HomeMy WebLinkAboutWAT2023-00178 - WAT Application - 9/14/2023 WAT/kV) - 66A -1i5 .
_ � COUNT
MASON CO 1 415 N.6'h Street
Shelton,WA 98584
NO !dk. .` � COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
. -�`r" $elfair 360-275 4467,Ext 400
! . �,,,` Barring,Planning,Environmental Health,Community Health Elma:360-482-5269,Ext 400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part 1 is fully completed.
2. Complete only the portion of Part 2 applying to the type of water connection utilized.
3. Submit completed application,with any required attachments for review.
4. An approved building site plan must accompany this application.
Part 1: Applicant! Parcel identification ` I
Name on Applicant: `Jane/J4 UtY)(14 111 , Date: l.i 'o2-(i
Mailing Address:'1 -"y- , C t:_. a(L Phone: cgj,(-L, •.3 3P)• 5rV!•)i (,- 1 `)'6,0,Wit).6.)-7`1
Parcel Number "bhp i +l S4 W' I& &4 -/j, »2-4 - I _9(X)r11) 1
Type of Water System Reason for Application •
XPublic/Community Water System (2 or more /Er Building permit -j-1 Zc)23 - wZ>` /.,4 •
connections) 0 Division of land:
0 Individual water source(one connection), #of Parcels? SPL
0 Well 0 Boundary line adjustment
❑ Spring/surface water
0 Other(explain) El
(explain)
0 Replacement or Remodel (please indicate name
If you have more than one residence connected of water system below if applicable—no
to this well, check the Public/Community Water signature required)
System box.
•
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System:
Water Facility Inventory(WFI) Number. (write"none"for two-party)
❑ I am the manager of this water system.The water system has been approved for services.There
are presently connection(s) in use.This will be the connection.
❑ I am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system (i.e.: recreational to full time). Please indicate on the following line the nature of
this change:
This water system is able and willing to provide water to this (these)connection(s)without exceeding the
limits of the water system or any limits set by state and local regulation.
Print Name of Water System Manager Phone
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Foams\Drinking Water Revised 4/27/2021
aim&
. Individual Water Well
1V r❑ Water well report(attached to application). Depth ft. �l
yWell capacity Test(attached to application) 7 gpm yo gpd.
The well driller often performs well capacity tests at the time the well is constructed. Results from
these tests are noted on the water well report. Results from these tests will be accepted. If the water
well report cannot be located by the applicant or if the water well report does not have a capacity test,
a well capacity test,which provides stabilization of draw-down and recovery data, must be performed
by a licensed contractor.
? Satisfactory bacteriological test(attach to application). y /2 coo Z y
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planning 14 X 15 16 22
Water use or limitation recorded N/A Ye?( Afty 2[ Vd 36
Well Drilled Date
Individual Spring/Surface Water
4
❑ WDOE permit(attach to application)
O Method of disinfection
❑ I have reason to believe that this water source can provide at least 800 gallons per day; and/or
provides water at a rate of 2 gallons per minute based on the following observations.
Author of Statement Date
Relationship to Applicant
• •
Part 3: Mason County Community Services Evaluation (staff use only)
Satisfactory Determination:
ii(
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the future,or guarantee compliance with all applicable WDOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.0Unsatisfactory Determination: 4'p
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s). Et)
lfgSQNC SEP 14 2023
Reviewer's Signatures: //11/? 3
0(/N7YENV/RO
Environ. Health:____Iil Date DJA NMfNrqL yFA(rH
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
26276 Twelve A
Trees Ln NW
Ste.0 ;' SPECTRA Laboratories - Kitsap
roulsbo,WA
98370 •••tViero azleriex�narrm
(360)779-5141 COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
Ii l.off z Collected
❑AN
-'I Monti Day Yea 3 : to 14PM OA AAcAlk
Type of Water System(check only one box)
CIOther�JC
Group A 0 Group B l
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID# •
System Name: —1 350
r yt&Are p c/
Contact Person: t q r!1 Jr
- Day Phone: lJu Cell Phone: 3 6 ( t i d T
Email: Eve.Pho e:
Send resits b:(Prtntlul name,address and>ip coda a abow tar Mtletlon nwlts)
_-!aret,Dewc _SAMPLE INFORMATION :7
Sample collected by(name):
Plart5C
Specific location where sample collected: Special instructions or comments:
Yce_
Type of Sample(check only one box)
1.❑Routine Distribution Sample(AIR) 2.❑Repeat Sample(AIP)
Chlorinated:Yes ❑ No❑ (from distribution system after unsa:routine)
Unsatisfactory routine lab number.
Chlorine Residual:Total Free
3.Ground Water Rule Source Sample —— —--
S
I I I unsatisfactory routine collect date:
Chlorinated:Yes No
❑Triggered (A/P) Chlorine Residual:Total Free
❑Assessment(A/P)
4.Surface or GWI Raw Source Water Sample(Enumeration)
S
Cl E.coil 0 Fecal Filtered Yes_No
5. arnpte Collected for Information Only:
LAB USE ONLY DRINKING WATER RESULTS USE ONLY
❑Unsatisfactory Total Coliform Present and isfactory
❑E.coli present 0 E.cod absent
Bacterial Density Results:Total Coliform mpn/100m1.E.cofi mpn/100m1.
Fecal Coliform cfu/100m1. HPC cfu/1mI.
Replacement Sample Required: 0 TNTC ❑Sample too old
❑ Sample Volume ❑Damaged Container ❑
Dat Re a Lab Reference Number
26 1 )LDO ZZb Dt —oi
Receipt emp C°: Method Code: QT-COUNT/SM9222D
C ry TNe reports.edeoley•Mull altlq perom•orc as .ylo
Dt(2 J/ 1 Out 41 — K's ed antic .i use.wppryar:367;7 dli tivnbyfa
7-+/�/ In+af.ka rooptadis ierulwl�.a.ryounwer«eiredfi.repalN
mar.please nosh Ice serdse rtene6elY/d 36b779S141 ell
cabby tole regal paapdy.
DOH Lab-Sample k
These nmfb robe.city b Meitma baled and Ill semple(s)as
010- 3001 V __ r�iredbr MlebasIcO.Ibis regal Val net be rep,educed meDl
n Ail.cad A p cs.,rase'Wen pm el by Spears Lebcretaea
DOH ram 11731419(eSecwe e6/17)
Spectra Labs - Kitsap, LLC (Poulsbo)
SPECTRA Laboratories -Kitsap 26276 Twelve Trees Ln NW Ste.C
...Where experience matters Poulsbo,WA 98370
Phone: (360)779-5141
www.spectra-lab.com
Spectra Labs -Kitsap, LLC (Poulsbo)received samples for Davis Pumps on Tuesday,April 25, 2023 at
12:00 pm. Unless otherwise noted, all samples were received in good condition and were tested in
accordance with the laboratory's quality control procedures.A summary of the samples received are
outlined below.
Sample No. Description Location Sampled
226308-01 4350 E Agate Rd Source 04/24/2023 15:10
This report package contains laboratory sample results and any attachments listed below. If you have any
questions please call (360)779-5141 or email us at www.spectra-lab.com.
This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other
than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at
360-443-7845 and destroy this report promptly.
These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced
except in full,without prior express written approval by Spectra Laboratories.
04/28/2023 Page 1 of 1
Die Pumps, Inc.
340 WE Davie rarm'lid
'Belfair,`Wa 98528
(360)801-6107
Project 4350 E Agate Rd
Capacity Test Shelton,Wa
TAG:NA
Date 4/21/2023
Pump % hp
Well Depth +65 - unknown
Static Water Level 54.2
Draw Down Recovery
Time Water Level GPM Time Water Lever
0 min 54..2 0 •
0 64.7
5 min 63.6 7 V 1 min 59.6
10 min 64.7 7 2 58.2
15 min 64.7 7 3 57.5
30 min 64.7 7 4 56.9
1 hr 64.7 7 5 56.2
2 hr 64.7 7 10 54.8
3 hr 64.7 7 15 54.2
4 hr 64.7 7 20
Capacity Notes:
Well seal with catch rope - unable to take well depth measurement with obstructions
2200036 MASON CO WA
07/26/2023 01:12 PM NOTCE
OMDRHL *1189167 Rec Fee: $204.50 Pages: 2
I IIIIIII I III III!:I!lilllll IIIIII IIIi IiiI III1I Dill lI!I'I I IIIII II!II 1lO III
•
R turn To
74ni 4 OM cicLhL -
i-1- 1) e 71/41c,141-7, LL _
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JUL 2 12023 JUL 2 6 2023
RECEIVED s 15 W. Alder Street
Grantor(s): (1) Ictiwy-,A v m Giz lit-' , (2)
Grantee(s): (1) PUBLIC /
Legal Description (1)€C- 2..,4 '\--\AD-pZ 0 a
(Abbreviated form:i.e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1) n 3. `i.. - 1 o9, - C 0 n 1-11 1
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA (WRIA)
I (We), the undersigned grantor(s), hereby place this notice on record that the described real
estate situated in Mason County, State of Washington is subject to water use restrictions and
conditions set by Washington State Senate Bill 6091 and Mason County Code 6.68. These
restrictions and conditions are based on location of property and/or Water Resource
Inventory Area or WRIA.
•
WRIA: 14
i
Maximum Annual Average Gallons Per Day: q`�o gallons
Dated on this �� ,day of 5V\W) , 20 9.3.
Signature of Grantor(s).
(1) C\` Eso \ , (2)
State of Washington )
County of Mason )
Page 1 of 2
•
•
I,the undersigned, a N9t,Try Public in end for the above named County and State, do hereby
certify that on this 2 day of 3-0 , 20 23 ,
"SGuNe5Sa Q'ah p rsonaliy appeared before me,who is known to be
signer of the above instrument, and acknowledged that he (she) (they)signed it.
GIVEN under my hand and official seal the day and .ear last above,written.
\\\���tt�iii�ilr/i��I/* Notary Public in and f the State of Washington,
�•cc� 31'on 2 Foyd�% residing at
NoTARY My commission expires: 121 3l] 20 2�"
r=U: �•i . -. l
PUBLIC N:
e ,vrnbec2•••
//f,�F WASN\�\\
Page 2 of 2
2196858 MASON CO WA
05/08/2023 01:43 PM DECL
DAVIS PUMPS INC 4186643 Rao Fee: $206.60 Pages: 4
Mil 1IIIIII !MlIIIIIIIHIII11114H11III1 Illu11l1n
Return To:
Davis Pumps Inc.
340 NE Davis Farm Rd
Belfair, Wa 98528
Declaration of Water Use Agreement
McLaughlin!Omdahl Water System
Private 2 Party
ABBREVIATED LEGAL DESCRIPTIONS AND PARCEL NUMBERS OF TRACTS BEING SERVED]
The well and water system being situated on:
Parcel#32024-21-90010
TR 1 OF NE NW EXC:O RAN'TR2OFSP#384
R3W T2ON Sec24 NW1/4-NE1/4
Granters:MCLAUGHLIN,PHILIP M&JANEEN A
Owners of:
Parcel#32024-21-90010
TR I OF NE NW EX CO R/W TR 2 OF SP#384
R3W T2ON Sec24 NW114-NE1/4
Grantee:Jasessa Onmdahl
Owners of:
Parcel#32024-12-90061
TR 6-A OF NW NE'FR l OF SP#2111 AF'#531308
R3W T2ON Sec24 NW1/4-NEII4
lias been designated to serve a source of water to the following parcels situated in Mason County,State of
Washington;herein described:
Parcel#32024-21-90010
TR 1 OF NE NW EX COR/W'TR 2 OF SP#384
R111 T2ON Sec24 N111/4-NE1/4
f '
Parcel#32024-12-90061
TR 6-A OF NW NE TR 1 OF SP#2111 AF#531308
R3W T2ON Sec24 Nw1/4-NE1/4
OWNERSHIP OF WELL AND WATERWORKS
It is agreed by the parties that the owners of the Parcel#32024-21-90010 TR I OF NE NW EX CO R/W TR 2 OF SP
#384 R3W T2ON Sec24 NW1/4-NE1/4 shall retain 100%ownership of well and water system. Each party shall be granted
use of well and water system. Each Party shall be entitled to receive a supply of water for one residential dwelling
and shall be furnished a reasonable supply of potable and healthful water for domestic purposes.
LOST OF MAINTENANCE OF WATER SYSTEM
Each party hereto covenants and agrees that they shall equally share the maintenance and operational costs of the
well and water system herein described. The expense of water quality sampling as required by the State of
Washington and Mason County shall be shared equally by both parties. If either party were to sell their parcel any
new owner(s)would have to create a reserve account with a mutually agreed upon banking system.
NOTICE TO FUTURE PROPERTY OWNERS
The water system is designed to provide for two services. Additional planning and design approval must be
obtained from the local health jurisdiction prior to expanding beyond this number of services. Design flow
standards account for domestic use and watering of a typical lawn and/or garden space only. The design assumes
that all residences will be equipped with ultra low flow plumbing fixtures and that all users will keep conservation in
mind whenever the system is used. Additionally,a water right,obtained from the Department of Ecology,is
required if the water system exceeds exemption standards.This system has not applied for or been granted any
waivers from specific provisions of the regulations.
EASEMENT OF WELL SITE AND PUMPHOUSE
There shall be an easement for the purpose of maintaining and repairing the well and components to complete and
maintain a properly functioning water system and appurtenance thereto,within 100 feet of the well site in any
direction of both properties listed. Said easement shall allow the installation,maintenance or repair of well,water
system,pump house,pumps,water storage reservoirs,pressure tanks,waterline,utility lines and/or anything
necessary to the operation of the water system.
MAINTENANCEAND REPAIR OF 121STRIBUTION LINES
All pipelines in the water system shall be maintained so that there will be no leakage of seepage,or other defects
which may cause contamination of the water,or injury,or damage to persons or property. Cost of repairing or
maintaining common distribution pipelines shall be borne equally by both parties. Each party in this agreement
shall be responsible for the installation,maintenance,repair,and replacement of pipe supplying water from the
common water distribution piping to their own particular dwelling and property. Easement shall be granted on both
lots to repair.replace or maintain the waterline as needed for distribution purposes.
PROHIBITED PRACTICES
The parties herein,their heirs,successors and/or assigns,will not construct,maintain or suffer to be constructed or
maintained upon the said land and within 100 feet of the well herein described,so long as the same is operated to
furnish water for public consumption,any of the following:septic tanks and drainfields,sewer lines,underground
storage tanks,county or state roads,railroad tracks,vehicles,structures,barns,feeding stations,grazing animals,
enclosures for maintaining fowl or animal manure,liquid or dry chemical storage,herbicides.insecticides.
hazardous waste or garbage of any kind.
The parties herein,their heirs,successors and/or assigns are required to keep the water supplied from said well free
from impurities which might be injurious to the public health.It is the purpose of these grants and covenants to
r•
r ,
prevent certain practices hereinafter enumerated in the use of said grantor(s)land which might contaminate said
water supply.
Exhibit A NOW,THEREFORE,the grantor(s)agree(s)and covenant(s)that said grantor(s),his(her)(their)heirs,
successors and assigns will not construct,maintain,or suffer to be constructed or maintained upon the said land of
the grantor(s)and within fifty(50)feet of the well herein described.so long as the same is operated to furnish water
for public consumption,ANY POTENTIAL SOURCE OF CONTAMINATION INCLUDING BUT NOT LIMITED
TO:cesspools,sewers,privies,septic tanks,drainfields,manure piles,fenced pasture.garbage of any kind or
description,any enclosure or structures for the keeping or storage of non biodegradable fertilizers,liquid or dry
chemicals,herbicides or insecticides as well as any enclosures or structures for the keeping or maintenance of fowl
or animals such as barns,chicken houses,rabbit hutches,pigpens,livestock sheds,and further agree(s)not to use.
apply,dispose or suffer to be used,applied or disposed,non biodegradable fertilizers,any liquid or dry chemicals,
herbicides or insecticides within the above described protective radius.These covenants shall run with the land and
shall be binding on all parties having or acquiring any right,title,or interest in the land described herein or any part
thereof,and shall inure to the benefit of each owner thereof.
WATER SYSTEM MANACi Fit
The owner of Parcel#32024-21-90010,TR I OF NE NW EX CO R/W TR 2 OF SP#384,R3W T20N Sec24
NW 1/4-NE1/4 is the designated"Manager"of the system.. The manager shall be responsible for arranging
submission of all necessary water samples as required in the Washington Administrative Code,and Mason County
Rules and Regulations and handling emergencies such as system shutdown and repair. The Manager shall provide
his/her name,address and telephone number to the Health Officer and shall serve as a contact person to the Health
Officer. The manager shall organize and maintain the water system records and notify the Health Officer and all
parties,service connections and lots that are included in this agreement,of the water quality tests that are required
by WAC 246-291 and Mason County Rules and Regulation.Water system records shall be available for review and
inspection by all parties in this agreement and the Health Officer.
HEIRS.SUCCESSORS AND ASSIGNS
These covenants and agreements shall run with the land and shall be binding on all parties having or acquiring any
right,title,or interest in this land described herein or any part hereof,and it shall pass to and be for the benefit of
each owner thereof.
I
I
ENFORCEMENT OF AGREEMENT ON NON-CONFORMING PARTIES AND PROPERTIE
The parties hereto agree to establish the right to make reasonable regulations for the operation of the system,such as
termination of services if bills are not paid within 45 days of the due date,additional charges for disconnection,
reconnection,etc. Parties not conforming with the provisions of this agreement shall be subject to interest charges
of 18%per annum together with all collection fees.
G 3Zo.Z
-
leLaughlin/Omdahl Water System Grantee Date
, si3/a, 0a3
__ _____ -
McLaughlin/Omdahl Water System Grantee Date
State of Washington,
County off
I, the undegned,a Notary Public in and for the named above County and State,do hereb certify that
on this ? day of NALLIA , 2023,personally appeared before me • re)c h li f1 /
to me known to be the individaal described on and who executed the wit in instrument,and acknowledge '-OJ ' '
that he(she)(they)signed and sealed the same as free and voluntary act and deed,for the users and {�d1/tdL 1 1 -
purposes herein mentioned.
GIVEN under my hand and official seal the day and year last above written.
\`\oktuiiitii//o
t 61\j2, _:ei
ary Public in and for the State of Washington, _�Q: (s r ?sr �•C)
,01 Q:c° p�ARY :�
residing at =V `' °°
My commission expires: 1 ?,1 2k r •� PUB1-� �'_`
�I,'VT'eNumbat2,.�C��'•
"/j,F�fiiWAS �`,