 46 ft.to 75 ft.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: 0 Yes O No 0 K-Packer ' Depth fl. information. Use additional sheets if necessary. Manufacturer's Name Material From To Type Model No. Diameter Slot size in.from _ft.to ft. Installed bentonite surface seal on existing well Diameter Slot size in.from ft.to_ft. Assigned Unique Well Tag I.D#:BRG650 Sand/Filter pack:0 Yes O No Size of pack material in. Materials placed from ft.to ft. Surface Seal: E Yes Cl No To what depth? 18 ft. Material used in seal Bentonite chips Did any strata contain unusable water? 0 Yes ©No Type of water? Depth of strata Method of sealing strata off Pump: Manufacturer's Name Goulds Type: Submersible H.P. 1 Pump intake depth:80 ft. Designed flow rate: 10 gpm Water Levels: Land-surface elevation above mean sea level 420 ft. Stick-up of top of well casing 1 ft.above ground surface Static water level 20 ft.below top of well casing Date 6/9/25 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? 0 No lal Yes c> by whom? Driller Yield 17 gpm with 47 ft.drawdown after .75 hrs. Yield 10 gpm with 18 R.drawdown after 4 hrs. Yield gpm with ft.drawdown after hrs. Recovery data(time=zero when pump is turned off-water level measured from well top to water level) Time Water Level Time Water Level Time Water Level Date of pumping test Bailer test_gpm with_ft dmwdown after hrs.1 Air test gpm with stem set at ft.for_hrs. H Date m Artesian flow_gp Temperature of water 52 °F Was a chemical analysis made? 0 Yes 0 No Start Date 6/9/25 Completed Date 6/9/25 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well construction standards.Materials used and the information reported above are true to my best knowledge and belief. O Driller O Trainee 0 PE—Print Phythian Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 2053 City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's Licen No. Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 6/9/25 ECY 050-1-20(Rev 09/18) if yott need this document in an alternate format,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. l NEW WELL WATER WELL REPORT DEPARTMENT Of Notice of Intent No. WE58430 ECOLOGY Unique •Ecology Well ID Tag No. BQC060 Type of Work: 1W1 State of Washington O Constniction Site Well Name(if more than one well) ❑ Decommission c- Original installation NOI No. Water Right Permit/Certificate No. Proposed Use: ©Domestic ❑Industrial 0 Municipal Property Owner Name Panhandle 4-H Association ❑Dewatering 0 Irrigation ❑Test Well ❑Other Well Street Address 370 W Panhandle Lake Rd Construction Type: Method: ❑New well ❑Alteration ❑Driven ❑Jetted 0 Cabk Tool City Shelton County Mason 129 Deepening ❑Other ❑Dug fill Air- 0 Mud-Rotary Tax Parcel No. 52035-41-60000 Dimensions: Diameter of boning 6 in.,to 181 fi. Was a variance approved for this well? 0 Yes ❑No Depth of completed well 181 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread ❑ 1 0 6 in. 0 .25 in. ❑ I 0 0 I 0 Location(see instructions on page 2): 0 WWM or❑EWM ❑ I ❑ in. in. ❑ I 0 0 1 0 NE 'A-%of the SE '/;Section 35 Township 20N Range 5W ❑ 1 0 in. in. ❑ 1 0 0 1 0 ❑ 1 0 in in ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47,12345) 47.178325 N _ Longitude(Example:-120.12345) -123.267847 W Perforations: ®Yes ❑No Type of perforator used Star No.of perforations 80 Size of perforations 1.25 in.by 3/8 is Driller's Log/Construction or Decommission Procedure Perforated from 99 ft.to 103 ft.below ground surface Formation:Describe by color,character,size of material and structure,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: I]Yes ❑No Ii]K-Packer r> Depth 117 fl information. Use additional sheets if necessary. Manufacturer's Name Alloy Machine Works ----- Material From To Type Wire-wrapped Model No. Diameter 5" Slot size.030 in.from 120 ft.to 130 ft. Gray silty clay,some fine gravel 103 106 Diameter 5" Slot size.000 in.from 130 ft.to 181 ft. Gray fine to medium silty sand and gravel,wet 106 109 Gray fine to coarse silty gravelly sand,moist 109 114 0 Sand/Filter pack:❑Yes ❑■ No Size of pack material in. Materials placed from ft.to ft. Light brown fine sandy silt 114 120 Brown silty fine to coarse sand 120 125 Surface Seal: 5]Yes O No To what depth? 18 ftII Brown fine to medium silty sand and gravel, 125 4. Material used in seal Bentonite chips Did any strata contain unusable water? 0 Yes El No weeps 130 Type of water? Depth of strata Reddish brown sandy siltbinder 130 147 Method of sealing strata off Brown sandy clay 147 174 Light gray fractured basalt 174 181 Pump: Manufacturer's Name Type: H.P. Pump intake depth:_ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level 434 ft. Slick-up of top of well casing 1_5 ft.above ground surface Static water level 79 it below top of well casing Date 12/4/24 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a primping test performed? E No ❑Yes =0 by whom? Yield gpm with_ft.drawdown after _hrs. Yield gpm with ft.drawdown after hrs. Yield gpm with IL drawdown after hrs. Recovery data(time=zero when pump is turned off-water level measured from well top to water level) Time Water Level Time Water level Time Water Level Date of pumping test Bailer test gpm with_ft.drawdown after Ius. Air test 20 gpm with stem set at 95 ft.for 2 hrs. - Date 12/4/24 Artesian flow gpm Temperature of water 51 ^F Was a chemical analysis made? 0 Ycs 0 No Start Date 12/2/24 Completed Date 12/4/24 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington welt construction standards.Materials used and the infonnation reported above are true to my best knowledge and belief Driller LI Trainee❑PE-Print Name Cory Johnson Drilling Company Arcadia Drilling Inc. Signature Address PO Box 1790 License No. 3441T Zt")'''rl;//.//''''''''..------ City,State,Zip Shelton,WA 98584 IF TRAINEE:Sponsor's License No.205 Contractor's Sponsor's Signature Registration No.ARCADDI098K1 Date 12/4/24 ECY 050-1-20(Rev 09/18) If you need this document in ate alternate formal.please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 71l for Washington Relay Service. 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