HomeMy WebLinkAboutWEL2023-00004 - WEL Application, Design, Letter - 2/21/2023 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269, EXT 400
FAX:360-427-7787
C Estrada Inc
11659 SE Black Rd
OLALLA, WA 98359
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2023-00004
101 NE MAPLE WOOD CT
123297590072
The 2-party water system, Sandhill, has been reviewed and is hereby APPROVED for 2 connections.
Please continue to follow best management practices with maintaining your water system including
regular water analysis, landscaping, keeping wellhead area free of contaminants, and stormwater
management around the water source.
If you have any questions, please contact me at 360.427.9670 x581 or email at
rthompson@masoncountywa.gov
Sincerely,
Rhonda Thompson
Environmental Health Specialist
Mason County Environmental Health
/��...Pc.�t.
e` t`' Date Received: • , to ��
MASON COUNTY ,
r--
COMMUNITY SERVICES Amoun • Receive
�I .._,., =
� ''r 1",w—
L;. Building,Planning,Environmental Health,Community Health
\ NAP
415 N.6ih Street.(Bldg 8)-Shelton,WA 98584 W E L e>1), 0
Shelton: 360-427-9670 x400 Bclfair.360-275-4467 x400 Nina:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT PH E
C- &\\Ca , i \uz (- J &s- 4. 3- 3\o -e 2 5
MAILING ADDRESS-STREET,CITY,STATE,ZIP
11G 5c\ S6 '3A0.r,_Y... \-), , , kcz Nc. W t^.\ ?3,35�
SITE AD RESS-STREET,CITY,STATE,ZIP
5 \ \ Ma . _W oo CT 3e-\\= \\" °‘8528
PRIMARY PARCEL NUMBER(WELL S )
\23ZG-1.5-cioof L
SECONDARY PARCEL NU(IF APPL� 1
WATERSOOURZCE`/''' G SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE
0 New ® Existing EU Well 0 Spring 1 72-5 AL \r-3I .
PROPOSED WATER SYSTEM ME(REQUIRED)
PROJECT-\42.*DESCRIPT ! 4N�TT\e. \`(\ Ocam, �D
DIRECTIONSTO C\1 I •
VV UYY‘ .)C-A 3V/0 \CAA- OIN1t S1C30'.1 \\\s\ 12.\
Z3c.)
ar Ma�\-�\.°C4 G\ , )-, LEA" on -t ` .� r
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
il
p Litt' ; VI. I �
FEB 21>2023L.
By Ice"
Submittals Checklist: (these additional items will be required for approval)
Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled)
fR Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
.& Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document)
• Septic Records (additional locating requirements may apply if there is a lack of septic records on file)
This form may be scanned and available for public view on the Mason County Web site. Revised: 10/13/2021
Page 1 of 2
Staff Use Only
Review Step 1: Well Site Inspection:
YES NO NA
❑ A ❑ Evidence of existing sources of contamination within 100 foot radius of water source?
(drainfields, tanks, buildings; indicate distance on plot plan)
❑ J J ❑ Are there roads within the 100 foot radius of the water source? If so, is road private, County or State.
What is distance to ROW?
IK ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
X —W ❑ Is the well cap satisfactory Rep ciO t( c-n 7/237Th 7
cJ t * ❑ Screened and vented?— II
❑ The well casing extends ,.. V above level ground / concrete slab? (circle one)
❑ ❑ 53 Is there evidence of a surface seal?
g ❑ ❑ Does the seal appear adequate?
❑ 2 ❑ Is a variance necessary for well site approval?
Comments
(414- : C- , LI I ‘a I `,( —]
X
1)i� a ,(—fit 2 2 ° FI L-i I `l b c-Pass ❑ Fail Inspector . Date 11 F-- b A' Z j
Review Step 2: Two-Party Review:
RS NO NA
❑ ❑ Water Well Report with adequate pump test on file?
If NO, date of Capacity Test Driller GPM
,� ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test Z I I )7- '7
X' ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN L\'7 Z-'t (Z
❑ ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments
APPROVED
❑ Approved ❑ Denied Reviewer ..2 4 2023 Date 2 l( it ) 16 7 3
Ggri EN RONMENTAL HEALTH
Findings in this review reflect obser is as existed on the day of the site inspection. No claim is made, express
or implied of the future success or failure of this system. Well site approval does not constitute water system approval. Water
System approval is a two-part process.
All proposed connections to new wells are subject to water adequacy requirements at time of building permit per MCC 6.68.
Water usage restrictions and additional fees may apply to all new wells drilled after January 19`", 2018 per ESSB 6091.
Revised: 10/13/2021
This form may be scanned and available for public view on the Mason County Web site.
Page 2 of 2
BO 2o22_ - d 172i-+c-)
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i, r
T APPROVEDto Plc,
Rici . uc ,n-e- r ,g • 4 2023
..'RYOfI-,* 1/329-75- 9007I
Ma i wood G T ,P P ��` ' IRONMENTAL EALTJ
5 l N1 E DJA
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C=ins+ Ho l�e
210 i ioY'. i'
III hole 3/4`+ 0Y /
. ivle Loam(' SGhd : T
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WI -1 .
0'0 `,‹60' ff i ,nary • 1 _r
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d1-ci�y\ i P 1 d -I�f e n c litc-s @ � '
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44.
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O Audio-Visual Alarm cn —— - lr
m � u
CO �, _ a poS ed. �.. )
13 Cleanout '. L-S 3 g i- --
i_
01200 Gallon Septic Tank ! _
2-Compartment with " "
Effluent Filter •
.
0 1000 Gallon Pump Chamber ',.
•
O5 Valve Control Box / '•
TI go
-- /� 0
e
e-PAULA5r0Y°3J409 HNSON (J, Ig�$7�;- -' - N Male \AIQo d L-r
30 e....sarA-
1
4,
Thurston County Environmental Health
if G 2000 Lakeridge Dr.SW Olympia,WA 98502
360 867-2631
THURSTON COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected I Time Sample County
i 3 I / Collected
2, DAM
Month Day Yea; -"pm $Y1
Type of Water System(check only one box) ❑ Private Househo'
❑Group A ❑Group B g Other\WQ_ 1.
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name:
Contact Person:C otyLL
Day Phone:( ) Cell Phone:n1)3 J9342j
),,J(.13 Eve Phone:( )
Send resul to: Pnn full nam address and zi emai ddress)
CQJ -a p c.6,57Ya4l uG ' t
\\65
SAMPLE INFORMATION
Samptad b na ):
� v
Specific location or address where sample collected: Special instructions or comments:
Type of Sample(must check only one box of#1 through#4 listed below)
1.($Routine Distribution Sample 2.Repeat Sample(after unsat routine)
Chlorinated:Yes No ❑Distrbution System
Chlorine Residual:Total Free Chlorinated:Yes No e D f)R O`v/E
3.Raw Water Source Sample Chlorine Residual:Total Free /"l i
❑E.co/i-GWR(A/P) FEB 2 4 2023
❑Fecal-Surface.DWI,springs(numeration( Unsatisfactory routine lab number:
Filtered;Yes No - _ MASON COUNTY ENVIRONMENTAL HEALTH
❑Assessment Monitoring(A1P) Unsatisfactory routine collect date: DJA
❑Other
S
-- I /
4.0 Sample Collected for Information Only
Investigative Construction/Repairs Other _
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and .` tisfactory
0 E.coli present ❑E.coli absent o .liform detected
Replacement Sample Required:
❑Sample too old(>30 hours) 0 TNTC 0
Bacterial Density Results:Total Coliform /100ml. E.coli /100m1.
Fecal Coliform 1100m1 Enterococci /100 ml.
Method Code:gSM 9223B ❑SM 9222D Date and Time Received:01g0
SM 9215B 0 Enterolert®
Date and Time Analyzed: —' —3.3 Date Reported Z-23
Sample Number(DOH number plus five digits; Lab Use Only:
0 8 0
DOH Form#331-319(revised 01/16)
start Card No. W 38685
File Original end opywith
D.p.ltvneRl of Ecologycology WATER WELL REPORT UNIQUE WELL I.D.I ABF 884
Second Copy—Own.r's Copy STATE OF WASHINGTON
Third Copy—D"Ilse a Copy
i Water Right Permit No.
i (1) OwnER: N.. Walt Allison _ Adbeee Maple Ct Lane Belfair WA 98528
I.
l• (2) LOCATION OF WELL: co" Mason NW Ira SW 1/4 Sec 29 r. 23 w.R 1W w.M.
: (2a) STREET ADDRESS OF WELL(amour address) Maple Ct Lane Belfair WA 98528
1
A (3) PROPOSED USE: ] Domestic industrial C Munidpai C (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION
] Irrigation D
1 : I De Water Test Well 71 peer U Forman. Daecrba by cola.Uerader.size of material and structure,and shore tMcknese of equilars
and the And and nature or the material in each stratum penetrated.with at least one entry for each
i (4) TYPE OF WORK: (""e's num a wan dvnpe of lnbnnation
(If more than!Amer)_ 12 MATERIAL FROM To
Abandoned I: New well 6p Method: Dug 0 Bored 0 -
Deepened ❑ Giblet Driven()
• Reconditioned U Rotary n Jetted 0 Tod loll 0 2
i (5) DIMENSIONS: Diameter of well 6 inches.
$ Drilled 79 feet. Depth of Completed well 79 - rt. Brown clay 2 40
) (8) CONSTRUCTION DETAILS: Blue clay _ 1 40 74_
Casing Installed: 6 Diem.from 0 kw 74 it
▪ Welded (X • Diam.from ft to ft.
Sand with water 74 79
1 Liner installed❑ _ - --
Threa ❑ — Diam from ft.to _ ft.
i —Perforations: Yes ❑ No 3
1 Type or perforator used
f SIZE of perforations at.by at.
i _, perforetlone from _ ft.to_ -- R
I
perforations from ft.to-- h.
t _--- perforations from h.to—. , _ h.
1 Screens: Yes Xn No❑ —
Manufacturer's Name Hpus ton
i Type stainless wire wrap Model No.
li Diem. 5"Slot size 25 from—i4 it to 79 It.
Diem. ,Slot size-- from _ ft.to__ It. _-
i . —441 __iit
Gravel pecked: Yee❑ No® Size of gravel —
i Gravel placed trom ft.to - It. l'
•
` Surface seal: Yes f] No ❑ To what depth? 18 _ h_ 4,4 —
) Material used In seer Betonite _ ONL.00N,Y
Did any strata contain unusable water? Yes El NO E ry�wf 4
1 Type of water? Depth of strata M '"‘4,, .
.a,.. ,,
I Method of sealing strata ott -.
)
f (7) PUMP: Manufacturer's Name A.Y 1 A.Y. McDonald --
msType: Slltl_ ,HP.. 3/4
1 (8) WATER LEVELS: LLaovs�0e�a lemon ft.
1 sta.tenet 26 h.bolo«top of well Date
1
) Artesian pressure - -__les per squwe Inch Date
Artesian water is CorrtrOled by
(Cap.rave.arc l Work Started -- 1 /16J93,is Unplered 12/: 1y 3 19
(9) WELL TESTS: Drawdown Is amount water revel rs towered below static Wei
) Was a pump test made?Yes® No❑ II yea,by wftom?_2062 WELL CONSTRUCTOR CERTIFICATION:
Yield: _30 _gel.rmin.with_ 24 h.drawdown after 1 hrs. I constructed and/or accept responsibility for construction of this well. and its
i compliance with ail Washington well construction standards. Materials used and
30 24 2 the information reported above are true to my best knowledge and belief.
L ,r 30 ^ 24 ,. 4
1 Recovery data(time tai<en as zero when pump turned oll)(water level measured from well NAME Davis Drilling
) top to water level) IPEASON.FIRM OR COWCRATION) (TYPE OR PRINT)
I Time
Water Leval Tins water Bevel Time Water Level
0 50 3 min. 29 — 10 min. 26' Address Belfair WA 98528
• 1 min. 35'_ 4 min, 28' (signed) 6,/aek___4,itu",447/fee&I___— License No. 2062
��in. 30 5 min. 27' t )
Rafe of test
Bailer test get.1min.with ft.drawdown atter_ - hrs. COMraCtOl's
Registration
Airiest _ gal./min.with stem set at_ ft for_ . ..—hrs- No. DAVT SDT 1100A _ Dale Dec. .19 93
Artesian ftow g.p.m. Date -_--
(USE ADDITIONAL SHEETS IF NECESSARY)
Temperature ofwafer was a dtem n
lcat analysis made? Yes No El
1 %
2182812 Mason County WA
0610812022 03:50:22 PM AGREE
eRecorded #175886 RecFee: $211.50 Pages: 9
Name and Mailing Address LAND TITLE CO
Rodney and Tracy Harker
4 101 NE Maple Wood Court
Belfair WA 98528
Document Title(s): Q212918LTC
WELL OPERATION & MAINTENANCE AGREEMENT
Reference Auditor's File Number(s):
Grantor(s):
RODNEY C HARKER AND TRACY L. HARKER
Grantee(s):
RICHARD D. BUCKNER AND CRISTAL M. BUCKNER
Abbreviated Legal Description:
SW 29-23-1 W (LOT B AND C SP 1748) ,q Pp
Assessor's Tax Parcel Number(s): '0 Le
Peg
12329-75-90072 and 12329-75-90071 MgSO,yCp�Nn E 4 20?3
D/JA '7E4 44 4,,
�Tl
WELL OPERATION&MAINTENANCE AGREEMENT
Grantors: RODNEY C HARKER AND TRACY L HARKER
Grantees: RICHARD D BUCKNER AND CRISTAL M BUCKNER
Description of Real Property Affected:
Parcel Which Contains Well(See Attached Exhibit A)- Assessors Tax Parcel Number: 123297590072
Parcel to be Shared(See Attached Exhibit B)- Assessors Tax Parcel Number: 123297590071
The purpose of this agreement is meant to assure specific water rights and maintenance responsibility for the current
and future owners involving two party well to share.
WELL MAINTENANCE(EQUIPMENT AND WELL HOUSE)
A. The cost of major changes in equipment,the repair and maintenance of in-place equipment,and any costs
for water testing needed or recommended by county standards will be shared equally by both parties.
B. Storage equipment(tank,lines,etc.)will be the responsibility of both owners.
C. The maintenance of the water lines outside of the well head serving the respective parties will be the
responsibility of the landowners they serve.
D. Electricity used for water pumping and protection of the well head from freezing will be paid equally by both
using parties.
E. Protection from freezing,minor leaks,inspections,and the maintenance of the well head(clean,insect free,
etc.)will be taken care of by the users.
F. In the event of a repair when the grantor is not home,the grantee shall have the right to access grantors
property to make such repairs.
The overall purpose of this agreement is to ensure a safe and adequate water supply for both parties;to maintain the
system in accordance with county health standards;to provide an equitable basis for sharing the water from the well
and costs of operating the well based upon usage. This agreement shall run with the land and be binding upon the heirs,
successors,and assigns of the parties herein.
THE UNDERSIGNED ACKNOWLEDGES THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT AND THAT FALSE
INFORMATION WILL NEGATE AND INVALIDATE THE WATER WELL OPERATION AND MAINTENANCE AGREEMENT.
RODNEY C HARKER DATE
TRACY L HARKER DATE
RICHARD D BUCKNER DATE
-aoa
CRIS TAL h B DATE
2182812 Page 2 of 9 06/08/2022 03:50:22 PM Mason County, WA
WELL OPERATION&MAINTENANCE AGREEMENT
Grantors: RODNEY C HARKER AND TRACY L HARKER
Grantees: RICHARD D,BUCKNER AND CRISTAL M BUCKNER
Description of Real Property Affected:
Parcel Which Contains Well(See Attached Exhibit A)- Assessors Tax Parcel Number: 123297590072
Parcel to he Shared(See Attached Exhibit B)- Assessors fax Parcel Number: 123297590071
The purpose of this agreement is meant to assure specific water rights and maintenance responsibility for the current
and future owners involving two party well to share.
WELL MAINTENANCE(EQUIPMENT AND WELL HOUSE)
A. The cost of major changes in equipment,the repair and maintenance of in-place equipment,and any casts
for water testing needed or recommended by county standards will be shared equally by both parties.
B. Storage equipment(tank,lines,etc.)will be the responsibility of both owners.
C. The maintenance of the water lines outside of the well head serving the respective parties will be the
responsibility of the landowners they serve.
D. Electricity used for water pumping and protection of the well head from freezing will be paid equally by both
using parties.
E. Protection from freezing,minor leaks,inspections,and the maintenance of the well head(clean,insect free,
etc.)will be taken care of by the users.
F. In the event of a repair when the grantor is not home,the grantee shall have the right to access grantors
property to make such repairs.
The overall purpose of this agreement is to ensure a safe and adequate water supply for both parties;to maintain the
system in accordance with county heatth standards;to provide an equitable basis for sharing the water from the well
and costs of operating the well based upon usage. This agreement shall run with the land and be binding upon the heirs,
successors,and assigns of the parties herein.
THE UNDERSIGNED ACKNOWLEDGES THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT AND THAT FALSE
INFOR TION WILL NEGATE D INVALIDATE THE WATER WELL OPERATION AND MAINTENANCE AGREEMENT.
/ ati4 C t bk,.
Li' 0 tit— ' • / /f)/6.7, ',.6 2
RODNEY C HARKED DATE
TRACY LHARKER DATE
r / /
RICHARD D BUCKNER , DATE
744 ---/ e.,::::;"----------------- /,. A 020c;R.
CRISTAL MBtkKN ` DATE
2182812 Page 3 of 9 06/08/2022 03:50:22 PM Mason County, WA
WELL OPERATION&MAINTENANCE AGREEMENT
Grantors: RODNEY C HARKER AND TRACY L HARKER
Grantees: RICHARD D BUCKNER AND CRISTAL M BUCKNER
Description of Real Property Affected:
Parcel Which Contains Well(See Attached Exhibit A)- Assessors Tax Parcel Number: 123297590072
Parcel to be Shared(See Attached Exhibit B)- Assessors Tax Parcel Number: 123297590071
The purpose of this agreement is meant to assure specific water rights and maintenance responsibility for the current
and future owners involving two party well to share.
WELL MAINTENANCE(EQUIPMENT AND WELL HOUSE)
A. The cost of major changes in equipment,the repair and maintenance of in-place equipment,and any costs
for water testing needed or recommended by county standards will be shared equally by both parties.
B. Storage equipment(tank,lines,etc.)will be the responsibility of both owners.
C. The maintenance of the water lines outside of the well head serving the respective parties will be the
responsibility of the landowners they serve.
D. Electricity used for water pumping and protection of the well head from freezing will be paid equally by both
using parties.
E. Protection from freezing,minor leaks,inspections,and the maintenance of the well head(clean,insect free,
etc.)will be taken care of by the users.
F. In the event of a repair when the grantor is not home,the grantee shall have the right to access grantors
property to make such repairs.
The overall purpose of this agreement is to ensure a safe and adequate water supply for both parties;to maintain the
system in accordance with county health standards;to provide an equitable basis for sharing the water from the well
and costs of operating the well based upon usage. This agreement shall run with the land and be binding upon the heirs,
successors,and assigns of the parties herein.
THE UNDERSIGNED ACKNOWLEDGES THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT AND THAT FALSE
INFORMATION WILL NEGATE AND INVALIDATE THE WATER WELL OPERATION AND MAINTENANCE AGREEMENT.
RODNEY C HARKER DATE
-\/(X la q7/2--L
TRACY L HARKER DATE
RICHARD D BUCKNER . DATE
/-o?e,64,Q
CRISTAL tv�Bt}GKlut ' DATE
2182812 Page 4 of 9 06/08/2022 03:50:22 PM Mason County, WA
NOTARY ATTACHMENT TO WELL OPERATION&MAINTENANCE AGREEMENT
STATE OF sr3 l.-n.va-.f
COUNTY OF >.,_r ri5 5 l l..
O - - A I certify that I know or have satisfactory evidence that
/ -,S� C,. �S� a.� t ,the person(s)who appeared
b ore me, and Aid e_etfp_ (s)acknowledged thatg/she/they signed this instrument and acknowledged it to be
(liiii/her/their free and voluntary act for the uses an purposes mentioned in this instrument.
Given under my hand and official seal the day and year last above written.
Sigm/ o
-- St GAYLE G.ASTORE
C sf�)�L L� ( . i9 124 � ,�'giS _°I, NOTARY PUBLUC for the
Print Name r State of MrtAna
SEAL Residing at Helena,Montane
Notary Public in aryl for the State of/47 t -zip_,L. `, � My Commission Fires
Residing at • • .•' ' February 15.2025
My Commission Expires(&?//5 ,-,,?.. -
STATE OF
COUNTY OF
On , I certify that I know or have satisfactory evidence that
,the person(s)who appeared
before me,and said person(s)acknowledged that he/she/they signed this Instrument and acknowledged it to be
his/her/their free and voluntary act for the uses and purposes mentioned In this instrument.
Given under my hand and official seal the day and year last above written.
Sign Name
Print Name
Notary Public in and for the State of ._._
Residing at
My Commission Expires _
2182812 Page 5 of 9 06/08/2022 03:50:22 PM Mason County, WA
NOTARY ATTACHMENT TO WELL OPERATION&MAINTENANCE AGREEMENT
STATE OF
COUNTY OF_ ISCP
On Le_ l22' , I certify that I know or have satisfactory evidence that
1P'C_L1 l • 4(U✓y tcU1/ , the person(s)who appeared
before me, and said person(s)acknowledged that he/she/they signed this instrument and acknowledged it to be
his/her/their free and voluntary act for the uses and purposes mentioned in this instrument.
Given and hand and is al the day and year last above written.
t
Sign Name
rn1C--he Lk Yrictin —
Print Name
' nn MICHELE MANU
Notary Public�i ` ,aAnd for the State of ( - NOTARY PUBLIC
Residing at �lC 1 trs^ SIATE OF WASHINGTON
My Commission Expires 1l ( L(( Zt-f COMMISSION NUMBER29601
COMMISSION EXPIRES DEC.4.2024
STATE OF
COUNTY OF
On , I certify that I know or have satisfactory evidence that
, the person(s)who appeared
before me, and said person(s)acknowledged that he/she/they signed this instrument and acknowledged it to be
his/her/their free and voluntary act for the uses and purposes mentioned in this instrument.
Given under my hand and official seal the day and year last above written.
Sign Name
Print Name
Notary Public in and for the State of
Residing at
My Commission Expires
2182812 Page 6 of 9 06/08/2022 03:50:22 PM Mason County, WA
•
STATE OF WASHINGTON }
n , }ss.
COUNTY OF I`'� acre- } I P D
On �/i AO 2Z before me,Leal M M. !okhoG j � G oiky c
personally appeared
(�ithtaftel D Bucun,eit 4 C--0b Nt BU - ,
personally known to me (or proved to me on the basis of satisfactory evidence)to be the person(s)whose
name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executec the
same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
person(s), or the entity upon behalf of which the person(s)acted, executed the instrument.
WITNESS my hand and official seal. \\�\UttiiiiIt,r/,��''%
.`` \\ M. ?O
v�oc>.,,m4..? 6'2o.'9�i
Signature ; .Co BUC o�
Printed Name t� M M . /�D k�ka ,,`' ' ''mbec\•OG��\.�
Commission Expires /t,L( I20 2-4
/////'�wASink\`'' \
'NOT.SkY SEA.)
THIS CERTIFICATE MUST BF ATTACHED TO Title of Document TypeJjVQ Of 0A 4� � IV-Art rltr.✓+
THE DOCUMENT DESCRIBED AT RIGHT. Number of Pages f,, D to of Document f 2-
Signer(s)Other Than Named Above
2182812 Page 7 of 9 06/08/2022 03:50:22 PM Mason County, WA
EXHIBIT "A"
Parcel 1
Lot C of Short Plat No. 1748, recorded January 11, 1988, under Auditor's File No. 476303,
being a portion of the Southwest quarter of Section 29, Township 23 North, Range 1 West,
W.M., in Mason County, Washington.
Parcel 2
An easement for ingress, egress and utilities as described and delineated in Short Plat No.
1748, recorded January 11, 1988, under Auditor's File No. 476303.
2182812 Page 8 of 9 06/08/2022 03:50:22 PM Mason County, WA
EXHIBIT "B"
Parcel 1
Lot B of Short Plat No. 1748, recorded January 11, 1988, under Auditor's File No. 476303,
being a portion of the Southwest quarter of Section 29, Township 23 North, Range 1 West,
W.M., in Mason County, Washington.
Parcel 2
An easement for ingress, egress and utilities as described and delineated in Short Plat No.
1748, recorded January 11, 1988, under Auditor's File No. 476303.
2182812 Page 9 of 9 06/08/2022 03:50:22 PM Mason County, WA
Davis Drilling
340 NE Davis Farm Rd
Belfair, Washington 98528
United States •
(360)275-5367 P al
C Estrada I Inc Invoice Number 0000104
151 Maplewood Court Date of Issue 02/23/2023
151 Maplewood Court
Belfair US Due Date 03/25/2023
Amount Due (USD) $0.00
Description Rate Qty Line Total
Properly seal well from contamination $200.00 1 $200.00
+Mason
Vented well cap with rubber gasket $150.00 1 $150.00
+Mason
Subtotal 350.00
Mason (8.5%) 29.75
Total 379.75
Amount Paid 379.75
Amount Due (USD) $0.00