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HomeMy WebLinkAboutWEL2023-00021 - WEL Application, Design, Letter - 4/17/2023 as MASON COUNTY 415 N 6TH STREET, SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 BELFAIR: 360-275-4467,EXT 400 f Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 JERRY BELL 1619 9th Ave W SEATTLE, WA 98119 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL 2023-00021 12651 E State Route 106 222203400090 The 2-party water system, Tollkuehn-Bell W.S (222203400090/222203100080), has been reviewed and is hereby APPROVED for 2 connections. Please continue to follow best management practices with maintaining your water system including regular water analysis, landscaping, keeping wellhead area free of contaminants, and stormwater management around the water source. If you have any questions, please contact me at 360-427-9670 Ext.353 or email at danderson@masoncountywa.gov Sincerely, David Anderson Environmental Health Specialist Mason County Environmental Health e`. PLAN dtirlOg _ MASON COUNTY Date Received: .. COMMUNITY SERVICES Amount Received: L4 I � R—i12023 Building Planning,Environmental Health,Community Health 2 es 415 N.6`^Street,(Bldg 8)—Shelton,WA 98584 - VIE L 2023 - 0 00 2, 1 Shelton: 360427-9670 x400 Bclfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT ��\ \ l PHONE ( 7 2-0 MAILING ADDRESS—STREET,CIT ,STATE,ZIP I "'� C� ��� — �v SITE ADDRESS—STREET,CITY,STATE,ZIP �f+l��I^Yr� 1 Z ( 1 S '� SI "\- -0.)+e 1(� ( 2 ?�e I PRIMARY PARCEL NUMBER(WELL SrrE) t ( �-7 7 ( )— 14 -00e 1b I; i\ 17 % �3 SECONDARY PARCEL NUMBER(IF APPLICABLE) 7,7 —Ci j\ -(2UC-fl)C BY: _ _WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE ,v PARCEL 2 LOT SIZE New ❑Existing ell 0 Spring PROPOSED WATER SYSTEM NAME(REQUIRED ix.t h,1 - 1�et\ L • S . PROJECT DESCRIPTION SUrrucx t11 1 l Af t1 LU 4z( 16( -, DIRECTIONS TO SITE/CONDITIONS \3() Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines, easements,etc...) Submittals Checklist: (these additional items will be required for approval) Q Satisfactory Bacteriological sample (this may be deferred if well is not yet drilled) Well Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled) Er Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document) Q 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 1 Staff Use Only ---_------------------------------ Review Step 1: Well Site Inspection: p gS If (0,U i/ 1tiSe imam k.e tt 1.0? Z Sihull Cr' IC S. © 83 0(444� 43` UY� r ��/it koc YES NO NA y ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) (/] ❑ ❑ 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? '41 tftly I* ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) ►,�; ❑ ❑ Is the well cap satisfactory? ❑ If ❑ Screened and vented? �, S fo(� ❑ The well casing extends )6 d(WT\Sl tk0/10 01' abbove level ground/concrete slab? (circle one) ❑ TA ❑ Is there evidence of a surface seal? 06w441-e -041 j'/i ❑ % ❑ Does the seal appear adequate? 1-0, 111.3735Vz4 6 ❑ ❑ ❑ Is a variance necessary for well site approval? Lan= - (2 L. r16SQ 1 6 g to16S1n k s G �u �r 't v t- is. rliy B P a �s8 Comments (� Cied *q 6,curdegfiace and '#i- WQi Ctc ccA5j 2 Iv j . �t Pass ❑ Fail Inspector //� DateNief 2V Z Pet eft__ _ l)s(zz z — — Review Step 2: Two-Party Review: cS NO NA ❑ ❑ Water Well Report with adequate pump test on file? If NO, date of Capacity Test 27Z/ 7j Driller >�Q VJ GPM 151�O ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test t(/l7O Z> ❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN ��{ Lf �p K ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments Nti6"Approved ❑ Denied Reviewer Date 513/7023 Findings in this review reflect observed conditions as they existed on the day of the site inspection. No claim is made, express or implied of the future success or failure of this system. Well site 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 19th, 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 i 17e8 SE Nis ril . aar arch'a,°f e.wA _ J i,_ SPECTRA Laboratories -Kitsap f ...Wkera.xpe,k uci arauers • ( COUFORM BACTERIA ANALYSIS SIS FORM 1 Date Sae Collided ( Time Sernple Calleded 4‘46 • 2,' IQ ' _ :4CDP 4'.0"(4%-"-. op -_ .J: Type of Water System(check only one box) . O Group A ❑Group B Group A and Group 8 Systems—Provide from Water Facilities Overlay(WTI): IDM SYstem Name: ` r .\ tLQ, 16\I v th v\ ___ " Contact Penton:, . Day Phone:( ) �Phcne( )—_ Emal: - [Send tx(Pant trine,address r a d cep orbs emery Send Wait • ix Ls ___ . s. .__Lvi..Lidie__Cettla_th(44141.4,61 SAMPLE INFORMATION • Sample collected by(name): . -- Specific location where sample collected Special instu tiol 1 or comment V\it\\ \\ICti(\ Typo nismOnenotign,f AtpsogaRte from tipKi ego*bbI e) i 1.❑Routine DMblbution Same a(AIP) ; 2.❑ Repeat Sample(AIP) CMainated:Yes No (kw diAiDrAon a filar mat roue* Unsatlstactay mains lab number: Chlorine Residud Tom_Free_ ~ - 3.Ground Water Rule Source 8septe Unsatisfactory routine collect Me: S ( ( 1 r I Chlorinated:Yes No 0 TillAufed OP) Chlorine Resit:WI:Toed Free_ ❑Assessment (AR) 4. Surface or MI Raw Source Water Sample(Enumeration) S I I I i } ❑E coi 0 Fecal Filmed Yes_ +o_ 1 1,, L I 5. sagla CcMraad IceY/onewie t OW USE ONLY , DRMKW4O WATER RESULTS LAB USE ON.Y ❑}lataddaebry To l Caiiortm Present ad y,cSaiihdory 0 Ecoipresent ❑Eooiabeent • f Bacterial Density Rawls:Total Coklam T mPm/100m1 Ecoi. tnpu/100m1. Fecal Colifo m^-_ du 110Ornl.. HPC ft►t Replacement Sample Required: ❑MC 0 S*fpb too old { ❑ Semple Voh 0 Damaged Container 0 ( Osten eM lab Relre V-11, nce NNunber FEB 1 °1 l Li Receipt Tatrp C' *add Cods: SM92238 or SM92220 • Oete Reprrled b DO Lab Use Orhy. OOM t.ab-Sample 225- u0\(T —_ rOH RV.031419( - Ka w i11:0er5b+r7MORNcorill 4owd err aLkloa w oda*atamJcnwF r"• WATER WELL REPORT DEPARTMENT 01 Notice of Intent No. WE50588 ECOLOGY Unique Ecology Well ID Tag No. ? ) 4.40 Type of Work: state of Washington Construction Site Well Name(if more than one we : ,, ❑ Decommission r—> Original installation NOl No. Water Right Pennit/Certiftcate No. Proposed Use: "fit Domestic ❑Industrial ❑Municipal Property Owner Name Michael Tollkuehn 21 Dewatering ❑Irrigation ❑Test Well ❑Other Well Street Address 12651 East SR 106 _ __ Construction Type: Method: E New well Fi Alteration 0 Drisen ❑Jetted :i:Cable Tool City Belfair _ __ County Mason __ ❑Deepening ❑Other ❑Dug 0 Air- 0 Mud-Rotary Tax Parcel No. 22220-34-00090 __— Dimensions: Diameter of boring 6 in..to 62 ft. Was a variance approved for this well? ❑Yes ❑No Depth of completed well 62 ft. If yes,what was the variance for? Construction Details: Wall Casing Liner Diameter From To Thickness Steel PVC Welded Thread E 1 ❑ 6 in. *1 62 in. ] I 0 EIO Location(sec instructions on page 2): O WWM or.J EWM ❑ in. in. ❑ 1 ❑ ❑ 1 ❑ SW y,-y,of the SW '4;Section 20 Township 22N kange 2W ❑ I ❑ in. _ in. ❑ I ❑ OID ❑ 1 ❑ in. _ _ in. ❑ I ❑ ❑ 1 Cl Latitude(Example:47.12345)47.37828 Longitude(Example:-120.12345)-122.96593 Perforations: El Yes A No Type of perforator used No.of perforations Size of perforations in.by_in. Driller's Log/Construction or Decommission Procerture Perforated from_ft.to ft.below ground surface Formation:Describe by color,character,size of material and structure.and the k--id and nature of the material in each layer penetrated.with at least one entry kr ca.h change of Screens: Yes ❑No J K-Packer ' ) Depth 40 tl. information. Usc additional sheets if necessary. Manufacturer's Name Johnson Material From To Type Stainless Model No. Diameter 5 in. Slot size 10 in.from 52 ft.to 62 ft. Top Soil 0 — 2 Diameter in. Slot size_ in.from fl.to R. Sand and gravel 2 20 Fine sand 20 45 Sand/Filter pack:0 Yes iL No Size of pack material in. Materials placed from ft.to ft. Fine sand water bearing 45 62 r--—— Surface Seal: !U Yes G No To what depth? 18 ft. —Material used in seal bentOnite -- Did any strata contain unusable water? Li Yes M No Type of water? Depth of strata Method of sealing strata off —— Pump: Manufacturer's Name Goulds Type:sub Ii P. 1/2 _ Pump intake depth:57 ft. Designed flow rate: 12 gpm Water Levels: Land-surface elevation above mean sea level fl. Stick-up of top of well casing 1 ft.above ground surface Static water level Flowing ft.below top of well casing Date 2-25-23 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap.valve,etc Well Tests: Was a pumping test performed.' 0 No l Yes t by whom'.'Mike Davis '"- Yield gpm with_ft.drawdown after hrs. Yield gpm with ft.drawdown after hrs. Yield gpm with_ft.drawdown after hrs. Recovery data(time=zero when pump is turned off water level measured from well top to water level) Time Water level Time Water Level Time Water Level Date of pumping test Bailer test 20 gpm with50 ft.drawdown after1_hrs. -- _ Air test gpm with stem set at ft.for hrs. Date 2-25-23 _ __ Artesian flow gpm Temperature of water "F Was a chemical analysis made? U Yes U No Start Date 2-1-23 Completed Date 2-25-23 WELL CONSTRUCTION CERTIFICATION: 1 constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well construction standards.Materials used and the information reported above are true to my best knowledge and belief. Oa Driller 0 Trainee❑ PE-Print Na ,, 2- �'Ic rJ Drilling Company Davis Drilling Signature �_7 I Address 340 NE Davis Farm Rd. _. License No.0797 City,State,Zip Belfair,WA 98528 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.DAVISDI1100A Date 2-25 23 ECY 050-1-20(Rev 08/19)if you need this document in an alternate Jurmal.please call the Water Resources Program at 360-4e7-6f 72. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. Davin Pump', Inc. 340` (1Vavia Farm lid fair,WWa 98528 (360)801-6107 Project 12651 Hwy 106 Capacity Test TAG: BPQ158 Date 02/29/23 Pump 1/2 hp Well Depth 62 Static Water Level flowing Draw Down Recovery Time Water Level GPM 0 31.7 0 min flowing 0 1 29 5 min 25.2 15.7 2 22.5 10 min 29.5 15.6 3 17 15 min 31.7 15.6 4 12.9 30 min 31.7 15.6 5 9.9 1 hr 31.7 15.6 10 1.9 2 hr 31.7 15.6 11 flowing 3 hr 31.7 15.6 4 hr 31.7 15.6 Capacity Notes: Well expected to be subject to tidal fluctuations - tide out during capacity - New well 2195454 MASON CO WA 03/31/2023 11 11 AM DECL DAVIS PUMPS INC #185554 Rec Fee: $207 50 Pages: 5 I IIIIIII IIIII III IIII IIIIIII IIIIII III I IIII IIIII IIIIIII III IIIII III IIII IIII Return To: Davis Pumps Inc. 340 NE Davis Farm Rd Belfair, Wa 98528 Declaration of Water Use Agreement Tollkuehn-Bell Water System Private 2 Party ABBREVIATED LEGAL DESCRIPTIONS AND PARCEL NUMBERS OF TRACTS BEING SERVED: The well and water system being situated on: Parcel#22220-34-00090 TR 9 OF GOVT LOT 3 12651 E State Route 106 Belfair,Wa 98528 R2W T22N Sec21 SE 1/4-SW'/. Grantors:MICHAEL H&JULIA E TOLLKUEIIN Owners of: Parcel#22220-34-00090 TR 9 OF GOVT LOT 3 12651 E State Route 106 Belfair,Wa 98528 R2W T22N Sec21 SE'/-SW'/. Grantee:BELL,GERALD H&ARNETA I.LIBBY Owners of: Parcel#22220-31-00080 TR 8 OF GOVT LOT 3&TAX 1370-A 12661 E State Route 106 Belfair,Wa 98528 R2W T22N Sec21 SE'/.-SW'/. Has been designated to serve a source of water to the following parcels situated in Mason County,State of Washington;herein described: Parcel#22220-34-00090 TR 9 OF GOVT LOT 3 12651 E State Route 106 Belfair,Wa 98528 R2W T22N Sec21 SE'/.-SW' Parcel#22220-31-00080 TR 8 OF GOVT LOT 3&TAX 1370-A 12661 E State Route 106 Belfair,Wa 98528 R2W T22N Sec21 SE'/.-SW / OWNERSHIP OF WELLAND WATERWORKS It is agreed by the parties that each of said parties shall be and is hereby granted an undivided one-half interest in and to the use of the 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. COST 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. The parties shall establish and maintain a reserve account at a mutually agreed upon banking institution. Each party shall be entitled to receive an annual statement from said banking institution regarding the status of the reserve account. The monetary funds in the reserve account shall be utilized for the sole purpose of submitting water samples for quality analysis and maintaining,repairing or replacing the well and components to complete and maintain a properly functioning water system and appurtenance thereto. 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 WEI.1.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. MAINTENANCE AND REPAIR OF DISTRIBUTION 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 . Easement shall be granted on both common water distribution piping to their own particular dwelling and property 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 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 MANAGER The owner of Parcel#22220-34-00090 TR 9 OF GOVT LOT 3 12651 E State Route 106 Belfair,Wa 98528 R2W T22N Sec21 SE'/.-SW'A 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. ENFORCEMENT OF AGREEMENT ON NON-CONFORMING PARTIES AND PROPERTIES 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. 3(.301P-./ Tollkuehn-Bell Water System Owne Date beg c9/2 42 Tollkuehn-Bell Water System Owner Date State of Washington, County of ex, I,the undersigned,a Notary Public in and for the named above County and State,do hereby certify that on this day of M d- ,2023,personally appeared before me 4¢M 7 - 444 v-6cI/ 4,4 to me known to be the individual described on and who executed the within instrumeneand acknowledge that he(she)(they)signed and sealed the same as free and voluntary act and deed, for the users and purposes herein mentioned. GIVEN under my hand and official seal the day and year last above written. ,r' ltiN a P N F�sy4s. I v*NOTAga 'p L = Nota blic in and for the State of Washington, • to• ��� +• __ �-y•0 ( al.IC� p2j residing at �Yr�o ;.�� ,IkC(`.'4!+2oto'!°••,4�: My commission expires: .-jUS/� _-�" �'.0R • ** ‘.•s• ENFORCEMENT OF AGREEMENT ON NON-CONFORMING PARTIES AND PROPERTIES 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. THIS IS NOT AN ORIGINAL DOCUMENT // 4 IA . -,._ r),_ 23 Tollkuehn-Bell Water System Owner Date i ,c(.. .ht,' . . jz,e/le/-it ...., -__, c uehn-> eII Water System Owner Date State of Washington, County of I (/ L e I,the undersigned,a Notary Public in and for the named above County and State,do hereby certify that on this /3 day of /4�,-� 4 ,2023, personally appeared before me A'1; /4e/ Q. ,a/,r re'I kuehit to me known to be the individual described on and who executed the within instrument,and acknowledge that he(she)(they)signed and sealed the same as free and voluntary act and deed, for the users and purposes herein mentioned. GIVEN under my hand and official seal the day and year last above written. 5 .OER L41) lib ,-r-1 C P— '" rD n S Qb%%%%%%%%%%%% % / Notary Public i0/+and for the State of Washington, _ GP+,RA N ��'O�i; residing at i ''6`/.— i 5" 2051110 ' My commission expires: 2- - /1 -Z 7 -;,1, 4,41.to Os if O2 G ,IlIlt 1\w�5������$ 2195455gSMMASON CO WA IIIIIIIIIIIIIIiIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIiIc IIlIIllIIIIIIIIIIIIIIIIIIIIIIIIIgeS 2 AFFIDAVIT No WA R.E. EXCISE TAX MAR 31 2023 Return To: EXEMPT Davis Pumps Inc. LISA FRAZIER Treas., NE Davis Farm Rd Mason County Belfair, Wa 98528 Tollkuehn-Bell Water Line Easement Grantor:J P W FAMILLY LLC.C/O LAURIE K COOTS Owner of: Parcel II 22220-31-00150 TR 15 OF GOVT LOT 3&TAX 1370-D R2W T22N Sec21 SE'/.-SW% Grantee:BELL,GERALD H&ARNETA L LIBBY Owners of: Parcel#22220-31-00080 TR 8 OF GOVT LOT 3&TAX 1370-A 12661 E State Route 106 Belfair,Wa 98528 R2W T22N Sec21 SE'/.-SW%. WATERLINE EASEMENT There shall be an casement for the purpose of installing,maintaining and repairing the waterline serving Parcel #22220-31-00080 TR 8 OF GOUT LOT 3&TAX 1370-A 12661 E State Route 106 Belfair.Wa 98528 R2W T22N Sec21 SE 'A-SW%. This easement shall run 20'from the center of E State Route 106 to the North along Parcel#22220-31-00150 TR 15 OF GOVT LOT 3&TAX 1370-D R2W T22N Sec21 SE 1-SW% and Parcel#22220-34-00090 TR 9 OF GOVT LOT 3 12651 E State Route 106 Belfair,Wa 98528 R2W T22N Sec21 SE 1/4-SW'/ Il '1 , JJIEIRS.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. X) a" Tollkuehn-Bell Water Line 6 ba 1 oG Date 3�ao�ad�.3 Tollkuehn-Bell Water Line e.- 6toriteG Date State of Washington, County of h%'a✓¢ I,the undetsned,a Notary Public in and for the named above County and State,do hereby certify that on this 2 01- day of MIA-/ek., ,2023,personally appeared before me� .G.ah. to me known to be the individual described on and who executed the within instrument;and acknowledge that he(she)(they)signed and sealed the same as free and voluntary act and deed, for the users and purposes herein mentioned. GIVEN under my hand and official seal the day and year last above written. ,,��►► ..ate Notary ublic in and for the State of Washington, —0_, residing at 9.. O�OUBLIC44. •O l • y�+2p101%. NCO My commission expires: S�f19�z,aL4 t�`••••,•,,.•.•• O• l pR . WAS #4 ., uuwNw Mason County WA GIS We ap n maga TEl TE QD ESTATEI ROUTE O 12708 ESTATEIROUTE Q 4/11/2023, 11:03:30 AM 1:383 0 0 0.01 0.01 mi iJ County Boundary I 0 0.01 0.01 0.02 km No Filled ° Site Address (Zoom in to 1:3,000) Source:Esri,Maxar,Earthstar Geographics,and the GIS User Community Tax Parcels (Zoom in to 1:30,000) Mason County WA GIS Web Map Application Maxar.Microsoft r . ..... . . . . ... ._ 1 --)ye 12/Z2 /c2r ' !/Q .wt. • LOWER HOOD CANAL FIELD INSPECTION FORM '(:: ‘ Initial Information: �� Area: Added to database(Y/N): Owner Name: 1,-94-►tseri Permission to Inspect?: Y Site Address: t: L2cot;I V1-1,u 1 f O C, Appointment Required?: Parcel#: 2 Zit e9 -3`i- aca996 Appointment Date: Occupant Name: • Inspections: • - �q Level 1: j Ziit/ Level IC: Level 2: ) f 2 c�l55' i ; Inspection Team: L Updated database(Y/N): • Inspection Results: Distance between septic tank and surface water: 5d . (ft) Distance between septic tank and well: (ft) • - 0 I Distance between drainfield and surface water: 3 d ? (ft) - • Distance between drainfield and well: (ft) Occupancy(occupants/bedrooms): 212- Odle;(Largerson-site,business..etc...): The septic system`appeared to be functioning at the time of the inspection; n obvious problems were observed. Q ; The drainfield area may be compromised due to vehicular traffic. (i.e.: p driving) • There are indications of poor system maintenance. (i.e.: lack of regular-pump' leaky • plumbing slow drains, excessive chemical dumping, high water usage) . Construction was noted in the drainfield area_ . r - -- Sewage was observed entering surface water;confirnied•by visual dye,and f coliform count of�200fc/100mL _ - An unpetmitted outhouse was observed. . • . V - Other. Nid ta -OhseruttAQ in� lk s0r- ; Itate:L/ r w tuer U{14k_. - Ounts A 4200-fec.a I .co I 04 pr ItO m I�. Additional Comments 12 System Clas=ilication: Pass: Fail: Suspect: `d Failure Priority: • rsioritia l: IDaew`iajmy=Wed.2: V'ruaa Dyc.upon or reufaciag aava(e miter*surface ram%out homes or ax400ls Brim<3n Vat Sep.Irma SHW.3: surfacing soepiet e!>3u>ot sot mterioe surface rater.4:OOcr maeoeptable instillations' iaRumiaenfly CarTfe system sine coterie( surface wow.S:Primus*wtbetica(odor) C:3 • Printed From Mason County U - Printed from Mason County OMS r3 TO 913604278425--84 P.02/02 MAY 18 2000 08:41 FR .•_. Tr d y P ..:: . . : \,... ,.: ..: .., . „ .. • • • .is t r • ' =;cam= -1. r 11 ` f "' :• '"• . • , ' ;il , �w . .,I `'•w :II.Z : __-_.\i\ LI IL ......_._. • 1 i i pf • • • •• . i''' ' . : " co ' : ;::. • •• . • 1 r o :I at'; i c;,; Ar.71411-,' A..:1,. .. •:.; : : . .•-.. . . . . . . .. : . .. ;.. . i • • . + 9A r ;i it}•i'''•. . . . ** TOTAL. PAGE.02 1 :lino.,,•• .; 1 Ai