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Group A Well - PLN General - 3/31/1981
V�, P 141 SANITARY COVENANTS: L SEWAGE SYSTEMS SHALL BE LOCATEO AGA/HST FLAT OF Ti-/E ROAD R/GHT-OF-WAY FOR ALL WATERFRONT LOTS WITH THE EXCE PTIOH OF THE SEWAGE SYSTEMS OF VISTA K N 0 L L SUB-DiV/S/ON Lors I. 2 ANO 3, WHICH WILL HAVE TO BE CO- CA 7E W/TN//V THE ROAD R/GHT'Op'/✓A SEC / T/!N RS REPEAT OF LOTS X18, 19 AND 20, BLOCK_I, PLAT ,1450(1,1450(1cou/vry w.vv/.! 2.PARK/NG FOR ALL WATERFRONT OF LOST LAKE PARK, dOV'T. LOT 7, SECTION I, T19N,R5WWM .vewes'se•e LOTS SHALL BE ON THE ROAD R/CNT- a°fe.sr sr s OF WAY MASON COUNTY, WASHINGTON ) / . L0T5 2¢°3 5//ALL \ALL eE LEVE Leo To peg / --� -�5 i— — THE O LCAT/O/✓ OF THE/R RESPEC FIVE SE/WAG S 5YSTEMS / '\ 1 ~ 3 �•J y. •�•�, 6 TO BE LOCHTEO WITH/N TWC.ROAO R/CHT OF WAY J ! 4.A STATE HEAD TN APP/90V60 WATER SYSTEM WILL BE /M6j'ALLEO ,\// V 2i.0 1 Og• Sy -AlE TIME 50% OP THE L'07.5NAVE SE Cf.' So CO. / . S. ANT/C/PATEG WATER RATC.3 WILL BE OEF//.CEO. � `� 1 Z L__ 6. FUTURE OWN-( ERSN/P AND M4/NTENANCE RESP'ON S/B/L/)'Y \ �• II,�� e '4) WILL BE OE- : F/NEO ALSO FOR THE WATER SYST6 � � •, . .',',0!= 1L£ `°A o/ fNO/'e ;)-...N". \`\.�:Y < / �� \\ Mi'Jll)'r...viVA0O. /YM ^ ( FOVNO MoH0 (RUSLL PLAo0 D ° •°°- S°° •r J/ ``/ 50d10,. A11 C C Y4 V L RC. I V • •.:-... " L!./ 111 e fie` •\`T ' • / 5 \ .. & f 1 0 •� H \\ °f ytA 5a.9 �' ey .(/ P W I \�W _ _ \�° zo_•..,�. _ I r `1 'L �i.' sr' 4 0. R• z25.00 � ,-.r' ,,�J� b �+ /\`°`��,,(.,noi / �n� t �� .....�_/a/.1e3 Wr 'rc.-ty :'/ .'1.4�,'��. �. V�1\ t Ve.ee ID ' /� �'4r�b ��Y D ! �* Y Y>'e 7i•�o e•t a � � w o r�� ��. � ��.lt r oh��'k°/ pN�ry'sry �e7y •../ i� la <get_!•s/.a-.✓ F �� Yjry •1- °'. -�°<;i i uy!•y 3, D •r•s!.0! I 30•°e ~ `,�rpi° / V �' 4 °n%� s v M10° 2 O r J 1:1� kI � ...'�P .' w v °�/rd•/)ai�R ,se.of P• b 'S -•r / / P D Y5y `G• ,\�oi,A r •`j`/ r/•It4.e/ Rr•/22.Os 55 oR/sINAL PL ArrIN• /.�/ ` —/h' , H ry / - —O— ROAD E 4401.1UMENT5I„, I I/ � , PLAT con. MON c,MQN T! 90!•I!•il/r•W /rf. e tJNA LA/ CE 00OR/ES EXTEND INTO LAE /O'O.5.5/f-/AGE 2$,O FROM /1/OH WATER SNOREL/NE y EASEMENT C' ' COVElZ4MT.S'. CURVe" ¢ SHOR EL/NE • / �, CALL LOTS SHALL SC VSEO FOR OWELL/NO P[/RPOSES ONLY \,c\ }'`L/N0 5ovr LOT " 1/ 2 NO DOCK OR DOA c—uss SHALL Oe SSEO FOR COMMCRC/AL OR PURL/C USE. .. ' 3 SC/IL O/N.O SET BACK SHALL SE /O FELT FROM STREET LINE. DESG'RIPTIoN 4. SIDE YARD JET BACK SHALL SE 3' FEET. THE PLAT OF VISTA KNOLL /S q REP AT OF LOTS S NO O0GKS, FLOATS,P/LING OR OTHER .5F.5TR UC T VR E3 SHAL L zxrr"o INTO LOST LAKE MORE THAN 25 FEET FROM THE ,/9 20, SLOGK / P, LAT OF LOS LAKE PARK � /B ANO HIGH WATER SHOREL/NE. AS RECORD EO/N VOLUME $ 0. PLq Tfr .AGE-J, NO OWNER SHALL /N TER PER E WITH THE REASONABLE USE - - .QEC 0ROS OF MASON CO UNTY,WA S,Y/NG TON ANO : OF THE COMMON/TY SEACH FOR OOAT/N OTHER OESCR/BED AS FOLLOWS PL EA 3VRE 113EL .145 OTHER OWNERS OH T/I.'/S PLAT. /N ...,p' BEGN/NG AT THE NOR TNEq 3T CORN ER or 7. SEWAGE D/3 POSALTH MO T /OOS S BE /N ACGOR DANCE p SA,O LOT ,4. THENCE /10 830 OS.W, 2q/.S/ FEET,' WIT/-/ MASON COUNTY HEALTH PEG ULA r/o NS ANC THENCE 9G 5.00'0' /00.00 FEET, TN ONCE 55/0500 APPRo VCO S THE COUNTY HEAL TN OEPA.57445/.I F /30.00 FEET THENCE S A5•/O 3/5"W 43.0!FEEL 8, NO -OULTRY OR L/VE STO CK JNALL SE KEPT OR MAIN- THENCE S 2.00"oo"C /53,42 FEES• THENCE T O ANY WATERFRONT LOT S 2d•A6'o2.d`W 203.!/ FEET/ THENCE N0!•/!'t/o it W. NO cclVr N T/ G of TREES EXCEPT AS REO U/R ED FOR I41.53 FEET; TN 5p/CE N!30I</ E /27.6/'FEET, BU/LO/NC S/rE WILL BE PERMITTED. THENCE N0d2f4/SE 34.01 EET,. THENCE SSB•JO'olE /0 NO HOUSE TRAILERS WILL BE ALLOWED. 120.00 FEET, THENCE N So•2J /2"E fl.O FEET, T E CE //.WA TER WILL O P50/. TO EACH LOT UPON COMPLETION N 0!•II'.(.4 .00 /S3.fe FEET THENCE NS)•O/r]'W 3.le OP THE SALE OP SO•/. OFVISTA KNOLL- LOTS, • FEETTo A Po/NT OF CUR vi To THE R/GNT W/TH A .040/OS OF 225.00 F/CT BEAR/N6 /152..56 53^E- THENCE ALONE 5.5/0 CURVE To THE R/CHT THRO AN ARc O/STANCE OF /S/.38 FEET TO THt PO/NT OF CEO/NN/N C, /J y6, P140 PLAT OF VISTA KNOLL A REPLAT OF LOTS I8, 19 AND 20, BLOCK I, PLAT OF LOST LAKE PARK, GOVT LOT 7, SECTION I, T.19N,,R.5W.WM. MASON COUNTY, WASHINGTON DEDICATION CERTIFICATES KNOW ALL MEN BY THESE PRESENTS THAT WE THE I HEREBY CERTIFY THAT THE PLAT OF VISTA KNOLt.,Y$ UNDERSIGNED, PHILIP N.HERBIG AND NORMA L.HERBIG BASED UPON AN ACTUAL SURVEY AND/Sj7B01Vl SION"OF, HUSBAND AND WIFE;GENIAM,UFMOINIL ANOGELS,.EM6P SECTION I, TOWNSHIP 19 NORTH, RANGE(S.'WEST W.M.,,THAT M. HUSBAND AN WIPE,OWNERS IN THE DISTANCES AND COURSES SHOWN{ THEREON ARE PEE 51MPLE OF THE LAND HEREBY, PLeTTCD hiEa EBY DecLA¢e rKts'PLAT - I CORRETI THAT THE MONUMENTS NAME ,BEEN SET AND AND DEDICATES TO THE USE OF THE PUBLIC FUH- LOT AND BLOCK CORNERS STATED' ON THE -GROUND. EVER ALL STREETS, AVENUES, PLACES AND SEWER EASEMENTS OR WHATEVER PUBLIC PROPERTY THERE '� IS SHOWN ON THE PLAT AND THE USE THEREOF 1�•.; FOR ANY AND ALL PUBLIC PURPOSES NOT INCON— - �:��ol .%' SISTENT WITH THE USE THEREOF FOR PUBLIC j4E,J { •'O(' HIGHWAY PURPOSES. ALSO, THE RIGHT TO MAKE S " ALL NECESSARY SLOPES FOR CUTS AND FILLS cC`j�agra '�'' UPON LOTS, BLOCKS, TRACTS, ETC. SHOWN ON THIS •C2 TcAi �t,M' PLAT IN THE REASONABLE ORIGINAL GRADING OF .'� ��/� ALL THE STREET, AVENUES, PLACES, ETC. SHOWN EXAMINED AND APPROVED THIS L�DAY OF✓ Lr , FILED FOR RECORD AT��pTHE REQUEST OF HEREON. ALSO, THE RIGHT TO DRAIN ALL STREETS 1967, THIS�DAY OF '� ,1967 AT!2 OVER AND ACROSS ANY LOT OR LOTS WHERE , ME \ MINUTES PAST/e•eew n O'CLOCK AND RECORDED IN VOLUME WATER MIGHT TAKE A NATURAL COURSE AFTER ^\ \V/�\� ,/) OF PLATS, PAGE IL°-Lip',RECORDS OF MASON THE STREET OR STREETS ARE ORIGINALLY GRADED. \\ \,` CH MAN,M N ANNWG COMM COUNTY, WASHINGTON. - I IN WITNESS WHEREOF WE HAVE SET OUR SIDS EXAI{�N �AW APPROVED THIS DAY OF l -.Gyy-¢ti,✓ AND SEALS THIS DAY OF II9� lrr•r .H%. ITO OF MASON COON 3V " I '//df K /7AO. 9 j I 1• cc/ r2,4-'.-- DEPUTY ;; CINEER FOR CON.COUNTY •7"' :'R''A EXAMINED AND APPROVED IN ACCORDANCE WITH STATE OF EXAMINED AND APPROVED SUBJECT TO THE PROVISIONS WASHINGTON L9W5 OF 1961, CHAPTER 262, THE LZ�' OF AMENDED REGULATIONS GOVERNING PLATS IN DAY OF 2r , 1967. _ MACON COUNTY AS ADOPTED THIS �_DAY OF BWLY , 1967. (l_�,�.: ASSESSOR OF MA Of COUNfY I ACKNOWLEDGEMENT IR AN,BOARD of COUNTY COMMISSIONERS I STATE OF WASHINGTON) 11 I HEREBY CERTIFY THAT ALL STATE AND COUNTY TAXES )S3.J HERETOFORE LEVIED AGAINST THE PROPERTY DESCRIBED %COUNTY "QF. W.ASO.[I.J: HEREON, ACCORDING TO THE BOOKS AND RECORDS OF I MY OFFICE, HAVE BEEN FULLY PAID AND DISCHARGED, Thl Q CERTIFY THAT ON THIS DAY OF INCLUDING ,'9F TAXES. 1967.BEFORE ME THE UIJDER- n SIGN A NOTAQY PUBLIC.,IN ANO POQ THE STATE ,-1 3 OK,W,KWI4iNGTOM.OULY COMMISS1oMEDANDSWOQN q, IRE RE OF MASON COUNTY PERSONALLY,APPEAU.ED PHI.LIP,N.HE-OS IC. AND (.IOA,lAA L HERPG:,HU TWANG/NND WIFE IBEIIIOMIII F MONK ANO00EAIDIEPMONK,H1VSQ AND,AND WIPE, TD,ME.IGNOWN TO DE THE IN Dw1DVAL5 WHO ExE- DEDICATION C KNOWLEDGEM ENT , GV TED THE FOREGOIN4 DEDlCATI-ON AND.AC ' KNOW ALL MEN WY THESE PRESENTS-THATc5 THI 31,414€1R500.Y OF JE 191 S MOWLEDG6 THAT THEY 51GN ED AND ' tA1_ED CP,/Q SRANOT,PASS{DENT,AND MARY MIGHAELS, PEQSONALLV APPEARED C•4. 5RI.NDT' 'THE SAME DP THEIR. PO.EE AND VO LUNTAQY SECRETARY OF•OLYMPIA SAVINGS AND LOAN HRESIDENT 4.46 MARY MICIIAEL5,SEA- - 45T AND DeeD POR THE USES AND PURPOSES ASSOCIAT IO N,O W N E Q3 IN FEE 51MPLe OF VIE RETARY OF'OLYMPIA 501411445 AND LOAJ {t IT}IeEIN MENTIONED. IL MIOED. LAND HEEBY PLATTED, DE DICATE5 TO TNE PUSLIG Ag So CLAYTON•Tb ME 0NOWN TO EE THE :WITNESS MY HAND AND OFFICIAL SEAL THE DAY AND FOREVER ALL STREETS ,EASEMENTS AND P4O1. INID\VIDVAL5 DESCPISED IN AND WHo YEAR FIRST ABOVE WRITTEN. AQEA5 PLATTED THEREON Ex EGUTED THE POQEGOING DEDICATION z' 8 {N/V ITH E5S THEREOF .^/E HAVE HE EXUN To 5er ou P- AND AGICNOWLE ODE THAT THEY 51GNED H KX)' D SEAL, AND SEALCO THE SAML OF TH EI O- PQ NOT Y LIC IN AND`F9R THE A7 /`//� ///p��]J��,Q��p�/� AN0 —l.NTeEU-ACr AND DEED F00. OF WASkNGTON, RESIDING ATC"" ^"�--LAJ •`-��`• rHE VSe3 AND PVRPo5 ES THEREIN PRESIDENT SE TAR, MaNTIONCD. WITNESS MY HANG OFF ICIAL SEAL THe DAY at-Jo'la AP- F1RST NOT QY OU6LIG IN ANo FOR- THE STATE OP.WAH1 G'tbr-I.eEf10l L1 SHEET I OF2 MASON COUNTY • COMMUNITY SEF Building,Planning,Environmental Health,Communi 1/6/2020 Mitch Edwards Vista Knoll Water Co Inc 991 W Lakeside Dr Shelton,WA 98584 Subject: Vista Knoll Water Co Inc,ID#91938 D,1N Inspection performed on 12/10/19 Dear Water System Manager: Thank you for meeting with me to conduct a survey of this of Drinking Water's(ODW)way to inspect public water s} Deficiencies that need your attention are summarized Belo' agreed with my findings. As you correct the items,send tJ the items have been completed as directed. Include the sy≤ deficiencies were corrected. Please send your information swro.sanitarysurveys@doh.wa.gov or by mail to Southwe5 Program,PO Box 47823,Olympia,Washington 98504-7F If you are not able to correct these deficiencies,you must assigned describing how and when the work will be comp RECOMMENDATIONS-The following recommendati managerial,or financial capacity. 1. The well tag assigned by the Dept.of Ecology on recommend you request a new well tag and updat 2. Raw water source sample taps have been added tc are currently configured in the up position. Reco facing downward. During the survey,you added downward-turned PVC extension to Well#1 (SO 3. Verify the wells associated with S01 and S02 are (360)236-3046 or email sophia.petro@doh.wa.gc Public Health (Community Health/Environmental Health) 415 N.6th Street—Shelton,WA 98584 Shelton:360-427-9670,Ext.400 Belfair:360-275-4467,Ext.400 Elma:360-482-5269,Ext.400 Regulations establishing a schedule of fees for sanitary surveys was adopted with WAC 246-290-990. Enclosed is the invoice for your survey. Please mail your payment and a copy of the invoice to: Department of Health,Accounts Receivable,PO Box 1099,Olympia,Washington 98507-1099. By completing this sanitary survey,your water system met the requirements in WAC 246-290-416. Your next survey is due in 5 years. If you have any questions about this report,please contact me at 360-427-9670 ext. 584 or by e-mail at wmathews@co.mason.wa.us. Sincerely, Wendy Mathews Environmental Health Specialist Enclosure cc: Mitch Edwards,Owner Denise Miles,ODW Public Health Community Development (Community Health/Environmental Health) (Permit Assistance Center/Building/Planning) 415 N.6th Street—Shelton,WA 98584 615W.Alder Street—Shelton,WA 98584 Shelton:360-427-9670,Ext.400 Shelton:360-427-9670,Ext.352 Belfair:360-275-4467,Ext.400 Belfair:360-275-4467,Ext.352 Elma:360-482-5269,Ext.400 Elma:360-482-5269,Ext.352 WATER FACILITIES INVENTORY (WFI) Quarter: 3 / FORM Updated: 05/13/2019 Washington State Drmontctf Iealth Printed: 1/6/2020 ONE FORM PER SYSTEM WFI Printed For: On-Demand D;v;.imt»/G»x,iral near Health Oj)ic'of brutki»g Watcr Submission Reason: No Change RETURN TO: Central Services-WFI, PO Box 47822, Olympia, WA, 98504-7822 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY L4. GROUP 5. TYPE 91938D VISTA KNOLL WATER CO INC MASON A TNC 6.PRIMARY CONTACT NAME&MAILING ADDRESS 7.OWNER NAME&MAILING ADDRESS KEVIN R.ODEGARD[OPERATIONS SUPVI MITCH EDWARDS PO BOX 123 991 W LAKESIDE DR PORT ORCHARD,WA 98366 SHELTON,WA 98584 STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE ATTN ATTN ADDRESS 7245 BETHEL-BURLEY RD SE ADDRESS CITY PORT ORCHARD STATE WA ZIP 98367 CITY 9.24 HOUR PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION Primary Contact Daytime Phone: (360)876-0958 Owner Daytime Phone: (360)490-9924 Primary Contact Mobile/Cell Phone: (253)377-1865 Owner Mobile/Cell Phone: ,4360)p182 357— 3(?D G') 9 Z Primary Contact Evening Phone: —(xxx)-xx wxxxx(bG)$ ?(e —p $ Owner Evening Phone: Fax: (360)876-4196 E-mail: I'Se rio to IgVjWA ' .eoln E-mail: x x t f-a D ,Co►^^ 1.SATELLITE MANAGEMENT AGENCY-SMA(check only one) ❑ Not applicable(Skip to#12) ❑ Owned and Managed SMA NAME: Northwest Water Systems,Inc. SMA Number:119 Managed Only Owned Only 12,WATER SYSTEM CHARACTERISTICS(mark all that apply) ❑Agricultural ❑ Hospital/Clinic / C2- _-1 "� ❑Commercial/Business ❑ Industrial e CJ � d` ❑Day Care ❑ Licensed Residentih ❑ Food Service/Food Permit ❑ Lodging 3 -, j Jr ❑ 1,000 or more person event for 2 or more days per year ❑ Recreational/RV P 3.WATER SYSTEM OWNERSHIP(mark only one) DID r i#1 ') ❑Association ❑County p Investor ❑City/Town ❑Federal 15 16 17 18 19__________ 0] L D/LI SOURCE NAME INTERTIE SOURCE CATEGORY USE LIST UTILITY'S NAME FOR SOURCE rn L- / �� i � " (( D - � . AND WELL TAG ID NUMBER. z z C �� " 0 Example: WELL#1 XYZ456 -Q . U D -n m IF SOURCE IS PURCHASED OR INTERTIE r r z m 3 z r 0 0 r A O m m z D m O A m m fn z r t to L0 G) r O D w GAi 0 c Z Z INTERTIED, SYSTEM ,S 1 n X m r > D r z O m m z > 3 3 LIST SELLER'S NAME ID rrrZrrmmZmZ > mzOOOCm mm z 0 m = 0 v m Example: SEATTLE NUMBER r o v c� v o z z z r 1 o m z z z 5 z z E w z A v m S01 WELL#1 AFif584, t,.,�( '[/parj x X X 80 50 NW SW 06 19N 04W S02 WELL#2 AKF585 X-133 133 50 NW SW 06 19N 04W DOH 331-011 (Rev. 06/03) DOH Copy Page: 1 WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE 91938 D VISTA KNOLL WATER CO INC MASON A TNC DOH USE ONLYI OH USE ONLY ACTIVE CALCULATED APPROVED SERVICE ACTIVE CONNECTIONS CONNECTIONS CONNECTIONS 25, SINGLE FAMILY RESIDENCES(How many of the following do you have?) 35 36 A. Full Time Single Family Residences(Occupied 180 days or more per year) 10 B. Part Time Single Family Residences(Occupied less than 180 days per year) 25 26. MULTI-FAMILY RESIDENTIAL BUILDINGS(How many of the following do you have?) A. Apartment Buildings,condos,duplexes,barracks,dorms 0 B. Full Time Residential Units in the Apartments,Condos,Duplexes,Dorms that are occupied more than 180 days/year 0 C. Part Time Residential Units in the Apartments,Condos,Duplexes,Dorms that are occupied less than 180 days/year 0 27, NON-RESIDENTIAL CONNECTIONS(How many of the following do you have?) A.Recreational Services and/or Transient Accommodations(Campsites,RV sites,hotel/motel/overnight units) 0 0 0 B. Institutional,Commercial/Business,School,Day Care,Industrial Services,etc. 0 0 0 28, TOTAL SERVICE CONNECTIONS 35 36 29. FULL-TIME RESIDENTIAL POPULATION A. How many residents are served by this system 180 or more days per year? 20 30. PART-TIME RESIDENTIAL POPULATION JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC A. How many part-time residents are present each month? 11 11 11 11 11 11 11 11 11 11 11 11 B. How many days per month are they present? 8 8 8 8 8 8 8 8 8 8 8 8 31. TEMPORARY&TRANSIENT USERS JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC A. How many total visitors,attendees,travelers,campers,patients or customers have access to the water system each month? B. How many days per month is water accessible to the public? 32. REGULAR NON-RESIDENTIAL USERS JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC A. If you have schools,daycares,or businesses connected to your water system,how many students daycare children and/or employees are present each month? B. How many days per month are they present? 33. ROUTINE COLIFORM SCHEDULE JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Requirement is exception from WAG 246-290 1 0 0 1 0 0 1 0 0 1 0 0 34. NITRATE SCHEDULE QUARTERLY ANNUALLY ONCE EVERY 3 YEARS (One Sample per source by time period) 501,S02 ;35.=Rear Submitting WFI: hange ❑ Update-No Change ❑Inactivate ❑Re-Activate ❑ Name Change ❑New System ❑Other 36. I certify that the information stated on this WFI form is co rest to the best of my knowledge. SIGNATURE: DATE: l l/ tt ! t ' Mpd J-� PRINT NAME: Wc TITLE: !' t//rrr ^` t7f R U SY DOH 331-011 (Rev.06/03) DOH Copy Page: 2 WATER FACILITIES INVENTORY (WFI) FORM Quarter: 3 Updated: 05/11/2018 �� W-Vngt-SWeDq-t—tof i ONE FORM PER SYSTEM Printed: 112412019 ri Hezl th WFI Printed For: On-Demand Submission Reason: No Change C)fftcr(!f 6rinking IV,rnv RETURN TO: Central Services-WFI,PO Box 47822,Olympia,WA,98504-7822 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE. 91938 D VISTA KNOLL WATER CO INC MASON A TNC 6.PRIMARY CONTACT NAME&MAILING ADDRESS 7.OWNER NAME&MAILING ADDRESS J8. NUMBER: 021386 t t KEVIN R.ODEGARD[OPERATIONS SUPV] MITCH EDWARDS .r PO BOX 123 991 W LAKESIDE DR PORT ORCHARD,WA 98366 SHELTON,WA 98584 - o N It' STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE ATTN ATTN ADDRESS 7245 BETHEL-BURLEY RD SE ADDRESS .� CITY PORT ORCHARD STATE WA ZIP 98367 CITY STATE ZIP 9.24 HOUR PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION Primary Contact Daytime Phone: (360)876-0958 Owner Daytime Phone: (360)490-9924 _. Primary Contact Mobile/Cell Phone: (253)377-1865 Owner Mobile/Cell Phone: 360)-482-396- W-&_- �y Primary Contact Evening Phone: (360)876-0958 Owner Evening Phone: "4 Fax: (360)876-4196 E-mail: Kevin@nwwatersystems.com Fax: E-mail: VistaKnoll@yahoo.com 1.SATELLITE MANAGEMENT AGENCY-SMA(check only one) ❑ Not applicable(Skip to#12) ❑ Owned and Managed SMA NAME: Northwest Water Systems,Inc. SMA Number:119 X Managed Only Owned Only 12.WATER SYSTEM CHARACTERISTICS(mark all that apply) ❑Agricultural ❑ Hospital/Clinic X Residential ❑ Commercial/Business ❑ Industrial ❑ School ❑ Day Care ❑ Licensed Residential Facility ❑ Temporary Farm Worker ❑ Food Service/Food Permit ❑ Lodging ❑ Other(church,fire station,etc.): ❑ 1,000 or more person event for 2 or more days per year O Recreational/RV Park 3.WATER SYSTEM OWNERSHIP(mark only one) 4. STORAGE CAPACITY(gallons) ❑Association ❑County ❑Investor ❑Special District ❑City/Town ❑ Federal XPrivate ❑ State 1,000 _ 1v 15 16 17 18 19 20 21 22 23 24 SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION C Z C) LIST UTILITY'S NAME FOR SOURCE p z y m 0 z = D m in 2 AND WELL TAG ID NUMBER. Z z c < c 0 A X r A\ 29 Example: WELL#1 XYZ456 D in D ° m m r c C -i m m 3 m 11 , r r z 3 mD z m 3D m IF SOURCE IS PURCHASED OR. I�' INTERTIE r r rn Q D z o 0 ' i< c V9/•. y O �e r O D m O D D z O -noZrr- 3 INTERT SYSTEM ?� ?� T ?� D D r < z O m m z _1 I LIST SE ER'S NAME Examp SEATTLE NUMBER z y z z M m S01 WELL#1 AFK584 7 X X x 80 50 NW SW 06 19N 04W S02 WELL#p7AKF585 yt�b L = ', dk11p I X X 133 50 NW SW 06 19N 04W ll DOH 331-011(Rev.06/03) r ' � (Local Health Jurisdiction lx` 3X1� L�1 R WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE 91938 D VISTA KNOLL WATER CO INC MASON A TNC DOH USE ONLYI OH USE ONLY ACTIVE CALCULATED APPROVED SERVICE ACTIVE CONNECTIONS CONNECTIONS CONNECTIONS 25. SINGLE FAMILY RESIDENCES(How many of the following do you have?) 35 36 A. Full Time Single Family Residences(Occupied 180 days or more per year) 10 B. Part Time Single Family Residences(Occupied less than 180 days per year) 25 26. MULTI-FAMILY RESIDENTIAL BUILDINGS(How many of the following do you have?) A. Apartment Buildings,condos,duplexes,barracks,dorms 0 B. Full Time Residential Units in the Apartments,Condos,Duplexes,Dorms that are occupied more than 180 days/year 0 C. Part Time Residential Units in the Apartments,Condos,Duplexes,Dorms that are occupied less than 180 days/year 0 27. NON-RESIDENTIAL CONNECTIONS(How many of the following do you have?) A.Recreational Services and/or Transient Accommodations(Campsites,RV sites,hotel/motel/overnight units) 0 0 0 B. Institutional,Commercial/Business,School,Day Care,Industrial Services,etc. 0 0 0 28. TOTAL SERVICE CONNECTIONS 35 36 29. FULL-TIME RESIDENTIAL POPULATION A. How many residents are served by this system 180 or more days per year? 20 30. PART-TIME RESIDENTIAL POPULATION JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC A. How many part-time residents are present each month? 11 11 11 11 11 11 11 11 11 11 11 11 B. How many days per month are they present? 8 8 8 8 8 8 8 8 8 8 8 8 31. TEMPORARY&TRANSIENT USERS JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC A. How many total visitors,attendees,travelers,campers,patients or customers have access to the water system each month? B. How many days per month is water accessible to the public? 32. REGULAR NON-RESIDENTIAL USERS JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC A. If you have schools,daycares,or businesses connected to your water system,how many students daycare children and/or employees are present each month? B. How many days per month are they present? 33. ROUTINE COLIFORM SCHEDULE JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Requirement is exception from WAC 246-290 1 0 0 1 0 0 1 0 0 1 0 0 34. NITRATE SCHEDULE QUARTERLY ANNUALLY ONCE EVERY 3 YEARS (One Sample per source by time period) S01,S02 35. Reason for Submitting WFI: ❑Update-Change ❑ Update-No Change ❑Inactivate ❑Re-Activate ❑ Name Change ❑New System ❑Other 36. I certify that the Information stated on this WFI form Is correct to the best of my knowledge. SIGNATURE: DATE: PRINT NAME: TITLE: DOH 331-011(Rev.06/03) Local Health Jurisdiction Copy Page: 2 _ Y+Y Use the space below to sketch a simple schematic of the water system facilities.You may use the templates shown below to help build your schematic.The sketch should show location of sources,treatment, pressure tanks, booster pumps, storage tanks,and a simple representation of the distribution system. Include direction of flow(directional arrows)and brief description of how the controls function. Source Name: WELL#1 (AFK584) WELL#2 (AFK585) (91938 D) Source Number: I &2 Example templates you can use to build your schematic: Pressure Chlorine Pressure Booster Distribution Well w/Pump Switch Injection Point Tank Pumo Reservoir System Well w/Pump ■ SO1 Sensor Probe Distribution System Hydropneumatic Pressure Tank Well w/Pump SO2 (Revised 01/2010) To download an electronic version of this system schematic,visit http://www.doh.wa.gov/ehp/dw/Programs/ss_third_party.htm «-4. �Ir��•-- r�^?,'f�.s"cTr_F,:_...s.riT rimed�x..>i., r.r _ .t�...n; -.�+._ ..cur,. r _ Use the graph below to locate any potential biological and chemical contaminants found within the source's Sanitary Control Area (SCA). The SCA is the protective area within 100 feet of wells or 200 feet of springs. Source Name: WELL#1 (AFK584) WELL#2 (AFK585) (91938 D) Source Number: 1 &2 — — :- ` X Lr _ LJ- i Ep≥ring `. _ f-.__._...<•.... _ .. ' i r �4' }} I ; I 1 y [Y�^'R. l y ! { P1 F I { H L1 LA I �. _ `_. L --�.....• 1 � r '� I,- E v t .,,.,,.p Slr' _ -H -'-- _i_ _ - - - - - -F -- - ( i i : I :: 711 50 P nr -I P I I E i E tT -., t __.. :'..,...._ _...»_�-�%.._..__,._.....f.. _ !...._�. #_ ' .��.—.�__.— � 1¢' --t---•-fir a � �a`e3+ ..�. =•- .? �-sr.rra- a�ckx:L .x.�• s..� n.. A. C E. _____ - ±t _____ 1 ____ _ D l5 Abandoned water wells Dumpsters Pesticide storage Animal burial Fuel tanks(above or below ground) Roads and parking lots Biological contaminants Graveyards Sewer lines,gravity or pressure Buildings Hazardous waste disposal site Storm water catch basins Chemical contaminants Hazardous waste facility Surface water Drainfields and septic tanks Irrigation canal Wastewater spray irrigation Drug lab Landfill,dump,disposal area Other: Dry wells Pesticide application (Revised 01/2010) To download an electronic version of this SCA drawing,visit http://www.doh.wa.goviehp/dw/Programs/ss_third_party.htm • • • r, irn • • System Name: VISTA KNOLL WATER CO INC Survey Date: 12/101. PWS ID#: 91938 D County: MASON System Type: p 5 Persons Attending Inspection: Inspector's Name: The following is a completed sanitary survey checklist and summary of inspection findings.This completed sanitary survey checklist is the basis for the cover letter you receive from your local health jurisdiction or from the WA Dept.of Health (DOH). The cover letter documents any significant deficiencies or significant findings that must be corrected.The cover letter may also summarize observations concerning compliance with certain rules, and offer recommendations you can use to make improvements to the operation and management of your water system.Contact your DOH regional office with any questions you have about this survey. Bolded and highlighted checklist items represent significant deficiencies that, if left uncorrected, create a significant public health risk. Highlighted checklist items represent significant findings that, if left uncorrected, create a significant risk to the physical safety, security, or reliability of the pub�licdrinkin9 water su fly. You will be required to take some sort of corrective action for each checklist answer that is bolded and highlighted, or highghted. Significant deficiencies and significant findings identified during this sanitary survey: Significant deficiencies or significant findings identified in the previous sanitary survey that remain unaddressed: 24a) 5O1 vent is covered by >24#mesh TPSS made a correction to WFI in 2014 San Surv:SO2 well tag was listed as AKF584 and corrected to AFK584.However 2018 update still has AKF584.(see Observation 15) below) Observations and recommendations identified during this survey 15) SO1 Well tag is missing (was AFK584) 24a) 5O2 vent is covered by nylon mesh (24#) 27) Raw water source sample taps have been added since 2014 Sanitary Survey. During survey,owner added temp non- threaded 90 degree downward-turned PVC extension to 5O1 tap (tap was installed upward-turned).He will replace with threaded plumbing fixture or cap until next available system service to adjust. 31) Both well heads are exterior to(locked) pump house,SO1 in brushy area;SO2 in cleared area next to pump house. Not a high traffic area. 331-487-F(1/2017) Page 1 12. Did you observe a source connected to the water system that is NOT listed on the WFI and in active use? ❑Yes ❑No 12a. If so,has the source received written DOH approval? (confirm with DOH post-survey) ❑Yes ❑NNa 13. DOH Source Number: SO#1 SO#2 14. Source Name from the WFI:(For example, North Well;Well#2;ABC334.) Well#1 Well#2 15. Dept of Ecology Well Tag Number:(Use Well tag ID#, None or Not readable) None AFK58S 16. Source Use: P- Permanent S -Seasonal E- Emergency P P 17. If this is an emergency source should it be.disconnected? = LI1s❑No®NA ❑s❑No®NA 18. Is the source a potential GWI source? Dyes No Dyes No WELL (if there is no well skip to question 34) _ = 19. Is the Sanitary Control Area (SCA) free of unmitigated potential sources of ®Yes❑ ZYes❑No. contamination? 20. Is the wellhead located in a pit or vault? ❑Yes No ❑Yes®No 21. Is the wellhead at risk of submergence? ❑-Yes®No ❑ ZNo 22. Is the well cap sealed,watertight,and free of unprotected openings? ®Yes❑.N ®Yes❑NR--6, 23. Is the well casing free of any unprotected openings? ®Yes❑ ®Yes❑�9 24. Is there a vent on the well? ®Yes❑No ®Yes❑No 24a. If yes, is the vent protected?(24 non-corrodible mesh screen or slots) ❑Yes Z Dyes®No 25. Are conduits and junction boxes sealed to prevent contaminant entry? ®Yes❑.N ®Yes❑Na 26. Is the well unreasonably at risk to physical damage? ❑ 3®No ❑I ®No 27. Is there a raw water source sample tap? ®Yes❑ DYes❑ 28. Is the source metered? ®Yes❑No ®Yes❑No 28a. If yes,is the source meter read at least monthly? Dyes❑No Dyes❑No 28b. If yes,are the water production records maintained? Dyes❑No ❑Yes❑No 29. Is the wellhouse properly constructed and maintained? If no,explain below ®Yes❑No ®Yes❑No 30. Is there any evidence of infestation by rodents or other pests? ❑Yes®No Dyes No 31. Is the wellhouse and well adequately protected from unauthorized access and ®Yes❑ ZYes DNo tampering? 32. Is there a pump control valve or vacuum relief valve without an air gap on the ❑Yes❑No®NA Dyes❑No ®NA valve discharge pipe? 33. Are the source pump and pump controls operational and adequate to prevent ®Yes❑ i ®Yes❑Nq chronic water outages or premature pump failure? If no explain below SPRING (if there is no spring, skip to question 41) _Y; 34. Is the springbox(structure,hatch,and overflow)constructed to prevent the = Dyes ❑Ng ❑Yes ❑No entry of contaminants or direct surface drainage? If yes,describe below. 35. Is there a raw water source sample tap? = Dyes ON Dyes❑ 36. Is the source metered? Dyes❑No Dyes❑No 36a. If yes,is the source meter read at least monthly? Dyes❑No Dyes❑No 36b. If yes,are the water production records maintained? Dyes❑No Dyes❑No 37. Is the springhouse properly constructed and maintained? If no,explain below Dyes❑No Dyes❑No 38. Is there any evidence of infestation by rodents or other pests? Dyes❑No Dyes❑No 39. Is the springhouse and spring box adequately protected from unauthorized access? Dyes❑ Dyes❑ 40. Is the Sanitary Control Area (SCA) free of unmitigated potential sources of Dyes❑N6 Dyes❑& contamination? Describe and evaluate the source facilities including maintenance,operations,sanitary and security observations and any major change made to the source such as pump replacement,deepening or reconstruction: 15) 5O1 is missing its well tag (was AFK584).24a)SO1 vent covered by nylon mesh, 24#;5O2 vent is covered by mesh >24# Page 3 61. Are pump and pump controls operational and adequate to prevent chronic water outages or _ Eyes ❑No premature pump failure? If no explain below 62. If there is a booster pump house/pump station, is it secure against unauthorized entry? If no,explain below ❑Yes ❑No❑NA 63. Is the booster pump house/pump station properly constructed and maintained? If no,explain below ❑Yes❑No Describe and evaluate the pump facilities and controls including maintenance, operations, sanitary and security observations: 64. Are there any pressure tanks in use? If no,skip Part H ®Yes❑No 65. For systems using an air compressor;is the compressor an oil-free type or does it use food_-grade oil? ®Yes❑No❑NA 66. Are valves present to isolate pressure tanks for maintenance or repair? ®Yes❑No 67. Is there an ASME pressure relief valve installed between each pressure tank and any shutoff valve? (see EYes❑No DOH publication#331-429) 68. Are the pressure tanks in good working condition? If no,explain below ®Yes❑No Describe and evaluate the pressure tanks including maintenance, operational,sanitary and security observations: From 2014 Sanitary Survey(unchanged):The 500 gallon up right hydropneumatic pressure tank is housed in a wood framed structure with insulated finished interior walls, concrete floor, proper lighting and a heat source. The garage type door is lockable and opens wide enough to have access to the pressure tank for efficient installation and removal when necessary. The pressure tank is an Air Lite Whitewater with an internal probe that monitors the water level eliminating the need for a sight glass. The probe relays water level information to the lag pump pressure switch to engage the alternating pump system. 69. Is there a finished water storage tank in use? If no,skip Part I Yes No 70. If unable to physically inspect the storage tank hatch,vent, roof,or overflow outlet,select the method you discussed with the purveyor to document their condition: a ❑ Reviewed and discussed maintenance records and recent photos b ' ❑Photos will betaken and mailed by purveyor-, additional follow-up required by DOH c ❑ Purveyor unable or unwilling to document;additional follow-up required by DOH Insert Tank Names 71. Is the storage tank protected from unauthorized entry or vandalism? If no,explain ❑Yes ❑ ❑Vnk Eyes ❑No ❑unk below 72. 1s the reservoir roof free of any unprotected openings? If no, explain below ❑Yes❑Nq❑unI ❑Yes ❑No❑qnk 73. Is the access hatch constructed and sealed to prevent the entry of - Dyes ❑Na�❑unl ❑Yes EN o❑unk contaminants?If no,explain below 74. If able to open hatch, is the stored water free of visible contaminants? If no, Dyes ❑No ❑unk ❑Yes ❑No ❑unk explain below _ 75. Is there a dedicated air vent on the storage tank? Eyes❑No ❑ k Eves❑No ❑unk 75a. If yes is theair vent constructed to prevent the entry of contaminants? If Eyes ❑l ❑unf ❑Yes❑No❑unk no, explain below 76. Is the overflow line constructed to prevent contaminants from entering the ❑Yes❑!K ❑uhf Eyes EN o❑unk tank? If no, explain below 77. Does the overflow line discharge near ground level? Eves❑No ❑unk Eves❑No❑unk 78. Is the overflow line discharge area protected from potential erosion? Eyes ❑No ❑unk Dyes❑No ❑unk 79. Does the overflow line discharge into a storm drain or surface water? ❑Yes❑No EkI Eyes❑No❑.unk 79a. If yes, is there an air gap at the discharge of the overflow OR does the Eyes ❑ E . Eyes❑ ❑unk overflow drop at least 34 vertical feet measured from the overflow connection to the reservoir down to the receiving water body? 80. Does the overflow line discharge directly into a sanitary sewer without an air ❑Y s❑No ❑unk ❑Yes❑No ❑unk gap? Page 5 + + a 99. Is the operator of the water system certified? ®Yes ❑No 100. Describe the operator's certification level (if certified),duration of employment with this water system, relationship with the system (e.g., contract operator,SMA, direct hire employee,volunteer,temporary,or owner),and duties and responsibilities. 101. Does the operator conduct self-inspections of the water system? If yes, describe frequency and scope of ❑Yes No these self-inspections below. 102. Is the operator performing measurements and calibration of water treatment monitoring equipment ❑Yes❑No ❑NA consistent with manufacturer recommendations? If no,describe below. 103. Is the operator using proper inputs to treatment plant operations reports,such as correct volume,peak flow ❑Yes❑No ❑NA rate, time,and making the proper calculations? If no,describe below. 104. Does the operator take compliance water quality samples at the proper location? If no,describe below. ❑Yes❑No DNA Additional operator comments: - • a Descriptions of any water quality tests, physical measurements,or simple repairs completed during the inspection: • • Supplemental comments from other parts of the checklist,and documentation of field safety concerns: If you need this publication in an alternative format, call 800.525.0127 (TDD/TTY call 711).This and other publications are available at www.doh.wa.gov/drinkingwater. Page 7 Use the graph below to locate any potential biological and chemical contaminants found within the source's Sanitary Control Area (SCA).The SCA is the protective area within 100 feet of wells or 200 feet of springs. Source Name: Source Number: ❑ 100 ft for Wells ❑ 200 ft for Springs � - it FTb. . - JJi( I.)kmTtWr.h Abandoned water wells Dumpsters Pesticide storage Animal burial Fuel tanks(above or below ground) Roads and parking lots Biological contaminants Graveyards Sewer lines,gravity or pressure Buildings Hazardous waste disposal site Storm water catch basins Chemical contaminants Hazardous waste facility Surface water Drainfields and septic tanks Irrigation canal Wastewater spray irrigation Drug lab Landfill,dump, disposal area Other: Dry wells I Pesticide application Page 9 System Name: VISTA KNOLL WATER CO INC Survey Date: 8/13/14 PWS ID#: 91938 D County: MASON COUNTY System Type: TNC Persons Attending Inspection: LOGAN ARNOLD. NWS TECHNICIAN MITCH EDWARDS, OWNER SANDRA EDWARDS,OWNER Inspectors Name: CAROL SPAULDING s /� it �i, of 4�r t is .gi•;,^ ",i. '••, v :.r}t , 'a :3.`x .'"!t b U s Ott' d F 1� il�..� a -• { !""",.sue.''i1��0.i-ts t��� f oi�.X w�`.i,1..d� hz.$N. •... v 4..'^r'r+`:: R'E.'`i. : ���:,,{ ;+,. ..t :,,'fu..q,.t,11; ��2:' apt r,.ki;. .., : •t•, . ., S,.S k 7 x.. The following is a completed sanitary survey checklist and summary of inspection findings.This completed sanitary survey checklist is the basis for the cover letter you receive from your local health jurisdiction or from the WA Dept.of Health (DOH). The cover letter documents any significant deficiencies or significant findings that must be corrected.The cover letter may also summarize observations concerning compliance with certain rules, and offer recommendations you can use to make improvements to the operation and management of your water system.Contact your DOH regional office with any questions you have about this survey. Bolded and highlighted checklist items represent significant deficiencies that,if left uncorrected, create a significant public health risk. Highlighted checklist items represent significant findings that, if left uncorrected, create a significant risk to the physical safety, security, or reliability of the public drinking water supply. You will be required to take some sort of corrective action for each checklist answer that is bolded and highlighted or highlighted. Significant deficiencies and significant findings identified during this sanitary survey: Significant findings. Part D: Sources. There are no raw source water sample taps installed on either of thiwo wells. Significant findings. Pan:D: Sources. The screen on well head #1 vent is not 24_mesh. — Significant deficiencies or significant findings identified in the previous sanitary survey that remain unaddressed: ' I Observations and recommendations identified during this survey OBSERVATION: Portions of the Small Water System Management Program are out of date. ___ _____-i ---ii Page 1 December 2013 ------ - i ~� t+ C �_wt 1 J Ft •+ tf ri...'F Y '.. � L ...i ►'[ L 0 t LPL['.. 9L - ► 1 t 12. Did you observe a source connected to the water system that is NOT listed on the WFI and in active use? ❑Yes No 4-•ti w om . 12a'. If so; has the source received-written DOH approval? (confirm with DOH"post-survey)`. ❑Yes❑N'o 13.DOH Source Number: SO# 1 SO# 2 14.Source Name from the WFI: (For example, North Well;Well#2;ABC334.) WELL#1 WELL#2 15. Dept of Ecology Well Tag Number: (Use Well tag ID#, None or Not readable) AFK584 ..AFK68#— (ll5s.t 16. Source Use P Permanent S-Seasonal E Emergency P P 1T:If this is an emergency source',should it be disconnected? ❑Yes❑No®NA ❑Yes❑No®NA 18. Is the source a potential G'WI source? ❑'Yes®No ❑tYes®No WELL:(if there is no well,skip to question 34)` 19. Is the Sanitary Control Area(SCA)free of unmitigated potential sources,of . ®Yes No ®Yes❑No contamination?. .. 20. Is the wellhead located in a pit or vault? Dyes No Dyes No 21:Is the wellhead at risk ofsubmergence? Dyes No ❑Yes No 22. Is the well cap,sealed,watertight,and free of unprotected openings? es Yes S� ® 23.Is the well casing free of any unprotected openings?. - :- ®Yes❑...No es Duo 24. Is there a vent on the well? ®Yes❑No ®Yes❑No 24a.If yes,is the vent protected?(24 nori corrodible mesh screen or slots) Dyes o p ®Ye o r 25 sAre conduits and junction.boxes sealed to prevent contaminant entry? ®Yes❑No ®Yes❑No 26..Is the well unreasonably at risk to physical damage? DS'es®No ❑1(es No 271s there a raw water source sample tap?: fi 4:. Jot, es- Ip &e *the a source metered? qp ®Yes No ®Yes❑No yes,is the source meter read at least monthly? ®No Yes®Nof yes,are the water production records maintained? ®Yes❑No ®Yes❑No wellhouse properly constructed and maintained? If no,explain below ®Yes❑No ®Yes❑No 30. Is there evidence of rodent infestation? Dyes No Dyes®No 311s the wellhouse a y ec e from unauthorized acces _ _ ®Yes❑No bo 1 ®Yes❑No S�Z 32.Is there a pump control v alve or vacuum relief valve without an air gap on the Dyes❑No®NA ❑Yes❑No®NA valve discharge pipe? 33.Are the source pump and pump controls operational and adequate to prevent ®Yes No ®Yes❑No chronic water outages or premature pump failure?: If no explain below:< SPRING-`(if there is no spring skip to question 41) 34 Is thee' '•ringbox.(structure,`hatch,and'overflow)constructed to prevent the ❑Yes No Dyes❑No entry of con minants or direct surface drainage? If yes;describe below 35t. Is there a ra titer source sample tap? ❑Yes❑No Dyes❑No 36. Is the source met d?. Dyes❑No Dyes❑No 36a.If yes, is the source eter read at least monthly? Dyes❑No Dyes❑No 36b.If yes,are the water pro tion records maintained? Dyes❑No Dyes❑No 37. Is the springhouse properly con cted and maintained? If no,explain below Dyes❑No Dyes❑No 38. Is there evidence of rodent infestatio Dyes❑No Dyes❑No r:..ly.^ rid ^3 Is the sp ringhouse and snng box adequ ly protected from unauthorized access? Dyes DI o Dyes DNo 40 Is the Sanitary Control Area(SCA)free of mitigated potential sources of Dyes❑No Dyes❑No, contamination? Describe and evaluate the source facilities including mai nance,operations, sanitary and security observations and any major change made to the source such as pump replacement,dee ning or reconstruction: Continue on next page with Source narrative information December 2013 Page 3 �._..�J. _ '�- 53. Is there any treatment other than chlorination or UV in use? If no, skip Part F. ❑Yes No 54 Did you observe a treatnientprocess connectedto the water system in active us-e that is NOT listed,on:the ❑Yes❑No WFI? If yes, describe below ~ 55 is there a water supply line plumbed directly into a chemical solution tank(e.g.,fluoride saturator) Yes❑No ❑NA without a reduced press`'ure liackflow assembly on the supply line? • 56. Are primary contaminant treatment facilities(e.g.,nitrate, corrosion control,arsenic)operating ❑Yes ❑No • properly? If no;describe below 57. Do the water treatment chemicals meet NSF/ANSI Standard 60? ❑Yes❑ o DNA 58. is there a post-treatment sample tap? _ ❑Yes❑ o Describe the treatment facilities including purpose for treatment, concerns with maintenance or operations, purveyor's record keeping of monthly reports, and sanitary and security observations: FKp�ti: C t' tl .1; j eta 59.Are there any booster pumps in use? If no, skip Part G ❑Yes®No 60.Are the booster pumps in good working condition? If no, explain below Dyes❑No 61.Are pump and pump controls operational and adequate to prevent;chronic water outages or Dyes❑No premature pump failure?If no explain below 62.If there is a booster pump house/pump station,is it secure against unauthorized entry?If no,explain below Dyes❑No DNA 63. Is the booster pump house/pump station properly constructed and maintained? If no, explain below Dyes❑No Describe and evaluate the pump facilities and controls including maintenance,operations, sanitary and security observations: December 2013 Page 5 Describe and evaluate the finished water storage facilities including volume, operational drawdown, configuration of the inlet/outlet piping, any concerns about operations and maintenance, and sanitary and security observations: f t 86. Is a complete, up to date and accurate map of the distribution system maintained? - ®Ys❑No 87. <Does the system provide adequate pressure throughout the distribution system? If no,explain 6efow ®Yes❑No 88. Are proper procedures followed for disinfection of new construction or repairs? ®Yes❑No 89.Are there blow-offs to flush the system? ®Yes❑No 90. Does the purveyor seasonally or annually flush the distribution system? If yes, describe below Yes ❑No No 91. Does the purveyor exercise its distribution system valves? If yes, describe below ®Yes ❑ Describe and evaluate the distribution system including maintenance, operational, sanitary and security observations 90. Mr. Edwards flushes the system three times per year. SO1 flows through a source meter and enters the pump house via a 2 inch galvanized iron pipe from the north hide and SO2 enters from the south and flows through a source meter in the pump house. The sources then converge and enter th pressure tank and then out to distribution. According to the distribution map, a 4 inch PVC main travels north west along Russell Plac until it branches west along Herbig Drive were it ends in a cul-de-sac. After branching west,the main travels north along Russell Dri a to Lost Lake View Drive ending in a 2 inch blow off and reduces to a 2 inch line to serve the last eight properties. AL December 2013 Page 7 +, s-..-__. _ _._J.-. 99. Is the operator of the water system certified? I ®Yes DNo 100. Describe the operator's certification level (if certified),duration of employment with this water system, relationship with the system /e.g., contract operator,SMA, direct hire employee,volunteer,temporary, or owner),and duties and responsibilities Vista Knoll Water Co Inc. has a contract with Northwest Water Systems, inc. (NWS)to manage their water system. The certified operator for NWS is Kelly Racke, operator#011822 er certifications include, WDM3 (Water Distribution Manager for up to 55,000 connections, CPS (Cross Connection ontrol Specialist) and currently WTTOIT(Water Treatment Plant Operator in training). The NWS technicians wore under her direction. For this system, the technician, Logan Arnold, is responsible for quarterly inspections of the water system which includes checking the performance of the pressure tanks ficpressure arjd leaks, recording quarterly source meter readings to a excel spreadsheet, and collecting quarterly bacterio ogical sa les. Additional duties and responsibilities performed t oughout th year by NWS technicians include; collecting annual nitrate samples and compliance samples when neede cycling puns and record recovery time and exercise the distribution valves Mr. Edwards drains and recharge pressj.4"annually, flushes the system 3 times per year and turns the,k�eater on during the winter when needed. —(p 7 101. Does the operator conduct self-inspections of the water system? If yes, describe frequency and scope ®Yes No of these self-inspections below. 102. Is the operator performing measurements and calibration of water treatment monitoring equipment DYes DNo ®NA consistent with manufacturer recommendations? If no, describe below. 103. Is the operator using proper inputs to treatment plant operations reports, such as correct volume,peak DYes DNo ®NA flow rate, time, and making the proper calculations? If no, describe 6elow. 104. Does the operator take compliance water qualty samples at the proper location? If no, descri6e 6elow. ®Yes DNo DNA Additional operator comments: 101. Quarterly water system inspections by the SMA are described above in Part L: OPERATOR. December 2013 _ Page 9 4'NSON Co Public Health Always working for a safer a healthier Mason County September 5, 2014 Northwest Water Systems Vista Knoll Water Co Inc PO Box 123 Port Orchard, WA 98366 Subject: Vista Knoll Water Co Inc, ID 91938 D, Mason County; Third Party Sanitary Survey Inspection Report Dear Water System Manager: Thank you for meeting with me to conduct the survey of this water system on August 13, 2014. The enclosed report documents the findings of my survey. Office of Drinking Water (ODW) has reviewed the information collected during the survey and agrees with my findings. The following summarizes the items that need your attention SIGNIFICANT DEFICIENCIES — None found SIGNIFICANT FINDINGS — By October 17, 2014, please submit verification that the items below have been corrected or an action plan with timeline indicating when the work will be completed. 1. There are no raw source water sample taps installed on either of the two wells. Install a water sampling tap downstream of each well and before treatment or storage facilities. You must be able to collect a raw-water sample to comply with the Groundwater Rule. 2. The screen on the Well #1 vent is not 24-mesh. Install a 24-mesh, non-corrodible screen on the Well # 1 vent. OBSERVATION 3. The Small Water System Management Program must be updated with current information. Please send information requested above to Denise Miles via email at swro.sanitarysurveys@doh.wa.gov or mail to Denise Miles, Southwest Drinking Water Operations, PO Box 47823, Olympia, Washington 98504-7823. In your response please reference the system name, PWS ID #, and date when the items were corrected. Mason County Public Health P.O.Box 1666,Shelton WA 98584 Shelton:(360)427-9670:• Belfair:(360)275-4467:• Elma:(360)482-5269 FAX(360)427-7787 www.co.ma so n.wa.us ODW will send you an invoice in a separate mailing in the amount of$600.00. If you have any questions about this letter or inspection report, please contact me at 360-427-9670 or by e-mail at cns@co.mason.wa.us. Sincerely, a &L nn i 9 Carol Spaulding, R.S. EH Specialist Enclosure: Sanitary Survey Report cc: Denise Miles, SWRO DOH Drinking Water Mitch Edwards, Owner, Vista Knoll Water Co Inc Mason County Public Health P.O.Box 1666,Shelton WA 98584 Shelton:(360)427-9670•3 Belfair:(360)275-4467•3 Elma:(360)482-5269 FAX(360)427-7787 www.co.mason.wa.us 1A, Wx)d, nSWeR?vtmmtof WATER FACILITIES INVENTORY (WFI) FORM Quarter:3 Health ONE FORM PER SYSTEM Updated:04/21/2014 Printed:8/1/2014 Dicisbn oo//Errvom+aolrtl Hvilk Off,,of 6 6kMg W W WFI Printed For:On-Demand Submission Reason:Owner Update RETURN TO: Southwest Regional Office, PO Box 47823, Olympia,WA,98504 SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE L938 D VISTA KNOLL WATER CO INC MASON A TNC PRIMARY CONTACT NAME&MAILING ADDRESS OWNER NAME&MAILING ADDRESS Owner Number 021386 +<EL LY N. RACK [MANAGER] ?M arcs N Cz�t�) MITCH EDWARDS TITLE: NORTHWEST WATER SYSTEMS 991 W LAKESIDE DR PO BOX 123 SHELTON,WA 98584 PORT ORCHARD,WA 98366 STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM TTN TTN DDRESS 7245 BETHEL BURLEY DDRESS ITY PORT ORCHARD STATE WA ZIP 98367 ITY STATE ZIP 9.24 HOUR PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION Primary Contact Daytime Phone: (360)876-0958 Owner Daytime Phone: (360)490-9924 Primary Contact Mobile/Cell Phone: (206)321-9020 Owner Mobile/Cell Phone: (360)482-3957 Primary Contact Evening Phone: (xxx)xxx-xxxx Owner Evening Phone: (xxx)xxx-xxxx Fax:(360)876-4196 1 E-mail:XXXXXX Owner Fax Phone: E-mail:XXXXXX 11.SATELLITE MANAGEMENT AGENCY-SMA(check only one) o Not applicable(Skip to#12) Owned and Managed SMA NAME: Northwest Water Systems,Inc. SMA Number: 119 X Managed Only Owned Only 12.WATER SYSTEM CHARACTERISTICS(mark all that apply) Agricultural D Hospital/Clinic XResidential Commercial/Business Industrial DSchool Day Care Licensed Residential FacilityTemporary Farm Worker Food Service/Food Permit Lodging 00ther(church,fire station,etc.): D1 000 or more person event for 2 or more days per year Recreational/RV Park 3.WATER SYSTEM OWNERSHIP(mark only one) 4. STORAGE CAPACITY(gallons) Association 0County Investor Special District City/Town ❑Federal Private 0State 1,000 15 16 17 18 19 20 21 22 23 24 SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION v to Z C7 ?� n O O� A m LIST UTILITY'S NAME FOR SOURCE INTERTIE �n m O O = r z m m ) AND WELL TAG ID NUMBER. SYSTEM ID I— rf� O {„ m ;o z 0 -�i O Z r - O NUMBER D n O m m z 'D—i z$A z = Example: WELL#1 XYZ456 D M z m z � O rn m IF SOURCE IS PURCHASED OR m T rrt z °z �- m O INTERTIED, F m 3 z LIST SELLER'S NAME FvamnI, CFCTTI F X X 80 50 NW SW 06 19N 04 S01 ELL#1 AFK584 X 133 50 NW S 06 19N 04 S02 JELL#2585 2 585 X fr ± II I = = X X DOH 331-011 (Rev.06/03) Page: 1 WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID 2. SYSTEM NAME 3. COUNTY 4. GROUP 5. TYPE 91938D VISTA KNOLL WATER CO INC MASON A TNC ACTIVE SERVICE DOH USE ONLY! DOH USE ONLY! CONNECTIONS CALCULATED APPROVED ACTIVE CONNECTIONS CONNECTIONS 5. SINGLE FAMILY RESIDENCES(How many of the following do you have?) 0 35 36 Full ime Single Family Residences(Occupied ays or more per year) 10 Part Time Single Family Residences(Occupied less than 180 days per year) 25 6. MULTI-FAMILY RESIDENTIAL BUILDINGS(How many of the following do you have?) Apartment Buildings,condos,duplexes,barracks,dorms 0 . Full Time Residential Units in the Apartments,Condos,Duplexes,Dorms that are occupied more than 180 days/year 0 Part Time Residential Units in the Apartments,Condos,Duplexes,Dorms that are occupied less than 180 days/year 0 7. NON-RESIDENTIAL CONNECTIONS(How many of the following do you have?) .Recreational Services and/or Transient Accommodations(Campsites,RV sites,hotel/motel/overnight units) 0 0 0 t. Institutional,Commercial/Buslness,School,Day Care,Industrial Services,etc. 0 0 0 28. TOTAL SERVICE CONNECTIONS 35 36 9. FULL-TIME RESIDENTIAL POPULATION A. How many residents are served by this system 180 or more days per 20 0. PART-TIME RESIDENTIAL POPULATION JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC . How many part-time residents are present each month? 11 11 11 11 11 11 11 11 11 11 11 11 3. How many days per month are they present? 8 8 8 8 8 8 8 8 8 8 8 8 1. TEMPORARY&TRANSIENT USERS JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC . How many total visitors,attendees,travelers,campers, atients or customers have access to the water system each onth? 3. How many days per month is water accessible tot the public? 2. REGULAR NON-RESIDENTIAL USERS JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC . If you have schools,daycares,or businesses connected to our water system,how many students daycare children and/or mployees are present each month? 3. How many days per month are they present? 3. ROUTINE COLIFORM SCHEDULE 7JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC 1 0 0 1 0 0 1 0 0 1 0 0 QUARTERLY ANNUALLY ONCE EVERY 3 YEARS 4. NITRATE SCHEDULE I S01, S02 (One Sample per source by time period) 35. Reason for Submitting WFI: o Update-Change ❑Update-No Change ❑Inactivate ORe-Activate Name Change EJNew System 0 Other 36. I certify that the i formation stated on this WFI form is correct to the best of my knowledge. SIGNATURE: /l=$ 1, (9'zp DATE: q/ y� /�` ' PRINT NAM Mi21 /1 � 5 l Id 1Zpj TITLE: DOH 331-011 (Rev.06/03) Page: 2 • vh . System Name: VISTA KNOLL WATER CO INC Survey Date: 8/13114 PWS ID#: 91938 D County: MASON COUNTY System Type: TNC Persons Attending Inspection: LOGAN ARNOLD. NWS TECHNICIAN MITCH EDWARDS, OWNER SANDRA EDWARDS,OWNER Inspector's Name: CAROL SPAULDING The following is a completed sanitary survey checklist and summary of inspection findings.This completed sanitary survey checklist is the basis for the cover letter you receive from your local health jurisdiction or from the WA Dept. of Health (DOH). The cover letter documents any significant deficiencies or significant findings that must be corrected.The cover letter may also summarize observations concerning compliance with certain rules,and offer recommendations you can use to make improvements to the operation and management of your water system. Contact your DOH regional office with any questions you have about this survey. Bolded and highlighted checklist items represent significant deficiencies that, if left uncorrected, create a significant public health risk. Highlighted checklist items represent significant findings that, if left uncorrected,create a significant risk to the physical safety, security, or reliability of the public drinking water supply. You will be required to take some sort of corrective action for each checklist answer that is bolded and highlighted, or highlighted. Significant deficiencies and significant findings identified during this sanitary survey: ______ Significant Significant findings. Part D: Sources. There are no raw source water sample taps installed on either of the two wells. Significant findings. Part D: Sources. The screen on well head#1 vent is not 24-mesh. deficiencies or significant findings identified in the previous sanitary survey that remain unaddressed:[Significant : Observations and recommendations identified during this survey OBSERVATION: Portions of the Small Water System Management Program are out of date. December 2013 Page 1 Provide a general description of the water system including changes, updates,connections, source(s),storage, number of pressure zones,treatment,and control system(s)and alarm(s). Make corrections and updates to the purveyor's water facilities inventory form (WFI). The water system serves a residential population with 10 full time single family residences and 25 part time residences for a total of 35 connections with a green operating permit which is adequate for existing uses and adding new connections up to the number of approved service connections. The two sources pump via alternating submersible pumps controlled by the sensor probe in the pressure tank,to the pressure tank and out to distribution. The system operates in one pressure zone, has no additional storage other than the pressure tank and does not require treatment. Ii1kSI .] J [TTCommunitv(≤1 000 connections): Has the water system taken the online Capacity Assessment Survey? Dyes❑No®NA ---_- - — — --- 2.Were water system records available for your review? ®Yes❑No DPartial 3. Has the purveyor developed and implemented either a Small Water System Management Program or a ®Yes DNo Water System Plan? 3a. If no, are the following planning documents complete and up to date: Service Area and Facility Map Dyes❑No❑Partial Cross-Connection Control Program Dyes❑No❑Partial Source Water Protection Program Dyes❑No ❑Partial Emergency Response Plan Dyes❑No ❑Partial Operation and Maintenance Program Dyes❑No❑Partial Coliform Monitoring Plan Dyes RNo o❑Partial Component Inventory and Assessment Dyes ❑Partial Asset Replacement and Other System Improvements Dyes❑No❑Partial Budget — Dyes❑No❑Partial 4. Does the purveyor plan to make capital improvements in the next 1-3 years? If yes, describe below Dyes®No 5. Is there a backup operator available if the regular one is not available?If yes, provide contact info below IYes DNo 6.Were the water system's current and future water quality monitoring requirements reviewed? Yes DNo 7.Was water quality sample results and trends reviewed with the purveyor? ®Yes No 8. Does the system have emergency power? ®Yes DNo 9. Does the system experience frequent power outages(>2 per year) If yes, explain below Dyes No ------- --------------------- -------- 10. Does the system experience frequent water outages(>2 per year)?If yes, explain below Dyes No — ---------------------- 11. Does there appear to be adequate reliability provided for this system?If no, explain below— _ ®Yes❑No —_ Describe the general level of planning and management documents developed by this water system and any recommendations for additional development, including updates, system management practices and processes,water rates,etc. 5. Northwest Water Systems (NWS) technicians, 1-888-881-0958 Mitch Edwards, 360-490-9924, cell#360-482-3957 Larry Weaver, 360-581-9425 Service provider, Arcadia Drilling, Inc. 8.There is a generator available if needed. A comprehensive water system plan was created for the system by NWS in 2005. Upon reviewing the plan, updates are needed in the Operation and Maintenance (O&M) section to reflect NWS personnel changes and procedural changes and in the Financial section for budget projections beyond 2010. The Coliform Monitoring Plan will need to be updated to include source sampling when raw water source sampling taps are installed. Mr. Edwards sets the rates per cost of O&M which includes a reserve fund for future system needs or capita improvements. For security, there is a 100 foot declaration of Covenant for the Sanitary Control Area (SCA). December 2013 Page 2 . , fi •-•- • • •• • • .•• • • 12. Did you observe a source connected to the water system that is NOT listed on the WFI and in active use? ❑Yes®No 12a. If so, has the source received written DOH approval? (confirm with DOH post-survey) Dyes Do 13.DOH Source Number: SO# 1 SO# 2 14.Source Name from the WFI: (For example, North Well;Well#2;ABC334.) WELL#1 WELL#2 15. Dept of Ecology Well Tag Number: (Use Well tag ID#, None or Not readable) AFK584 AFK585 16.Source Use: I P-Permanent S-Seasonal E-Emergency -_-_ P P 17. If this is an emergency source, should it be disconnected? ❑Yes ❑No®NA ❑Yes❑No®NA 18. Is the source a potentia(GWI source? ❑`Yes®No ❑'Yes®No WELL (if there is no well, skip to question 34) 19. Is the Sanitary Control Area(SCA)free of unmitigated potential sources of ®Yes❑No es No contamination? -- - --------- ------------------------- 20. Is the wellhead located in a pit or vault? ❑Yes®No Dyes®No 21.Is the wellhead at risk of submergence? Dyes®No ❑Yes DNo 22. Is the well cap sealed,watertight,and free of unprotected openings? — - ®Yes❑No Dyes❑No 23.Is the well casing free of any unprotected openings? ®Yes❑No ®Yes❑No 24. Is there a vent on the well? ®Yes❑No ®Yes❑No 24a.If yes,is the vent protected?(24 non-corrodible mesh screen or slots) ❑Yes®No ®Yes❑No 25.Are conduits and junction boxes sealed to prevent contaminant entry? --- ®Yes❑No ®Yes❑No 26. Is the well unreasonably at risk to physical damage? _ — ❑Yes®No ❑Yes®No 27. Is there a raw water source sample tap? Dyes No ❑Yes® lo 28. Is the source metered? ®Yes❑No ®Yes❑No 28a. If yes, is the source meter read at least monthly? Dyes®No Dyes®No 28b. If yes,are the water production records maintained? ®Yes❑No ®Yes❑No 29. Is the wellhouse properly constructed and maintained? If no,explain below ®Yes❑No ®Yes ONO 30. Is there evidence of rodent infestation? Dyes®No ❑Yes®No 31. Is the wellhouse adequately protected from unauthorized access? ®Yes❑No ®Yes DNo 32. Is there a pump control valve or vacuum relief valve without an air gap on the ❑YeS❑No®NA Dyes ❑No®NA valve discharge pipe? 33.Are the source pump and pump controls operational and adequate to prevent ®Yes❑No ®Yes❑ lo chronic water outages or premature pump failure? If no explain below SPRING (if there is no spring, skip to question 41)_ ---- 34. Is the springbox(structure, hatch,and overflow)constructed to prevent the ❑Yes❑I10 Dyes ❑No entry of contaminants or direct surface drainage? If yes,describe below. 35. Is there a raw water source sample tap? Dyes❑No Dyes❑JVo 36. Is the source metered? Dyes❑No Dyes DNo 36a. If yes,is the source meter read at least monthly? Dyes❑No Dyes❑No 36b.If yes,are the water production records maintained? Dyes❑No Dyes❑No 37. Is the springhouse properly constructed and maintained? If no,explain below Dyes❑No Dyes❑No 38. Is there evidence of rodent infestation? Dyes❑No Dyes❑No 39. Is the springhouse and spring box adequately protected from unauthorized access? Dyes❑NNo Dyes❑ lo 40. Is the Sanitary Control Area(SCA)free of unmitigated potential sources of Dyes Do Dyes Do contamination? Describe and evaluate the source facilities including maintenance,operations, sanitary and security observations and any major change made to the source such as pump replacement, deepening or reconstruction: Continue on next page with Source narrative information December 2013 Page 3 -- Describe and evaluate the source facilities including maintenance, operations, sanitary and security observations and any major change made to the source such as pump replacement,deepening or reconstruction (continued): 24a. The screen on well head#1 vent is not 24-mesh 27. Every well must have a sample tap before any form of treatment. The raw-water tap allows an operator to take a "triggered" source sample in compliance with the Groundwater Rule. The incomplete well log report for Well#1 (SO1) shows the well was drilled in 1968 by Williams Drilling Company to a depth of 80 feet. Current capacity is stated as 50gpm. Well#2 (SO2)was drilled by Williams Well Drilling, Inc. in 1998 with an 8 inch casing to a depth of 133 feet through several restrictive areas with the first open interval of perforations from 51-66 feet , a Bentonite seal to 18 feet and a reported capacity of 50gpm. Both wells have pitless adapter style well heads and are located beside the pump control house on a secluded dead end street with one residential connection outside the SCA. • • • • o • • • 41. (Does the operator batch chlorinate the source, the distribution system, or the reservoir just before collecting Yes®No routine or repeat colform samples? If yes,provide details below_ 42. Did you observe disinfection treatment connected to the water system in active use that is NOT listed on the ❑Yes❑No WFI?If yes, explain below 43. Is ultraviolet light(UV) used for disinfecting a drinking water source?If no,skip to question 46. ❑Yes❑No 44. Is the UV unit sized for the maximum flow rate,and is there a UV transmittance sensor controlling a solenoid ❑Yes No valve or other device to shut off supply if the UV light fails? 45. Describe the UV equipment including: UV manufacturer and model number: Rated capacity(gpm) : Cleaning frequency of quartz sleeve : Mo/Yr UV light last replaced:461s there continuous chlorination? If no, skip to Part F T❑Yes ❑No 46a. If yes, please measure the free chlorine residual from a representative location in the distribution system. Location description: Free chlorine residual: 47. Is there a water supply line plumbed directly into a chlorine solution tank without a reduced pressure Dyes❑No backflow assembly on the supply line? 48. Is there a post-treatment sample tap? Dyes No 49. Does the chlorine compound meet NSF/ANSI Standard 60?-household bleach exempted ❑Yes DNo 50. Is a backup chemical feed pump or spare parts for the operating chemical feed pump available onsite? Dyes❑No 51.According to the operator, is there a DOH requirement for Chlorine Contact Time? If no, skip to Part F ❑Yes❑No 51 a. If yes, measure and record the free chlorine residual at the CT6 compliance location: (Describe compliance sampling location below—location must 6e prior to the first service connection downstream of chlorine addition. 52. Is the chlorine pump and pump controls constructed and maintained to provide uninterrupted, reliable CT6 ❑Til____ ❑No treatment?If no, describe below. Describe the chlorination facilities including purpose for chlorination,concerns with maintenance or operations, purveyor's record keeping of monthly reports, and sanitary and security observations: December 2013 Page 4 i 53. Is there any treatment other than chlorination or UV in use? If no, skip Part F. ❑Yes No 54. Did you observe a treatment process connected to the water system in active use that is NOT listed on the ❑Yes❑No WFI? If yes, describe below. 55. Is there a water supply line plumbed directly into a chemical solution tank(e.g.,fluoride saturator) ❑Yes❑No❑NA without a reduced pressure backflow assembly on the supply line? 56. Are primary contaminant treatment facilities(e.g., nitrate, corrosion control,arsenic)operating Dyes ON properly? If no, describe below 57. Do the water treatment chemicals meet NSF/ANSI Standard 60? ❑Yes❑No DNA 58. Is there a post-treatment sample tap? Dyes❑No Describe the treatment facilities including purpose for treatment,concerns with maintenance or operations, purveyor's record keeping of monthly reports,and sanitary and security observations: 59.Are there any booster pumps in use? If no, skip Part G Dyes No 60.Are the booster pumps in good working condition? If no, explain below ❑Yes❑No 61.Are pump and pump controls operational and adequate to prevent chronic water outages or Dyes❑Ho premature pump failure?If no explain below 62. If there is a booster pump house/pump station, is it secure against unauthorized entry?If no, explain below":' Dyes❑No DNA 63. Is the booster pump house/pump station properly constructed and maintained? If no, explain below ❑Yes❑No Describe and evaluate the pump facilities and controls including maintenance,operations,sanitary and security observations: December 2013 Page 5 64.Are there any pressure tanks in use? If no, skip Part H —_— — ®Yes DNo 65. For systems using an air compressor, is the compressor an oil-free type or does it use food-grade oil? ®Yes Do DNA 66. Are valves present to isolate pressure tanks for maintenance or repair? ®Yes DNo 67. Is there an ASME pressure relief valve installed between each pressure tank and any shutoff valve? ®Yes No (see DOH publication#331-429) 68. Are the pressure tanks in good working condition?If no,explain below ®Yes DNo Describe and evaluate the pressure tanks including maintenance,operational,sanitary and security observations: The 500 gallon up right hydropneumatic pressure tank is housed in a wood framed structure with insulated finished interior walls, concrete floor, proper lighting and a heat source. The garage type door is lockable and opens wide enough to have access to the pressure tank for efficient installation and removal when necessary. The pressure tank is an Air Lite Whitewater with an internal probe that monitors the water level eliminating the need for a sight glass. The probe relays water level information to the lag pump pressure switch to engage the alternating pump system. 69. Is there a finished water storage tank in use? If no, skip Part I ❑Yes ZNo 70. If unable to physically inspect the storage tank hatch,vent,roof,or overflow outlet,select the method you discussed with the purveyor to document their condition: _--__- a ❑ Reviewed and discussed maintenance records and recent photos b ❑ Photos will be taken and mailed by purveyor; additional follow-up required by DOH c ❑ Purveyor unable or unwilling to document;additional follow-up required by DOH Insert Tank Names -- -------- ----------- 71. Is the storage tank protected from unauthorized entry or vandalism? If no, explain ❑Yes DNo Dunk Dyes DNo Dunk below — --- j 72. Is the reservoir roof free of any unprotected openings? If no, explain below Dyes DNo Dunk ❑Yes DNo Dunk 73.Is the access hatch constructed and sealed to prevent the entry of Dyes❑ to Dunk Dyes❑to Dunk contaminants?If no,_explain below __--__.__._._-_ 74. If able to open hatch, is the stored water free of visible contaminants?If no, explain ❑Yes DNo Dunk Dyes DNo Dunk below 75. Is there a dedicated air vent on the storage tank? Dyes DNo Dunk Dyes DNo Dunk 75a.If yes, is the air vent constructed to prevent the entry of contaminants? If Dyes DNo Dunk Dyes Do Dunk no, explain below —76. Is the overflow line constructed to prevent contaminants from entering the Dyes❑$o Dunk Dyes DNo Dunk tank? If no, explain below —_-- 77. Does the overflow line discharge near ground level? ❑Yes DNo Dunk Dyes❑No Dunk 78. Is the overflow line discharge area protected from potential erosion? Dyes DNo Dunk Dyes DNo Dunk 79. Does the overflow line discharge into a storm drain or surface water? Dyes DNo Dunk ❑Yes DNo Dunk 79a. If yes, is there an air gap at the discharge of the overflow OR does the overflow drop at least 34 vertical feet measured from the overflow connection to Dyes DNo Dunk Dyes DNo Dunk the reservoir down to the receiving water body? _ 80. Does the overflow line discharge directly into a sanitary sewer without an air ❑Yes DNo Dunk I Dyes DNo Dunk I gap? _ ----------�------ 81. Can the reservoir be isolated from the rest of the water system and be drained Dyes DNo Dunk Dyes DNo Dunk through a dedicated drain line? — 82.When was the tank inspected last? Explain below if necessary —. 83.What is the tank cleaning frequency?Explain below if necessary 84. Does the tank size,operation,and internal piping configuration appear to provide adequate water turnover(i.e.separate inlet/outlet, baffling or mixing to reduce stagnant Dyes DNo Dunk Dyes DNo Dunk water)?If no, explain below 85. Does the tank show signs of excessive leakage, significant structural cracking,or a ❑Yes DNo ❑Yes DNo advanced concrete spalling? December 2013 ��� Page 6 Describe and evaluate the finished water storage facilities including volume,operational drawdown,configuration of the inletloutlet piping,any concerns about operations and maintenance,and sanitary and security observations: 86. Is a complete, up to date and accurate map of the distribution system maintained? ®Yes No 87. Does the system provide adequate pressure throughout the di tri6ution system? If no,ep(ain 6e&ow ®Yes❑No 88. Are proper procedures followed for disinfection of new construction or repairs? ®Yes❑No 89.Are there blow-offs to flush the system? ®Yes❑No 90. Does the purveyor seasonally or annually flush the distribution system? If yes, describe below ®Yes❑No 91. Does the purveyor exercise its distribution system valves? If yes, describe below ®Yes DNo Describe and evaluate the distribution system including maintenance,operational, sanitary and security observations: 90. Mr. Edwards flushes the system three times per year. SO1 flows through a source meter and enters the pump house via a 2 inch galvanized iron pipe from the north side and SO2 enters from the south and flows through a source meter in the pump house. The sources then converge and enter the pressure tank and then out to distribution. According to the distribution map, a 4 inch PVC main travels north west along Russell Place until it branches west along Herbig Drive were it ends in a cul-de-sac. After branching west,the main travels north along Russell Drive to Lost Lake View Drive ending in a 2 inch blow off and reduces to a 2 inch line to serve the last eight properties. December 2013 Page 7 92. Does the water system serve a single connection? If yes, refer the purveyor to the Uniform Plumbing Code ❑Yes®No and skip Part K 93. Is the water system known to serve one or more high health hazard premises, such as those listed in ❑Yes®No Table 9 in WAC 246-290-490? If yes, describe the premise(s)below. 94. Has the purveyor established the legal authority to implement a CCC program (i.e.,formally adopted an ordinance, resolution, by-laws, or other document defining the purveyor's CCC program requirements, and ®Yes ❑No empowering the purveyor to enforce them)? 95. Has the purveyor designated a CCC Specialist(CCS)to be in responsible charge of the CCC program? ®Yes❑No 95a. If yes, has the CCS conducted a hazard evaluation to identify high health hazard premises? ®Yes❑No 95b. If yes, has the purveyor completed installation of a backflow prevention assembly on the service line to DYes❑No ®NA each identified high health hazard premise? ___ 96. Has each testable backflow prevention assembly installed for premises isolation been tested by a DOH ❑Yes❑No®NA certified backflow assembly tester(BAT)within the past 12 months? 97. Did you observe the end of a hose connected to the potable water system submerged in a pool, hot ❑Yes ®No tub,watering trough,or other non-potable body of water observed during the survey? _ 98. This question only applies to a facility operating a sewage dump station: Is there a sewage dump ❑Yes ❑No®NA station without a reduced pressure backflow assembly on the water supply at the dump station? Additional cross connection control program comments: December 2013 Page 8 99. Is the operator of the water system certified? ®Yes ❑No 100. Describe the operator's certification level (if certified), duration of employment with this water system, relationship with the system (e.g.,contract operator, SMA, direct hire employee,volunteer,temporary, or owner), and duties and responsibilities Vista Knoll Water Co Inc. has a contract with Northwest Water Systems, inc. (NWS)to manage their water system. The certified operator for NWS is Kelly Racke, operator#011822. Her certifications include, WDM3 (Water Distribution Manager for up to 55,000 connections, CPS (Cross Connection Control Specialist) and currently WTTOIT(Water Treatment Plant Operator in training). The NWS technicians work under her direction. For this system, the technician, Logan Arnold, is responsible for quarterly inspections of the water system which includes checking the performance of the pressure tanks for pressure and leaks, recording quarterly source meter readings to a excel spreadsheet, and collecting quarterly bacteriological samples. Additional duties and responsibilities performed throughout the year by NWS technicians include; collecting annual nitrate samples and compliance samples when needed, cycling pumps and record recovery time and exercise the distribution valves Mr. Edwards drains and recharge pressure annually, flushes the system 3 times per year and turns the heater on during the winter when needed. 101. Does the operator conduct self-inspections of the water system? If yes, describe frequency and scope ®Yes❑No of these self-inspections below. 102. Is the operator performing measurements and ca116ration of water treatment monitoring equipment ❑Yes❑No ®NA consistent with manufacturer recommendations? If no, describe below. 103. Is the operator using proper inputs to treatment plant operations reports,such as correct volume,peak Dyes❑No ®NA flow rate, time, and making the proper calculations? If no, describe 6elow. 104. Does the operator take compliance water quality samples at the proper location? If no, descri6e Below. ®Yes❑No DNA Additional operator comments: 101. Quarterly water system inspections by the SMA are described above in Part L: OPERATOR. December 2013 _ _ Page 9 Descriptions of any water quality tests, physical measurements,or simple repairs completed during the inspection: lii • • Supplemental comments from other parts of the checklist, and documentation of field safety concerns: Part D: Sources, 27. Mr. Edwards plans to have source sample taps installed on the system later this year when the seasonal population is gone and water demand is low. December 2013 Page 10 Ci • IIi'r'ii Use the space below to sketch a simple schematic of the water system facilities.You may use the templates shown below to help build your schematic.The sketch should show location of sources,treatment, pressure tanks, booster pumps, storage tanks, and a simple representation of the distribution system. Include direction of flow(directional arrows)and brief description of how the controls function. Source Name: WELL#1 (AFK584) WELL#2 (AFK585) (91938 D) Source Number: 1 &2 Example templates you can use to build your schematic: .................R................. ■ Pressure Chlorine Pressure Booster Distribution Well w/Pump Switch Injection Point Tank PumD Reservoir System Well w/Pump ■ SO1 Sensor Probe Distribution System Hydropneumatic Pressure Tank Well w/Pump SO2 (Revised 01/2010) To download an electronic version of this system schematic,visit http://www.doh.wa.gov/ehp/dw/Programs/ss_third_party.htm .�A L; ✓ 5' � Y�a� A �1 1 1 7 7•`u �.'y� t *a� e ..: .i� � : ��y!�'a�! -•�.;:c. f+�.;r�^� .�{i. �rMlg.W''r`+ji,.k.';-'�`•t3�,t�•ut �i. _°,., • � ������� �!°°i�_t•'�������r � ° • � �tc' .,`�!. .�.d�'i1 ? `:::.« �-,,... � _ S � ..�: � .. . Lt: ��ra'� �.,..._ `'- ., ... a ,,.•.{. ..i.. ..._. ..,: - Use the graph below to locate any potential biological and chemical contaminants found within the source's Sanitary Control Area (SCA).The SCA is the protective area within 100 feet of wells or 200 feet of springs. Source Name: WELL#1 (AFK584) WELL#2 (AFK585) (91938 D) Source Number: 1 &2 Th i ] 11 :': .I :'i:4 II TI TI TI i t t t I , 200'ff for Springs., �µ t •� a t i� r� E � 4 c _.�� a, E i I w I r �. bA(^Jib �..SeE %1 ±a .. c 4 t z H L42 4 _ - T ±tt '1Ttt1 H-F -T\ ± ! + y, r°'yi'.n„"�T' Y 1� „3i °+ t st i�i 't y 5 tG `' o • �• C G 3'�1wv^ '�. �.>�F.'s?d .Yd�' ��,'^,•� .t` 7?yN".�air,�.;�R.:� la .�.'.ai.���tS�'.�.��S��y�,,` Rr.�.,:4,y._ r_,*c��._ �.a..����..�.�,� �.._ A. C. E. F "! Abandoned water wells Dumpsters Pesticide storage Animal burial Fuel tanks(above or below ground) Roads and parking lots Biological contaminants Graveyards Sewer lines,gravity or pressure Buildings Hazardous waste disposal site Storm water catch basins Chemical contaminants Hazardous waste facility Surface water Drainfields and septic tanks Irrigation canal Wastewater spray irrigation Drug lab Landfill,dump,disposal area Other: Dry wells Pesticide application (Revised 01/2010) To download an electronic version of this SCA drawing,visit http://www.doh.wa.gov/ehp/dw/Programs/ss_third_party.htm VISTAL KNOLL WATER CO INC #91938 D CAROL SPAULDING 8/13/14 r,� •t r r tv ui k ^ PUMP CONTROL HOUSE WITH VIEW OF SO2 CLOSEUP VIEW OF SO2. AT LEFT BACK. 501 IS CONCEALED BY SHRUBS AT FRONT LEFT. VISTAL KNOLL WATER CO INC #91938 D CAROL SPAULDING 8/13/14 ' •� ... .. � *j, y .. om.. iP - • ` t '►.� �` ,,"s yr. �, ` � � iM'°"' y'4h. r,, fr e � . CLOSEUP VIEW OF S01 SO1 SOURCE METER VISTAL KNOLL WATER CO INC #91938 D CAROL SPAULDING 8/13/14 S. 1 � CLOSEUP VIEW OF COMPRESOR, PRESSURE GAUGE & PRESSURE SWITCH. HYDROPNEUMATIC PRESSURE TANK WITH COMPRESSOR, PRESSURE SWITCH & PRESSURE GAUGE. VISTAL KNOLL WATER CO INC #91938 D CAROL SPAULDING 8/13/14 is 1 VIEW OF ISOLATION VALVES FOR PRESSURE VIEW OF THE SO1 WATER LINE ENTERING TANK & DISTRIBUTION FLOW METER. SO1 MANIFOLD FROM THE LEFT. WATER LINE ENTERS MANIFOLD FROM THE LEFT & SO2 ENTERS FROM THE RIGHT. VISTAL KNOLL WATER CO INC #91938 D CAROL SPAULDING 8/13/14 I ::: T:? F ter, ,., tD .-µ!ms ��(F♦ , I • ISOLATION VALVE FOR SO2 LINE & PRV. VIEW OF THE 2 INCH BLOW OFF LOCATED AT THE NORTH END OF THE DISTRIBUTION SYSTEM ALONG LOST LAKE VIEW DRIVE. uJ Lositi r- 'ti f�.•. ake, Washington 98584, USA Cu rLI L t C'r Z me << 2014 Googlz q File Original and First Copy with Application No; --...._ ....._................. Department of Ecology WATER WELL. REPORT Se�q�n¢Copy Copy——Owner's Copy Tt�lr DriltOr s C!�PY �. $TAT} OF WASHINGTON Permit No., ..,. '.............----__..._::.. (1).OWNER: /, {� /� J Name..._.........!/..I...� .Y....__:.tp:l'4��f_-..._..._...:....... .... ..._. Address.J( /.-(-___- Y Grh�1�, .. x -...... { _ . {l .h ......_._....._.•..........-__......_..--...... .-- }��v.f 51 }a.sec..:.-..,.._.. T._!_-..-_N., h,..: ... WM. (2) LOCATION OF WELL co,intv--....... .................. ... .. .. Bearing;and distance from section o subdivision corner (3) PROPOSED USE: Domestic 10 WELL LOG: Industrial ❑ Municipal❑ �) Irrigation ❑ Test Well 0 Other ❑ Formation:Describe by color,character sire of material and structure,and show thickness of.aciu fers and the.kind.and nature of the material in each stratum penetrated, with at least one entry for each change of fonr+attoti (4 TYPE OF WORK- Owner's number of well ) (if more than one).... .......... MATERIAL FRbM TO New well 1 Method: Dug ❑ 'Bores ❑ � �� ;�� Deepened ❑ Cable ❑ Driven 0f Reconditioned❑ Rotary-W Xetted ❑ a A / Qp '7 CSC' r . d.. (5) DIMENSION Diameter of well - pohes, (ZbLc,ie /1 ( e _ Drilled.-.-,-_ ... .. _..,_ft. Depth of completed well_.._--:. -__...__._ ,.ft, (6) CONSTRUCTION DETAILS: Casing installed:--..t.,...'• Diam. from __.0 It. to Mc3 ft / •� Threaded ❑ :_._-__.." Dism.from .:_.,_.....__ft,to _..—......... ft. Welded -._._......-.. Dtam,from •,...._.. ... ft.to ._........-....it. Perforations: Yea' No .-- Type of perforator used_....i. 1:.)_!,15,' SIZ�'of perforations ,. 7 .... ....--... In. by -«..._...... n /...`JL........ in perforations from .... .....ft,to .. _4Lf ft., _._..-___•.. .. perforations from „_.___..._......ft.to , ..._..._.... .... it. - perforations from .____.-_.._.._..•... ft• to ......«-......., Screens: Yes ) l'1°1A ManufacturersName..... _....._... .............,......_..._.._.__. _ - -_....... } Type.....,_.. :..__._...:......,_....:•._..................... ode] No.-.__«________ Diem. Slot size ....... from ..........: ...ft,to :...:..........•ft. Diam...---_......... Slot size ................from ....._.._._...ft. to ...-.. . .ft. . Gravel packed: .Yes❑ No$' Size of gravel: ... ............ Gravel placed from _._-.:.._.-_......•............ft.to ._-_----------,-......_--:..-.ft: Q Surface Se 1: Yes.j� Ng j] 'To wh,t depth? .......L 8 ...... t.. it. Maters l used in seal.__ .T¢N..�i� '._... _.................._..._........ .. Did any.,strata contain unusable water? Yes❑ - No I( Typeof water?..--•.....................__....... Deptli:of.strata_.._......_...._...«... ,... Method of sealing strata of@:............„. _ __ .... (7). PUMP: Manufacturer's Name.._.-. .._ ... ................_. ....._._......... Types .. ..« _ __._..._ HI' - - (8) WATER;LEVEES: Land-surface elevation -. b E a bve mean sea lays] ,, �.,r !�-+y.i•. Static level .. _-., •,•-••••••........ft.below top of well Date-4-:�J -r-•r Artesian pressure ..._.... ....................lbs,per square inch Date........_._.__... _.__ ;. Artesian water is controlled by......................,.... .............._..._.........._-. (cap,.valve, eta.) Drawdown is.amount water level.'is p� (9) WELL TESTS: lowered below.statio level 7fi.. Gom leted_.... _� ...... 1S 1i.... �i� (r Y� �f ry✓•ork started .. ._..:._...... 19 R � r• Was a pump teat.made? Yes)( No p If yes,by-whom?....... LLt......w...'.. "— « Yield• '1QC� gal/min with ft. drawdown after / hrs• WELL DRILLER'S STATEMENT: This well was drilled under my jurisdiction and this report is �j �• true to the best of my knowledge and belief. Recovery data (time taken as zero when pump turned off) (water level measured from'well top to water level) �' I Q S r'/ f J 1 �/Z __•-•-• NAME. L !ttl�°l.(._...._:.:..._F..�•---. tine water Laye1 Ti a Wat}eyr Lev O� Time r Lyve� (Person, firm, or corporation) (T for print) . ...... s •: .. "...... Address..� ?/ .._fill? "_ i °... . .. Date of test ..-_... -- .4.............'__... [Signed]. . _:1C.� i=..`.'..........._. c_s1 :y .i'..:.--.__-...::_.--__--_.-_.........• Sailer test......_ .._..._galJinin.with....................ft. drawdown after.-...-..............bra. (Well 1 Driller) • Artesian flow......,_..-_........:.................._.--. g.p.m. Date..........._..._...........................:....... �_�ry , Temperature of water....•.__.....Was a chemical analysis made?Ye!iiNo❑ License No...._.. 4�.�?!. ..............._...Date....:..._..� ._�..�.0:. 1 ___.. (USE ADDITIONAL SHEETS IF NECESSARY) ECY 060.1-20 • DAILY REPORT WILLIAMS Dr LING CO. ROUTE 1, TOLEDO, WASHINGTON 98591 Phone 864-2951 b 160 tie No. Date�� r G� � Ft. In. To Geology 36 ys' I 7I remarks: �. Coliform Monitoring Plan Water System Name: Vista Knoll Source System ID Number: 91938D DOH Source No: SO1/SO2 Population Served: 15 (estimated) Category: wells Active Connections: 30 Well Depth: 801133 Storage Capacity: 0 gallons Treatment Process: none Purpose of treatment: Number of Routine Samples Number of Sample Sites Needed to Required by Regulations: Represent the Distribution System: Site Number Location SITE Routine A Pumphouse GROUP Repeat B SVC 66 I Repeat C SVC 27 Repeat D SVC 32 Repeat E SVC 52 SITE Routine B SVC 66 GROUP Repeat C SVC 27 II Repeat D SVC 32 Repeat E SVC 52 Repeat A Pumphouse SITE Routine C SVC 27 GROUP Repeat D SVC 32 III Repeat E SVC 52 Repeat A Pumphouse Repeat B SVC 66 SITE Routine D SVC 32 GROUP Repeat E SVC 52 IV Repeat A Pumphouse Repeat B SVC 66 Repeat C SVC 27 For maximum coverage of the system, the routine samples will be rotated as indicated below: Month Site Month Site Month Site January A May A September A February B June B October B March C July C November C April D August D December D If an unsatisfactory sample is taken at a site, five additional samples will be taken at the following locations: 1) the unsatisfactory site; 2)another site in the same group; 3-5) one from each of the other site groups. Confirmed coliform samples will result in posting the appropriate notices and notifying services door-to-door. Report Prepared By: Todd Krause Position: EIT Daytime Phone#: (360) 876-0958 Reviewed By: Mitch Edwards Position: Owner/Operator NWS Northwest Water Systems, Inc. P.O. Box 123 Port Orchard, WA 98366 360-876-0958 0cflTJTh APR 0 7 2005 April 5,2005 PERMIT ASSISTANCE CFNTFP Mason County Health Arlene Hyatt,R.S. P.O.Box 1666 Shelton,WA 98584 Re: Vista Knoll Water System Dear Ms.Hyatt: This letter is to inform you that the Vista Knoll Water System serves homes on Lost Lake Park Ct,Lost Lake Park Drive,and Lost Lake View Drive. The sources for this system are two wells located near the pumphouse on Vagabonds Place(first building on the left). The source is protected by a 100-foot covenant radius. The wellheads will be protected by locking caps. Please let us know if you are aware of any potential sources of contamination within the well protection Radii. Copies of the site plan have been provided to Mason County Planning and Emergency Sevices. Should you have any questions,or require further information,please call Mitch Edwards,owner and operator of the water system(360)490-1345. Sincerely NORTHWEST WATER S STEMS,INC. Tod ause,EIT Cc: File: projects\04090601\05040501 MASON COUNTY DEPARTMENT OF HEALTH SERVICES ENVIRONMENTAL HEALTH PERSONAL HEALTH jill/I/i 426 W.Cedar 303 N,Fourth PO Box 1666 PO Box 1666 Shelton,WA 98584 Shelton,WA 98584 ' (360)427-9670 • Fax(360)427-7798 • Elmo(360)482-5269 • Belfair(360)275-4467 • www.co.mason.wa.us Mitch and Sandy Edwards December 28,2004 991 W Lakeside Drive Shelton, WA 98584 Re: Vista Knoll Water System Sanitary Survey, WFI#91938D Dear Mr. Edwards, Thank you for your assistance in conducting a sanitary survey of the above referenced water system. Mason County routinely conducts sanitary surveys of the public water systems in the area. The purpose of a sanitary survey is to review the design, construction, operation, maintenance and overall management of the water system in order to determine its adequacy for producing and distributing safe drinking water. This letter is intended to document the findings of the sanitary survey. The survey findings are listed below as recommendations.Your attention to these findings will help resolve potential problems before illness results. The other findings are listed for your information. General Survey findings: Approvals-Approved for 30 connections. Permit color: green. Water Facilities Inventory-Updated and forwarded to DOH. Recommendations- ❑ Restrict unauthorized access to the sources. ❑ Install screened well vents on each source. ❑ Seal around power conduit on well# 1. ❑ Send copy of SWSMP to DOH. The results of this survey have been forwarded to DOH. Please, feel free to contact me with any question you may have regarding this letter or your sanitary survey. My number is(360)427- 9670 ext. 293. Sincerely, Arlene Hyatt Environmental Health Specialist Always workina for a safer and healthier Mason County SANITARY SURVEY INSPECTION REPORT Inspection Date: November 08, 2004 Water System Name: Vista Knoll Water System ID: 91938D County: Mason County Owner: Mitch and Sandy Edwards 991 W Lakeside Drive Shelton, WA 98584 Manager: Mitch and Sandy Edwards 991 W Lakeside Drive Shelton, WA 98584 1. Persons Attending Inspection: Mitch Edwards, System owner; Arlene Hyatt, MCDHS. 2. Purpose of the Inspection: Sanitary Survey 3. General Description: According to the Water Facilities Inventory Form, the system is considered a transient non-community water system. However, the system consists of four full-time single family residences and twenty-one part-time single family residences.No recreational connections currently exist on the system. The full-time residences serve approximately eight individuals and the part-time residences serve from ten to forty-two individuals each month. The water system appears to be well managed and maintained by the owner. 4. List of Potential High Public Health Deficiencies: ❑ Susceptible sources with high risk sanitary control area threats o Inoperable treatment facilities, when treatment is required by DOH for primary acute contaminants (e.g., surface water, required disinfection, nitrate remediation, etc.) ❑ Newly discovered unfiltered surface water sources and/or unapproved groundwater sources in use with no water quality history and not listed on the Water Facility Inventory form (WFI) ❑ Confirmed backflow incidents ❑ Documented cases of fraudulent operation and/or reporting or willful neglect by the operator o Other cases based on professional judgment Page 1 of 3 Description of deficiency(s) checked above: Additional Inspection Findings: A. Sources: The system is served by two sources. Both sources are located just outside the pumphouse structure. The sanitary control area contains a county road, which is ditched. The sources are currently susceptible to unauthorized access. Recommend restricting unauthorized access to the sources.Neither source has a screened well vent. Recommend installation of screened well vents for each source. Sources alternate and the meter is logged monthly. Source 01: Tag number AFK 584. This source appears to have been installed by the original owner. Current owner indicated that the well was constructed in 1969. A log exists but is incomplete. The source appears to be 80 feet deep with a capacity of 50 gallons per minute. There is no mention of a surface seal on the well log (see attached). The power conduit is not completely sealed. Recommend sealing around power conduit. Source 02: Tag number AFK 585. Installed in 1978 by Williams Well Drilling. This source is 133 feet deep with a capacity of at least 50 gallons per minute. It has an 18- foot bentonite seal and several restrictive layers. The casing is eight-inch steel with perforations from 51 to 66 feet. B. Distribution: From the sources, water enters the pumphouse via two-inch galvanized iron pipe. Water flows through the source meter and into the pressure tank and then out to the system. The four-inch PVC main carries water west to the intersection of Herbig Drive and Russell Drive where it branches west and north. The west branch serves properties along Herbig Drive and culminates in a one- inch blowoff assembly. The north branch serves properties along Russell Drive and at the two-inch PVC blowoff assembly an additional two-inch PVC branch carries water to the final eight properties. C. Water Quality: The coliform monitoring plan is attached to this report. The system experienced one non-acute MCL violation in December of 2002. No other incidents on file for the system. D. Operations and Maintenance: Northwest Water Systems created a Small Water System Management Plan(SWSMP) in October of 2004. All sections appear to have been addressed. Emergency response numbers are distributed with billing along with conservation information. System anticipates installation of service meters by 2010. A Cross-Connection Control Program is in effect. As the system is likely to be reclassified as a community system, recommend that a copy of the SWSMP be sent to DOH for approval. E. Tests: None performed. Page 2of 3 F. Water Supply Security: Recommend increasing security by reducing unauthorized access to the wellheads. During site visit, installation of padlocks on each well cap was discussed to increase security. G. Photos: Photographs attached. ( i4LL EHS II December 28, 2004 Inspector Signatur Title Date of Signature _Arlene Hyatt Print Name of Inspector Page 3of 3 Page 1 of 2 WASHINGTON STATE DEPARTMENT OF HEALTH Small Water System Sanitary Survey Checklist 1.Name of System I/S Toy £70// f&p 7V .h)4'1 2.Survey Date: //— 3. PWS ID#®❑®a®°4.County _�_�� 5.Phone# 3/ '-$33 /h, � 6.Water System Contact Person ,4'.'/c- I L� cl_/ r7 7a.DOH Source# SO# / Cz`' r SO#_ ? b.Name of well(if any) c.DOE unique well identifier#(if available) 8. Is this for permanent or seasonal use? ( ❑S L ❑S 9.Are there biological contaminants located within 100 ft.(i.e.sanitary sewer,drainfield,surface water,waste lagoon,manure pile,storm water,irrigation canal)? Dyes RTcJo ❑Yes 10 10.Are.there obvious chemical contaminant hazards located within 100 ft(i.e.gasoline,diesel fuel,pesticides)? ❑Yes L�No ❑Yes 10 11.Is there a known or obvious risk of the wellhead being covered by flood.water?; ❑Yes Es10 Dyes L o.. 12a.Is'there a sealed well cap? [1r ; ❑N es: ❑No b.Is there a properly constructed screened well vent? ❑Yes ( 11 o ❑Yes El1No es 13.a. Is the well located in a pit? ❑Yes Lo ❑Ye 19Mo b.If yes,is the pit adequately drained? ❑Yes ❑No ❑No 14.Is the distance from the floor or the ground to the top of the casing 7 greater than 6"? Ii 'S eS ❑No es ❑No - 15. Is a water sampling tap provided at the wellhead? Yes ' ❑,Y"es 16. Is the source metered? ❑No tuxes ❑No 17.Is this source chlorinated? ❑Yes [moo ❑Yes If yes,a.is chlorinator operational? Dyes ❑No ❑Yes ❑No b.Are adequate records kept(i.e.chlorine residual at least 5 days Dyes ❑No ❑Yes ❑No per week:forms submitted to DOH and maintained by system.residual tested by approved method)? c.Has there been a problem with chemical addition(i.e. 4KOYes maintaining adequate residual,run out of solution,overfeeding)? ❑No ❑DY/es ❑No [� 18. Is a pressure tank being used? es ❑No [ Yes ❑No If yes,a.Is there an ASME relief valve located between tank ,". and shutoff valve? Dyes jWo ❑Yes ENo b.Does the tank appear to be functioning/operating properly(i.e. does the well pump cycle less than once every 10 minutes)? Yes ❑No [)Ye.- ❑No 19. Is there a non-pressurized storage tank? Dyes 1i _a If yes,a.Are al openings secured(i.e.locked,tight over-lapping cover on access; screened vents and overflow or hinged flap)? . . Dyes /1/K 20.Are there obvious cross connections(i.e.hose in stock trough,swimming pool)? .. ❑Ye No 21.Does system have Cross Connection Program acceptable to DOH(i.e.DOH letter)? des ❑No 22.a. Does system have a written Coliform Monitoring Plan? Z7e ❑No b. If yes,is it adequate(i.e.at least 3 routine sites and 4 repeat sites/routine site, narrative and map)? ❑No 23.Are proper procedures followed for disinfection and sampling of new construction and/or repairs? ❑No 24.Is there a Small Water System Management Program in effect(WAC 246-290-105)? Les ❑No 25. Please describe any other significant concerns or hazards on page 2. Dyes ❑No ❑Reviewed/revised WFI attached ❑ Photographs labeled and ttached QSS Name(please print) � � Q, Signatur) FtDate: t) SCA: (draw schematic of pumphouse) Sources: (for each source describe the well, sanitary control area, wellhead enclosure, and piping components) Distribution: (describe distribution system and components) Water Quality: (describe water quality monitoring sample collection sites and any sample collection training issues identified during the inspection) Operations and Maintenance: (describe standard and emergency operations procedures,personnel availability, 0&M documentation, special water usage restriction policies, and any documentation from the Small Water System Management Plan provided by purveyor) Water Supply Security:(list all observations that could assist the purveyor to enhance the security and safety of the water supply such as locks,fences, authorized entry to facilities, etc.) State of Washington Please Print Plainly Department of Social and Health Services USE HEAVY PENCIL Health Services Division DO NOT WRITE IN SHADED AREAS PUBLIC HEALTH LABORATORIES 1409 Smith Tower, 817-9,Seattle,Washington 98104 WATER SAMPLE INFORMATION FOR INORGANIC CHEMICAL ANALYSES AB.NUMBER CO. ClTYI DATE RECEIVED DATE COLLECTED COLLECTED BY: 5 _ Telephone: Is this a follow up of a previous out of compliance sample? Yes ❑ No ❑ If yes, what was the laboratory number of the previous sample? — — — — — — — ;YSTEM I.D. NO. SYSTEM NAME SYSTEM CLASS COUNTY (circle one) 1 2 3 4 SAMPLE LOCATION THIS SAMPLE TAKEN BEFORE O AFTER IF TAKEN AFTER TREATMENT WAS IT-FILTERED -FLUORIDATED / TREATMENT U T _.CHLORINATED-WATER SOFTENER:TYPE USED ----------CHECK__ - CHECK ONE OF THE ABOVE BOXES SOURCE SOURCE NO. IF SOURCE IS LAKE OR STREAM,ENTER NAME IF SAMPLE WAS DRAWN FROM DISTRIBUTION SYSTEM TYPE: - 1. SURFACE -3. WELL IT WAS COLLECTED FROM SYSTEM AT:(ADDRESS) 2. SPRING -4. PURCHASE - DATE OF FINAL SEND REPORT TO: (PRINT FULL NAME&ADDRESS) REPORT: /— - Name REMARKS: Street WA. City Zip Code Telephone: ( Area Code LABORATORY REPORT (DO NOT WRITE BELOW THIS LINE) UNITS Compliance Chemist LABORATORY SUPERVISOR THAN RESULTS (Name or Initials) TESTS •MCL YES NO Initials Arsenic As 0.05P • mg/I .._��• Barium Be 1.0P • mg/I CHARGE: r " Cadmium Cd 0.01 _ - - mg/I Chromium Cr 0.05P • mg/I REMARKS: Iron Fe 0.3 • mg/I Lead Pb 0.05P • mg/I Manganese Mn 0.05 — • mg/I ;,.. r ., /yo" Mercury Hg 0.002 P - • mg/I 0 .. Selenium se 0.01P - - - mg/I Silver Ag 0.05P • mg/I Sodium Na — — — — — mg/I mg/I Hardness AS CaCo3 Micromhos/cm Conductivity 700 25° C Turbidity 1.0P • NTU Color Color 15.0 • Units Fluoride F 2.0P • mg/I Nitrate as N 10.0P • mg/I mg/I Chloride c1 250 - - Sulfate SO4 250 — — mg/I •MCL is the Maximum Contaminant Level Allowed State of Washington ease Print Plainly Department of Social and Health Services iE HEAVY PENCIL Health Services Division D NOT WRITE IN SHADED AREAS PUBLIC HEALTH LABORATORIES 1409 Smith Tower,B17-9,Seattle,Washington 98104 WATER SAMPLE INFORMATION FOR INORGANIC CHEMICAL ANALYSES B.NUMBER CO. CITY DATE RECEIVED DATE COLLECTED COLLECTED BY: _ Telephone: this a follow up of a previous out of compliance sample? Yes ❑ No yes, what was the laboratory number of the previous sample? _ — — — — — — STEM I.D.NO. SYSTEM NAME SYSTEM CLASS COUNTY (circle one) 1234 SAMPLE LOCATION THIS SAMPLE TAKEN BEFORE O AFTER DI IF TAKEN AFTER TREATMENT WAS IT-FILTERED -FLUORIDATED / �� __ TREATMENT U T _CHLORINATED WATER SOFTENER:TYPE USED ,_,1-�__--- CHECK ONE OF THE ABOVE BOXES DURCE SOURCE NO. IF SOURCE IS LAKE OR STREAM,ENTER NAME IF SAMPLE WAS DRAWN FROM DISTRIBUTION SYSTEM YPE: - 1. SURFACE -3. WELL IT WAS COLLECTED FROM SYSTEM AT:(ADDRESS) 2. SPRING -4. PURCHASE DATE OF FINAL SEND REPORT TO: (PRINT FULL NAME&ADDRESS) REPORT: /— '— Name EMARKS: Street WA. City Zip Code Telephone: ( ) Area Code LABORATORY REPORT (DO NOT WRITE BELOW THIS LINE) THAN RESULTS UNITS Compliance Chemist LABORATORY SUPERVISOR ESTS *MCL YES NO Initials (Name or Initials) trsenic As 0.05P • mg/I larium Ba 1.0P • mg/I mg/I CHARGE: :admium Cd 0.01P • 'hromium Cr 0.05P • mg/I REMARKS: ron Fe 0.3 • mg/I _ead Pb 0.05P • mg/I RECEIVED Aanganese Mn 0.05 • mg/I Mercury Hg 0.002p • mg/I OCT 1 198 4 Selenium se 0.01 P • mg/I MASON COUNTY HEALTH r1Ft';.' Silver Ag 0.05P • mg/I Sodium Na mg/I mg/I Hardness -AS CaCo3icromhos/cm Conductivity 25°CTurbidity NTUColor Color Units Fluoride F 2.0P • mg/I Nitrate as N 10.0P • mg/I Chloride Cl 250 mg/I Sulfate SO4 250 — — mg/I 'MCL is the Maximum Contaminant Level Allowed o .,_.�_... e..,...�...� r.._...... C....i,,ncr nr I nral Health Deot. CODV x 3 Please Print Plainly State of Washington Department of Social and Health Services SEE BACK USE HEAVY PENCIL Division of Health DO NOT WRITE IN SHADED AREAS PUBLIC HEALTH LABORATORIES FOR INSTRUCTIONS 1810 N.E.150th St.,,Seattle WA 98155 WATER SAMPLE INFORMATION FOR INORGANIC CHEMICAL ANALYSES USE THIS FORM FOR THE COMPLETE CHEMICAL ANALYSIS ONLY LAB. NUMBER DATE RECEIVED DATE COLLECTED COLLECTED BY: 5 SYSTEM I.D. NO. SYSTEM NAME I SYSTEM CLASS COUNTY (circle one) ------ 1 2 3 4 SOURCE TYPE SOURCE NO IF SOURCE IS LAKE OR STREAM ENTER NAME (Well No.) FEES ARE CHARGED FOR CHEMICAL TESTING -1. Surface -3. Well _2. Spring _4. Purchase A fee schedule is available from this department. THIS SAMPLE WAS TAKEN IF SAMPLE WAS DRAWN FROM DISTRIBUTION SYSTEM IT WAS COLLECTED FROM SYSTEM AT: (Address) PARTY TO PAY FOR FEE FOR SERVICE TESTING ❑ Before Treatment ❑ After Treatment IF TAKEN AFTER TREATMENT WAS IT FILTERED FLUORIDATED Signature(Required) (Print Full Named Address) CHLORINATED WATER SOFTENER: TYPE USED REMARKS: (Water quality problems, address for additiional copies, etc.) Name Street � 8Ele r,r ArWA. City Zip Code Telephone: ( ) Area Code LABORATORY REPORT (DO NOT WRITE BELOW THIS LINE) LESS Compliance CHEMIST I DATE OF FINAL REPORT: TESTS MCL THAN RESULTSr UNITS YES NO INITIALS dSeniC . • { 1- mg/I larium B. 1.0' 4.. •=Y— mg/I` .. ;admium 0.01' mg/I �,. LABORATORY SUPERVISOR (Name or Initials) ;hromium cr 0.05' x_ • ,( mg/I /' On F. 0.3 Sao i _ • { mg/I CHARGE: ead ' 0.05' • 7 mg/I itanganese . 0.05 • / C. mg/I f,. REMARKS: Aercury "c 0.002' C • ' t." mg/I Y selenium s. 0.01' • r mg/I t A iilver a 0.05, • / ( mg/I ✓ )/ ;Odium "� `�+ mg/I �, mg/I lardness AS CaCo3 r>+ ;onductivity 700 j f Micra25hoa/cm urbidity 1.0' • NTU Color ;o1or 15.0 0 • Units :luorlde r 2.0' • : mg/I litrate ..a 10.0' • ' mg/I ;hlorlde c1 250 f. mg/I sulfate so, 250 mg/I OS 500 mg/I open c. 1.0 • mg/I zn 5.0 mg/I • 'a the Maximum Contaminant Level Allowed 'Primary Standard 3 92F (Rev. 7/85) -873- rs IJQ I nl.n.ntnry A flats P--inn Cnnv f 1 I.I Pillion Cnnv Water Runnlinr Cnnv llintrint Fnninaar Cnnv I noel Health font Cnnv Please Print Plainly State of Washington USE HEAVY PENCIL Department of Health SEE BACK DO NOT WRITE IN SHADED AREAS DIVISION OF LABORATORIES FOR INSTRUCTIONS 1610 N.E.150th St.,,Seattle WA 98155-7224 (206)381-2898 WATER SAMPLE INFORMATION FOR INORGANIC CHEMICAL ANALYSES LAB. NUMBER DATE RECEIVED DATE COLLECTED COLLECTED BY: 5 E .Q1 G--' _/__/_ �r/� / Telephwe, W I_ .1 J, SYSTEM I.D. NO. SYSTEM NAME SYSTEM CLASS COUNTY (circle one) 1.' 1'..t V y ` 17 I r' 'AR C a , 2 3 a N1ASoN SOURCE TYPE SOURCE NO IF SOURCE IS LAKE OR STREAM ENTER NAME (Well No.) FEES ARE CHARGED FOR CHEMICAL TESTING _1. Surface .., .3. Well _2. Spring -4. Purchase i2j--.- A fee schedule is available from this department. THIS SAMPLE WAS TAKEN IF SAMPLE WAS DRAWN FROM DISTRIBUTION SYSTEM IT WAS COLLECTED FROM SYSTEM AT: (Address) PARTY TO PAY FOR FEE FOR SERVICE TESTING Before Treatment ❑ After Treatment IF TAKEN AFTER TREATMENT WAS IT FILTERED FLUORIDATED Signature(Required) (Print Full Name&Address) CHLORINATED WATER SOFTENER: TYPE USED j ater quality problems, address for additiional copies, etc. V I5ANC)LL_ t4JATG/?_ 2 O Name no . WIS + WAN 1 Street j9&P_D '1 WA. X39 0 city Zip Code Telephone: ( �'� ) —5 " Area Code LABORATORY REPORT (DO NOT WRITE BELOW THIS LINE) LESS Compliance CHEMIST DATE OF FINAL REPORT: TESTS MCL THAN RESULTS UNITS YES NO INITIALS Arsenic A 0.05' • mg/I Barium B. 1.o P • mg/I p mg/I LABORATORY SUPERVISOR Cadmium �a 0.01 • (Name or Initials) Chromium 0.05' • mg/I Iron F. 0.3 • mg/I CHARGE: Lead Pb 0.05 r • mg/I Manganese an 0.05 • mg/I REMARKS: Mercury Nr 0.002 • mg/I Selenium s. 0.01 P • mg/I Silver Al 0.05P • mg/I Sodium N• mg/I mg/I Hardness AS CaCo3 Micromhos/cm Conductivity 700 25°C Turbidity 1.0' • NTU Color Color 15.0 • Units Fluoride F 2.0° • mg/I Nitrate •'N 10.0P •—�— mg/I Chloride cr 250 .�~ mg/I Sulfate so, 250 mg/I TDS 500 mg/I Copper C. 1.0 mg/I • `nc z. 5.0 • mg/I •L is the Maximum Contaminant Level Allowed P Primary Standard ti I'17, STATE OF DEPARTMENT OF SOCh._. AND HEALTH SERVICES Ac } 1 WASHINGTON Olympia,Washngton 9.3501 Y.,� Y Dixy Lee Ray INM' Gouer;nor August 28, 1979 RECEIVED ([ REGE.I Y E.D AUG 4 iJ80 Phil Herbig "`A H�A._•r 110 East Wishkan Street ' Aberdeen, WA 98520 Re: Vista Knoll Water System !)car Mr. Herbig: This letter acknowledges receipt of the certification of inspection and installation for the subject water system which was signed by your engineer, Wesley E. Berglund. This certificate indicates that the project has been completed according to plans and specifications which were approved by this office. The system is now capable of serving 30 domestic service connections. Sincerely, John C. Kirner, P.E. Central Operations Engineer Water Supply and Waste Section MS LD-11 . JCK:dab Wes Berglund Grays Harbor-Pacific Health District �l:•; "' ,� STATE OF DEPARTMENT OF SOCIAL AND HEAL IH SERVICES '1: • WASHINGTON Olympia,WasIlu:•yton 9,504 %> . '1 Dixy Lee Ray Governor August 13, 1979 Phil Herbig 110 East Wishkan Street Aberdeen, WA 98520 RE: ' Vista Knoll Water System, Mason County, 30 Service Connections Dear Mr. Herbig: "As-built" plans and specifications for the above project received in this office August 11, 1978, December 1, 1978 and August 10, 1979 have been reviewed and, in accordance with the provisions of WAC 248.54 are hereby APPROVED. You are required to submit a completed WFI form in order that this water system may be assigned an ID number. Sincerely, John A. Beare, M.D. , M.P.H. Division Director 0B-44j Health Services Divsision John C. Kirner, P.E. Central Operations Engineer Water Supply and Waste Section Mail. Stop LD-11 JAB:JCK:dab cc: Mason County Health Department Wes Berglund Enclosures ..z •:+rte prr .� ,079 -+rRATYY.a'^'t.'!"1�^GL'Y.> .M.lw-.+a..M• .rwn.was.n.a.nws.-_ .n.. .. ........_.._._ ..._.. __...___.____ ...._.. _._ _______.. `i ,rA7' STATE OF DEPARTMENT OF SOCIAL AND HEALTH SERVICES WASHINGTON Olympia,Washington 98504 ' Dixy Lee Ray IAHy G^uernor , 3 January 4, 1979 Wesley E. Berglund, P.E. 216 East First Street Everett, Washington 98520 Re: Public Water System Serving Vista Knoll Development, Mason County Dear Mr. Berglund: Your submittal of November 30, 1978 to this department regarding the Vista Knoll water system has been reviewed. When we have received the following remaining items, an approval of this project can be made. 1, It will be necessary for this department to receive a water right permit from the Department of Ecology for well #2. 2. A well site inspection for both wells is necessary. This inspection should be made by -a representative of the Mason County Health Depart- ment. 3. Restrictive covenants will be necessary for a 100 foot radius surrounding both wells. The restrictive covenants should be similar to the sample document which is enclosed for your review. 4, An airline and gauge should be provided at both wells to allow a deter- mination of static and pumping water levels. An alternative to provision of an airline and gauge would be the availability of a sounding tape and an access port to allow determination of water levels. Sincerely, P/ John C. Kirner, P.E. Regional Engineer Water Supply and Waste Section MS LD-11 JCK:dgs cc: Mason County Health Department Enclosure .,z Thurston - Mason Health District December 6, 1978 J.V.DESHAYE,M.D.,D.P.H. SHELTON,WASHINGTON 98584 DISTRICT HEALTH OFFICER Medical-Nursing 110 West K Street 206-426-4407 OLYMPIA,WASHINGTON 98501 Environmental Health 529 Southwest Fourth Ave. 428 West Birch Street 206.753.8067 206.426-5561 John C. Kirner, P.E. District Engineer, D.S.H.S. Airport Mail Stop LD-11 Olympia, Wa. 98504 Re: Well site for Well #2, Vista Knoll Water System Dear John: On December 6, 1978, I made a well site inspection for well #2 with Phil Herbig and Wes Berglund. The 100 foot radius is in brush and timber with no source of pollution except the county road. The pavement is 80 feet from the well. The right-of-way is 60 feet. The top of the well casing is at least a foot above ground level. Surface drainage does not appear to be a problem around the well. If you have questions or need additional information, please contact this office. Sincerely, J. V. Deshaye, M.D. , D.P.H. District Health Officer Marjory Dilworth-Dale, R. S. Environmental Health Specialist MD-D:vl cc:Phil Herbig Wes Berglund Equal Opportunity Employer W�SL�Y E. Q�RGLUfD / 1 \ PROFESSIONAL ENGINEER • LAND SURVEYOR 532-7630 216 EAST FIRST STREET • ABERDEEN, WASHINGTON • 98520 November 30 , 1978 Ms . Marjory-Dilworth-Dale, R.S . Environmental Health Specialist Thurston-Mason Health District 428 West Birch Street Shelton, Washington 98584 Dear Ms. Dilworth-Dale: This letter is in reference to a site inspection of the existing wells at Lost Lake which furnished water to the Vista Knoll Water System. We are in the process of obtaining state approval of this system which has been in existence since 1968 .and will need an inspection of approval from your office in regards to the well site. If you would like the owner to be present during your visit to the site, please let me know. Very trul yo rs, W. E. rg und, Profes al Engineer WEB/jw Enclosures G.. 3OP1 nA f., STATE OF J) DEPARTMENT OF SOCIAL AND HEALTH SERVICES WASHINGTON Olyn'P is Washington 99504 Yy ov Dixy Lee Ray Governor , 3 September 14, 1978 Wesley E. Berglund, P.E. 216 East First Street Aberdeen, Washington 98520 Re: Public Water System to Serve Vista Knoll Water System, Mason County Dear Mr. Berglund: Plans and specifications for the Vista Knoll , Lost Lake Park, and Lost Lake View Tracts water system which you submitted to this office for approval have been reviewed. Before this department's approval of this project can be given, it will be necessary for you to respond to the following items. 1. This department must be provided with water rights issued by the Department of Ecology for both wells. 2. The well site at this project should be inspected by either a repre- sentative of this office or a representative of the county health department. 3. Restrictive covenants or easements must be provided for the 100 foot isolation radius surrounding well #1 and #2. 4. Source meters must be provided at the wells unless individual services will be metered. 5, Raw water sample taps, an air line and gauge, and a screened vent must be provided at both wells. 6. ' It was noted in the complete chemical analysis that well #1 had an iron concentration of .43 ppm. This is in excess of the limit of .3 ppm which is set by state regulation. However, since this is an asthetic concern rather than a health related concern and this water system has been in service for some time, we would be able to waive the .3 limit if problems have not occurred with staining at this time. 7. Approval of this proposal would involve a provision that no service be provided to Camp Bishop, that no more than two services be provided in Lost Lake Park, and that no more than eight services be provided in Lost Lake View Tracts. �® 1 CT çO ' Mr. Berglund September 14, 1978 Page 2 8. There is not a good pump test available for well #1 . However, since well #2 appears to be very satisfactory and well #1 has functioned satisfactorily for a number of years, the need for a pump test on well #1 will be waived at this time. If there is desire to expand this project beyond 30 service connections then it will be necessary for a satisfactory pump test to be provided on well #1 . When the above items have been satisfactorily resolved, this project can be approved. Sincerely, John C. .Kirner, P.E. Regional Engineer Water Supply and Waste Section MS LD-11 JCK:dgs cc: T stun-Mason Health District, Shelton RECEIVED SEP 15 1978 THURSTON-MASON HEAI:..TN O�gTRIGT August 18, 1977 Wesley E. Berglund Professional Engineer 216 East First Street Aberdeen, Washington 98520 SUBJECT: VISTA KNOLL WATER SYSTEM AT LOST LAKE, MASON COUNTY Dear Mr. Berglund: The design concepts for the Vista Knoll Water System which you submitted to this department for approval have been reviewed. The concepts put forth in your letter of August 4, 1977 were found to be acceptable. Final approval will be given after we have reviewed the final. plans and source data. Sincerely, JOHN C. KIRNER, P.E. Regional Engineer JCK:st cc: Thurston-Masan Health District - Shelton REcE1 O `U G 2 '. 1977 -rHURSTON MASO 1 May 18, 1977 fir. W. E. Berglund, P.E. 216 East First Street Aberdeen, Washington 98520 Re: Vista Knoll, Lost Lake park, Lost Lake View Tracts Water System, Mason County Dear Mr. Berglund: The plans and engineering report for the Vista Knoll water system wnich you submitted to this office for approval has been reviewed. Before this department's approval of this project can be given, it will be necessary for you to respond to the following comments. 1 . It is our understanding frost conversations with the Thurston- Mason Health District that the plat of Vista Knoll requires a public water system as part of its plat approval . 'Therefore, the water system must provide adequate capacity to serve the existing 20 lots in Vista Knoll. In addition, it appears that 10 existing service connections are in operation in Lost Lake Park and Lost Lake View Tracts. This makes a minimum number of service connections of 30 which must be provided for in the system approval. Service of water to Camp dl shop would add an additional 15 gallons per minute. This would require a maximum instantaneous demand of 91.9 gallons per minute for the total system. This capacity of wter appears to be wi tni n the develop- able capacity of the system if your engineering report is iple- mented. 2. Specifications for system construction such as M WA or AWWA should be sited. 3. It was noted that elevations were not provided in the discussion of the system hydraulics. Will elevation differences be a factor? ;•r. derjluna 6sy l , 1977 Page 2 4. This oapartment necks well data for both toe existing '.yell and the proposed second well before an approval can be given. It is necessary that this data i nc1 ude a al 1 10 (al read! provided for first well), cheriical test, bacteriological test, ane pump test. A copy of the location ap for toe seconu wel 1 ::dust oe provided. The isolation distance for both the first aria second well :rust ho controlled torough owners�rii' or easc�o.ent. If control of the isolation area is to sae through easer ent the tnis c,epartment sr oul d be provided with copies of the caste rent. '. If it will ae ireipossiblo to maintain vi poundsper square iaca'o pressure in the water service to `ao�ip isi�op, toeei a booster pump sAoul d ae provided in order to °:jai ntai n eAM= of pounds of pressure. 6. iiscussion with representatives of the county engineers office and the county health ciepart=eerat iave indicated that frequent „.power outages occur in this area. i oerefore, soe werrs of staridoy power should be provided In order to assure eater cyst N reliability. This auxi l l i ary power could consist of a standby jasol i cie 6rivr:n generator, or a right angle drive in conjunction with a deep dz 1l turbine pump. The right angle drive would allots tnu: use of a tractor with power takeoff to provide water service under power outage condi tions. Shen we have received your response to toe preceding i tends, review of l ai s project will be continued. Si ncereiy,, dung v. Ki rner iegiunal Engineer JCK dgs cc: Thurst n-ason seal th district October 6, 1976 Douglas P. Hoffmann 1302 - 41st Avenue MW Puyallup, WA 98371 Dear Ir. Hoffr.iann: Subject: Vista Knoll Water System, Mason County We have reviewers your letter requesting the approval status of the Vista Knoll Water System at Lost Lake in Mason County. This Department received plans and specifications from Hr. Wesley E. Berglund, P.E. , on May 9, 1969. Mr. Ken Merry of this office requested additional information from Mr. Berglund by letter dated May 23, 1969. This Departs-lent did not receive a response to Mr. Merry' s letter until February 3, 1970. In this February 3 cot munication from Mr. Berglund, the information requested by,, Ken Merry' s earlier letter was not presented. Mr. Merry again sent a letter to Mr. Berglund dated February 4, 1970, in which he again included a copy of his 1969 letter requesting further information. We have received no response from fair. Merry' s letter of February 4, 1970. Therefore, this water system remains unapproved and is in operation in violation of the regulations of the State of Washington. Sincerely, John Kirner, P.C. Regional Engineer Water Supply and Waste Section 3K:P.ih cc: Thurston-Mason Health District Shel ton, WA kEr ,tIVED Wesley E. Berglund, P.E. 216 East First Street 0CT 13 1976 Aberdeen, .WA 98520 TWURSTON:MASON HEALTH nISTRyrT THURSTDN-MASON DISTRICT HEALTH CENTERS Shelton, Washington Aug. 20, 1976 I. V.DESHAYE,M.D., D.P.H. OLYMPIA, WASHINGTON 98501 529 West Fourth Avenue .,:Z_RICT HEALTH OFFICER 206 - 753-8067 SHELTON, WASHINGTON 98584 Dept.of Social&Health Svcs.Bldg. Post Office Box 746 206-426-4407 Phil Herbig Re: Lost Lake Park 110 E. Wishkah Water Supply Aberdeen, Wa. 98520 Dear Mr. Herbig: We received a complaint that the water supply that serves the Vista Knoll-Lost Lake Park area did not have adequate pressure. We installed a graph recording pressure meter to determine the validity of this complaint. We found that the water pressure at the residence was 10 to 35 p.s.i . (pounds per square inch) . Minimum pressure to all services at all times is 20 p.s.i . (WAC 248.54-) During the investigation of this water supply it was also found that, though some preliminary engineering was done, plans were never approved, nor was the system certified as completed by a licensed professional engineer. This water supply, therefore, stands as an un-approved water supply. Until such time as you havd complied with the provisions of the state law regarding public water supplies, you may not make any additional service connections. With the completion of the water supply and com- pletion of the water supply and certification to DSHS we may again permit additional service hook-ups. If there are questions in this regard please call me at 426-5561 . Sincerely, J. V. Deshaye, M.D. , D.P.H. District Health Officer Charles D. Leaf, R. S. Environmental Health Specialist CDL:hh cc: Legal Counsel District Engineer b.c. Doug Hoffman 1302 = 41st Ave. N. W. Puyallup, Wa 98371 STATE OF WASHINGTON DISTRICT OFFICES: DEPARTMENT OF HEALTH SMITH TOWER-SEATTLE 98104 PUBLIC HEALTH BUILDING 924 W. SINTO-SPOKANE 99201 OLYMPIA Public Heeltb Building #'7 Olympia Airport February 4, 1970 Wesley E. Berglund, P.E. 216 East First Street Aberdeen, Wash. 98520 Subjec ter S as Mason County Dear Mr. Berglund: In your recent letter rega.rdi t subje t w ter system you indicated you had not received any co espo once on his office subsequent to your plan submittr1 of My 6, 19 P ease find attached a copy of a letter ••hieh we sent to your fief ad y 23, 1969, in 1~>hich e out- lined the additional informati squired te ,ould appreciate ur coopers. on furn hang the needed data •Ln order that :e may c let r rev , o. h *Later system. ( ) very truly yours, Kenneth J. Harry District Engineer KJH:bg ` \ v � cc: Th sto Mason He. th istrict Q t Phi Herb Ab ten Enclosure Et tt':USS0N-ra1A ' �,x�k�c,Ia.;.as�;;r�tc•i l-- 304 Public Health Building Olympia, Idashiugton 98501 May 23, 1969 1i esley i . l>ergluczd, P.R. 21.6 last a?i:cut Street Aberdeen, Wash. 98520 Subject: Lost Lake Eater System Mason County Dear Mr. Berglund: Thank you for suurait'ting the plans and specifications for the subject water system. Before we can complete our review of this project, we will need some add:i c �na:_ iLlforwation regG>>:_ii :e. the ssupp".y source. so, we request that two items be changed on the submitted plans. zh regard to the well tae need the following :i nfc: .zbic u: (1) well .loci and test pumping results (2) chemical acid bacteriological aaal.y<,i.:: data (3) statement of how the well site :i:,. to be protected. The submitted plans indicate that minimum pipe cover is tc• be 24 inches. t7e consider 30 inches to be the minimum allowable cover. On sizing of service lines, we ask that single service lines not be less than 3/4 inch and double service not less than one inch. We will hold these plans pending receipt of the additional information requested. V ry truly yours, Kenneth J. Merry District Bnginer. cc Thurstoa--iiason liralth Lis t MAY 28 1969 THURSTON.MASON HEALTH DISTRICT 5th and BIRCH SHELTON, WASHINGTON STATE OF WASHINGTON DISTRICT OFFICES: DEPARTMENT OF HEALTH SMITH TOWER-SEATTLE 98104 PUBLIC HEALTH BUILDING 924 W. SINTO-SPOKANE 99201 OLYMPIA December 19, 1969 Mr. Phil Herbig 110 B. Wishkah Street Aberdeen, Wash. 985'0 Subject: e Pa Water System MasD n County Dear Mr. Herbig: I have received a copy of a "Re rt of Bra nation on Ground Water" from the Department of Water P sour erta. nice to ta:s subject vatr supply. I wish to remind yo at is ti tl t the plans submitted to this Department over a year ago vs nev r b en approved because our request for more informati was r tly gnored. Until this system is approved, is bet operated in violation of the rules and regulati he to Bo 1 of ileolth. I urge you to comply with these r irements tho .Eurth r 'Ielay. O Ve truly yours, Kenneth J. terry DiEtr5 t ro Jaenr KJM:bg cc: urst n-Mason H Ith District DEC N NEALTN DISTwO �ht}RSUN• ,' d BIRCH 4fUON. W HtNGTG'd 3 LAST 150-FEET OF DISTRIBUTION SYSTEM 27 MAYBE2"PVC 61 28 DISTRIBUTION SYSTEM 26 29 SITE INFORMATION PROVIDED BY THE CLIENT AND BY SITE INSPECTION. EXACT LOCATION OF DISTRIBUTION SYSTEM IS UNCERTAIN. NOTES ON OLD ELEV. 24 23 SITE PLAN INDICATE THAT"MOST PIPE IS BURRIED 1-2 FEET OFF THE EDGE 25 505 OF PAVEMENT;BURY DEPTH 18-30"(EXCEPT UNDER BOAT LAUNCH-4-5)" 20 ALL DISTRIBUTION MAINS ARE 4-INCH PVC UNLESS OTHERWISE INDICATED 78 22 ELEV. 503' EXISTING 1"BLOWOFF 21 19 PROPOSED CHANGE TO 7' ❑- SERVICE CONNECTION 78 © ELEV. o-- ISOLATIONBLOW-OFF VALVE BLOWOFF2 16 OA COLIFORM MONITORING SITE DISTRIBUTION MAIN 76 1 SERVICE NUMBERS PAST THE BLOW-OFF MAY BE 2"PVC 80 17 Ni NODE 15 LOSTLAKE ELEV.480' 75 14 a 12 74 , ELEV. 71 499' 13 69 73 ELEV. C7 49 60 68 493' m ELEV. W 48 67 501' f = 11 9 47 64 72 8 63 30 31 46 60 ELEV O 10 32 ELEV. 91' E 59 491' 70 ■ 33 34 4"pVC 54 C1� ■ 45 N3 ELEV. OD 38 0 521' 43 y ER 62 61 7 LEV. 358 516 ELEV. W LEV. 6 1'7 504' 57 O �� 51T RUSSELL DRIVE 4"P 56 N2 VC 5 y 55 41 C-) 52 3 35 36 39 40 51 a� 4 42 IQNAL 2 EXPIRES LOST LAKE ROAD ELEV. D"AWNBY SYSTEM OWNER VISTA KNOLL MITCH EDWARDS 521' CHECKED a,,: FVE ND.04090601 FILE NAMEDISTRIBUTION 82 6NEETND. REVISION \ DESRDP110N DATE DAIESEPTEMBER 13, 2004 6CA`E. 1" = 150' NORTHWEST WATER SYSTEMS, INC. DESIGN-CONSULTING-MANAGEMENT P.O.BOX 123 PORT ORCHARD,WA 98366 (360)876-0958 SERVICE AREA 27 © SITE INFORMATION PROVIDED BY:THE CLIENT AND BY SITE 81 28 INSPECTION AND BY THE MASON COUNTY ASSESSOR'S OFFICE 29 0--- SERVICE CONNECTION 25 24 23 O— BLOW-OFF 20 Dd ISOLATION VALVE 78 QA COLIFORM MONITORING SITE 21 19 O WELL OB 79 16 18 1 SERVICE NUMBERS 76 17 15 75 80 14 LOST LAKE 74 71 69 12 13 49 50 68 48 67 73 64 11 9 6 47 6063 72 10 O 31 5254 32 33 O 66 37 38 43 44 8 62 65 Z 61 7 DE2 58 6 RUSE RIVE 56 57 5 55 41 5 3 - 35 36 38 40 51 4 4 42 85 86 87 2 `�'y LOST.►A�ROAD 82 84 NODE 1 PUMPHOUSE E 83 WELL 1 ELEV.• t `� _ 100'RADII 515 C`�'! ,_, : t WELL2 CZ' A- AL (EXPIRES 7(L2-/d REVISION BYSTEN VISTA KNOLL ONaEB MITCH EDWARDS DESCAFTCMI DATE DRAW"B'. FLE ND.04090601 FLENM€ SVC AREA SNEET�. GECICED BY: °"SEPTEMBER 23, 2004 SG`E 1" =240' SE CORNER OF THE NORTHWEST WATER SYSTEMS, INC. SW 1/4,NW 1/4,SW 1/4 DESIGN-CONSULTING-MANAGEMENT SEC.6,T 19N,R 4W,W.M. P.O.BOX 123 MASON COUNTY,WASHINGTON PORT ORCHARD,WA 98366 (360)876-0958 WELL 2 GROUNDWATER TRAVEL RADII SITE INFORMATION PROVIDED BY:THE CLIENT AND BY SITE INSPECTION AND BY THE MASON COUNTY ASSESSOR'S OFFICE o-- SERVICE CONNECTION O- BLOW-OFF X ISOLATION VALVE O WELL LOST LAKE NODES NODE2 FIGURE DEPICTS 6-MONTH,1,5,AND 10 YEAR RADII IN SUCCESSION, PUMPHOUSE THE ONLY KNOWN SOURCES OF CONTAMINATION WITHIN THE 10-YEAR RADIUS ARE WELL 1 SINGLE FAMILY RESIDENCES IVkD A4 WITH ON SITE SEPTIC o NODE 1 \\�O SYSTEMS. ALL LOTS WITHIN 515, , , S�r�C THE 1 0-YEAR RADIUS HAVE Q POTENTIAL BUILDING SITES; HOWEVER,NOT ALL LOTS WELL 2 HAVE BEEN BUILT UPON. 4. r� cIs1S-iE ø' �Po SI0NAL 'co EXPIRES 7/27I2( REVISION BYRE., OWNER VISTA KNOLL - MITCH EDWARDS DESCRIPTIDN DATE DRAW"B' FILE NO.04090601 FEE NAME WELL RADII SHEET NO. CHECKED BY:r"� APRIL 5, 2005 BCA1 1" =240' KN0RTHWEST WATER SYSTEMS, INC. SW CORNER OF THE DESIGN-CONSULTING-MANAGEMENT SW 1/4,NW 114,SW 1/4 P.O.BOX 123 SEC.6,T 19N,R 4W,W.M. PORT ORCHARD,WA 98366 MASON COUNTY,WASHINGTON (360)876-0958 AS-BUILT PUMPHOUSE SCHEMATIC THIS SCHEMATIC REPRESENTS THE AS-BUILT CONDRION OF THE PUMPHOUSE. UNDERGROUND PLUMBING DETAILS ARE UNKNOWN. THE ONLY SHOWN FEATURES NOT CURRENTLY EXISTING ARE THE WELL 1 ASME RATED PRESSURE RELIEF VALVE AND THE LAG PUMP AFK 585 PRESSURE SWITCH. ED PRESSURE REUEF VALVE ALL PLUMBING IS 2-INCH GALVANIZED IRON PIPE,UNLESS PRESSURE GAUGE OTHERWISE INDICATED. UNION WATER METER GATE VALVE PROPOSED ASME RATED PRESSURE RELIEF VALVE SAMPLE TAP/TANK DRAIN KUNKLE 912 D SET TO 100 PSI CHECK VALVE HYDROPNEUMATIC TANK 300 GALLONS WELL PUMP#1 AIR COMPRESSOR IN ATTIC CONTROLLER (2 HP) WELL PUMP N2 CONTROLLER (3 HP) ALTERNATOR LAG PUMP PRESSURE SWITCH(3580) LEAD PUMP PRESSURE SWITCH(4080) 3/4"SAMPLE TAP z WALL-MOUNTED HEATER a >4 WITH THERMOSTAT, JJJJ o 3/4"SAMPLE TAP TO BE ADDED a Q = m v U 10-FOOT LOCKING GARAGE DOOR 0 FO�pA. MO WASyj SOURCE METER FOR WELL 2 11663 SICNAL EXPIRES 1 REVISION SYS OWNER WELL 2 DESCRIPTION DATE VISTA KNOLL MITCH EDWARDS AFK 584 DRAWN BY: FILE M. FILE NAME SHEET P . 04090601 AS-BUILT HOUSE CHECKED BY. SEPTEMBER 24, 2004 2004 S- 1" _ 3' NORTHWEST WATER SYSTEMS, INC. DESIGN-CONSULTING-MANAGEMENT P.O.BOX 123 PORT ORCHARD,WA 98366 (360)876-0958 , 7LS 17 QL T'7f° _ 1?JO 1j9/ ,/