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HomeMy WebLinkAboutWAT2023-00106 - WAT Application - 6/30/2023 • Apr1023.01:19p Lakeview RV Resort ENV!RONM EN a7C0395 p.4 HEALTH •tErtif MASON COUNTY AT RECEIVED 3 COMMUNITY SERVICES r, °'°'tmn^^^^„nuison^,.nWHNV4Cemmm>yne41n MAY 11 2023 415N81^Street,Bldg 8.Shelton WA 96584, . Alder Street Shelton:(360)427-9870 ext 400 4 Belair:(360)275 67 eM 40D a Era:(360)482-526944 44II 'N FAX(360)427-7787 Application for Determination of Water Adequacy [EM Instructions JUN 3 0 2023 1. Complete Part 1. No determination can be made until Part 1 is fully comoleed. RECEIVED 2 Complete only the portion of Pan 2 applying to the type of water connection util¢ed. 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 Name on Applicant Stacey Stagg Date: 04/10/2023 Mailing Address: 6120 NE North Shore Rd. Phone'425-220-1182 Parcel Number. 22209-54-90057 Type of Water System Reason for .,Application q ff��,,��G /^ ® Public/Community Water System (2 or more C Building permit C i....0 /i0t�7_CC (0 connections) W L207i)-0005N ❑ Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) 0 Other(explain) ❑ Replacement or Remodel(please indicate name ftyou 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 sedan appropriate for the type of water connection being evaluated: Public Water System Name of Water System: DoE Well ID Tag#BME355 Water Facility Inventory(WFI)Number None (write"none"for two-party) ❑ I am the manager al this water system.The water system has been approved for 2 services. There are presently 1 .connection(s)in use.This will be the 2nd 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 re9ulalion, Signature of Water System Manager Date Y/twit This form may be scanned and available for public view at ants."uon.wa.us. tttH kerns,IMnkins Wawa Revue.]luiimx Apt 1023.01:20p Lakeview RV Resort 7137230395 p.5 Individual Water l Well g/ Water well report(attached to application). Depth (CS ft Well capacity Test(attached to application) If qpm 73n 0 mad, 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(crated by the applicant or if the water well report does not have a capacity test, a well capacity test,which provides stabNizalfon of draw-down and recovery data, must be performed by a licensed contactor. pi Satisfactory bacteriological test(attach to application). (O/Zilro ZZ Water Resource Inventory Area(WRIA) Development within which WRIA httpl/cis.co.rnason.wausiplann:nc 14n 15j3 1602211 Water use or limitation recorded NIA( wee® iWZI14i Well Drilled Date 9/24 let 1 Individual Scramg/Surface Water o WDOE permit(attach to application) ❑ Method of disinfection ❑ I have reason to believe tat 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 Vie LS Relationship to Applicant YY • • Part 3: Mason County Community Services Evaluation (staff use only) ❑ Satisfactory Determination: This determination does not address adequacy of the rlrstdbution system,guarantee an adeq 5t)pl water indefinitely In the future,or guarantee compliance with all applicable WDOE water res /�61 Recommended approval Indicates requirements of Sanitary Code,Title 6,Chaptere68.040-Detsnnln on O VF Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter D 36.70A ROW. ❑ Unsatisfactory Determination: Mqg �C j 2 O 2r11 Applicant's water supply does net appear adequate to meet the needs of its intended use fOr5GefoAaNng reason(s). AVG-�i • n Reviewer's Signatures: /�/' /� Environ.Heath: Date to/i0 /zo& CSD Director: Date m°'z 14 PA dd eel' WATER WELL REPORT !;'.'' DEPARTMENT OF Notice of Went No.WE45751 i ;: ECOLOGY UniqueFoolbgy WelID Tag No. Commotion BME355 'type ontio - -State of WashingtonWashingtonSite Well Name(if more ban one well)* ❑Deomm Decommission mlannnh OdgEulivblhEoa NOI No. Water Righ[PermiVCeruSu¢Na. Proposedui. O Domestic ❑Industrial ❑Muacipal Property OwmerName.REI CONTRACTORS ❑Dewatmg ❑Lnptloa ❑Test Well ❑Other Wall Street Address N SHORE RD Canevucgogrypo: Method: City BELFAIR County MASON El Now well ❑AIRMEN' 0 Driven 0 1<hel ❑Cable Tool C ❑Deepening 0 Otha ❑Dog EE Ai ❑MudRomy Tax Parcel N9j 22 7Q — )J Dlmaslom: Dmmatervfbe[ig 6 in,In loll R Was a varianceapproved for this well? (]Yes CI No Depth of convicted'yell 105 R. Cbmtrucdon Details; Wall If yes,what was the valiance for!.__ -.-- casing :Una Olamater From To Thickness $twl PVC Weldtd Thread 0a I CI 6 , il 100 .2ii0 H.. 0 I ❑ MIO Location(see instruction oil page 2): OWWM or EWM DID m p I ❑ DID❑ I ❑ in. m ❑ I CI ❑ I ID :NE /_ of the SE %;Section 9 Township 22N Rani, 1 — — . ❑ I ❑ 1n. _ _ In. ❑ I ❑ ❑ I ❑ Lntitvde(Example:47.1234$) Longitude(Example -120.12345) ' Recf 8 n CI yes .Na Ape ofpef used a No ra fotIons _ Size of as_ In by_m. D Log/Construction o Decommission Procedure ua Perforated fWmfl.to R Wow erewdamfae P IonhDacnbe I hore size ef Ith'mdaren dthe and a DMA toSih end pnehacd,wW at lou one moyfor ocM1 change of p Screens: Ell Yes dNo ❑%Pazkv r�-Depth ([ iformatpa Use additional shoots i(attmry. 3U MmWeturtea Name _ Material.. . Prom To 03 Type RIMLESS_ Moaeom CLAY&GRAVEL BROWN 0 49 E Diameter 6 is sktzaa 12 in born 100 R to 105 0. e« LiaroPer . Oa Slut Ciao_ W.Bam_¢to_II CLAY Sr PEAT 40 58 oc - - CLAY Si GRAVEL BROWN 69 97 o e Saud/Filter paeda❑Yet R Na Size ofPP:matedal_in. GRAVEL H2O BROWN 97 105 Mahnlalsplaced from En to. 4- Go surt mseal:NI Yee ❑No To idiot depth?20 O. LE M tenal walla seal BENTDNITE . - . pF Did any zna unusable waters Ova "O No Type ofonio r m Depth ofstrata RECEIVED - Morbod ofthalingerate off - - h •Primp: ManuknnWtaNaew GOIILDS Type:Sue a PHASE WELL CONSTRUCTION AND m g R.P.1 pump puke _ Designed flow raps 10 pm LICENSING OFFICE aa A R Water Levels: ndaarfzce elevation above moo sea level_ pa Slink-upoftoF of well urine 1 R aboveground surfs SEPT 222021 -- c ' Slade water level E6. ft.below top of welt easing Date 0-1021 K Arlesiaaprenum lbs.per square bxb Dale ra - Maaawmr le coenolledby (cap,"Nth,ma.) _-_ Le Well Talc c� Was e pimping test paThcmed? ❑No ©Yu b by whom' RECEIVED;3 Yield 18 spin wipeR drawdewaga4 ere. Vidd gp wit_IL dmwdown aM hn. - Yield spin wiibA(Lowdown afterbn. Recovery data Come=zero b pn*p is tined MI-waterlevel sarc w enured Crop wait __ N(1V '1 1 2022 op top to water level) op Time Water Level Time tame level Terse Watts Level L19RNh171BI1l of ECotociy L ee+o Liu Dale ofpwaping min c Had tat pm with Rdnwdowna8 M.� At test spin with t N R for_Liz. Dale A11011Poi Co p m EE Temperature of water_r F Was a<hawN analysis made? El Yes El No Start Dale 8-31-21 Completed Date 9-2-21 m. WELL CONSTRUCTION CERTIFICATION: I constructed and/or attepupsponsibility for construction oftbis well,and its compliance with all Washington well oral onstmctionstondatds.Materials used and the infommtion reported above ara true to my bestlmowlcdge and belief. X3 clei 0 Driller 0 Trainee❑PH-Print Name MADI TROTTER Drilling Company COOLWATER DRILLING,INC Si PPalure / lsp4.� t �/��•--' Address 10921 NW HOLLY RD LicenseNo.3367 • - - City.State,Ztp BREMERTON WA 98312 IF TRAINEE:Sponsors License No.1773. - Contractor's Sponsor's Signature Itcpstrafion No.CODLWDI9410M Data 9-22-21 ECY 050-1-20(Itev it/lS) If you need this document in on alternate format,please call the Wales Resotaces Program at 3 6040 7-68 72. Parsonsw(N hearing loss can call 711for Washingon Relay Seance. Persons train a speech Arability can call 877-33-6341. StaSpectra Labs - Kitsap, LLC SPECTRA Laboratories - Kitsap (Poulsbo) ...Who-e.iee,ien=e matters 26276 Twelve Trees Ln NW Ste. (—ENPoulsho, WA 98370 R Phone: (360)779-5141 Ir1' ENVIRONMENTAL www.spectra-Iab.com b15 � • - Al33ht ac3 HEALTH Ot• ORCDb5 69 Spectra Labs - Kitsap. LI.0(Poulsbo) received samples for Jim Seymer on Tuesday, October 25,2022 at 12:05 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 22 1 5 8 8-0 1 Private Well 6150 North Shore Belfair 10/24/2022 13:30 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. RA] JUL 2 0 2023 RECEIVED 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. 10/28/2022 Page 1 of 1 I786 SE Mile -111 Hill LW Port Orchard,WA SPECIR.1 Laboratories Kitsap 98366 ...IL..t up.nn¢a manen _ (360)443a845 -COLIFORM BACTERIA ANALYSIS FORM I �. Date Semple Collected Time Sample county__. i. if,— 1_4r2LZ2 Col lee Oen�:3D a I �elG`>c1 I Mum Day Yea Type dWater System(area only one box) �l 1e We-II Group __ OGroupO._ _ cl�iahe• Yr\J atII._ . Gaup A and Group B Systems-Provide from Water Facilities Inventory(WFIy it IDSSystem Name: Contact Pawn Day Phone:zlic cell Phone 253211 i-16s°1 r Ema2 5es. 7 I.s5, m 'S1.1,1 a hono __ I sera resat m-P:eVIn.m..Bae...M more.a email em.ew,elm ronkPo,yal mural EINkyt L- _S.�y.Ciagr_Li c21"\S JJ. i F il is:: ` I 'A G- J.2.±2f:2_ 1i SAMPLE INFORMATION �i Sample collected by(name)' l 1 1.rn. S A,y1C r l Specific location whoresample collected. Special Asmrctons or comment+ /4160 iitrWI Short 13e.- '..1-,:‘Lk: WA 92'6.1-7' I. Ir Type of Semple(check only one box) t I U Routine Distribution Sample(AIP) 20 Repeat Sample(AIP) 1 Chlorinated.Yes D No Rem deo-bueen system anerunsm mutest Unsatisfactory routine lab number. CModne Residual:Total_ _Free_ 2.Gmuntl Water Rule Source Sample Unsatisfactory route collect date: 1 I S 1 I I Chlorinated:Yes No ❑Triggered(NW) Chlorine ReSitlual:Total_._FriI. ❑Assessment(AR) : LSurfece or DWI Raw Source Water sample(Enumeatibnl S I ❑ E.solinee❑Fecal nee yes No 5.0 Nenpre Collected M Information only. r LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Gollorm Present and atlsfaclow I 0 Eroti Present C Ecobabsair ' Bacterial Density Results:Total Colkim mpnllOOmL Ecof _repn/IOOml. Fecal Cdlam__ cm/IOOml. UPC ddtml. Replacement Sample Required: 0 TNTC 0 Sample tar rid ❑ Sample Volume 0 Damaged Container ❑__ Deere,Reeved I tab Relreree Km* Receipt Temp Cl. 1 Method Code'. SM9223BIDTLWMISM2222D Date Re et �.anb r.he n..„...„ we.,..a:e.e.a�,�.:.remr,m.7 l0 L I �'..��* es mese,seamen ea ear. DOH Tao-Sample Or ..Mae. DIo_geo i .. .r.,b vete ELD2aa3-oo5ac9 2198183 MASON CO WA 00/12/2023 11:45 AM NOTCE Siz.ce y S�a� IVIIIIIII?IIIIIIP1IIII IN��II IIIIiIiiIIIIIHIINI 14yes 2 Re4Un To `113 S /L' St RECE ro= � -'✓u I la ,_Q Tc�Cot^O.r LJC-. i 't� �n�• 9 `j0 — Ju,r 12 j 615 W. Alder Street Grantor(s):(1) Sto-ts-1 S 1 &5 q . (2) te Granels):(1)PUBLIC .] taus;Description(1)(:IiFbn3rahople.Ae Aesoifics1'nett afis.SAl'e-B 4I3. (Abbreviator!form: r s.qiLe.lot block plat or .towns/WA rases/Assessor's Tax Parcel:(1)aa2 Q1-��-�QQs�.1 Sc)y ¶Z;- R. a. TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA) I(We),the undersigned grantat(s),hereby place this notice on record that the described real estate situated In Mason County,State of Washington S subject to water use restrictions and conditions set by Washington State Semite BID 0091 end Meson County Cods 8.68. These restrictions and conxliilon a ere base'on location of property and/or Water Resource Inventory Area or WRIA. WR/1: 1S Maxhn an Annual Average Gallons Per Day: 450 gallons Dated on this day of Mar 20 .13. Signature ofooff/f rentnmr(s): (1)T (� State of Washington County elitism; piffle Page 1 of 2 I,the undersigned,a Nokry Pubic in and for the above named County and State,do hereby qrd umront s r/ 20 �'rY.YC ` r ofMr/WI c �A p`reonaky appeared before me,who Is known to he signer o !Is above instrument and acknowledged Mat he(she)(they)signed i. GIVEN under my hand and official seal the day end test above ren. ``\.��\\\\\Ihh Notary in and four the State of Washington, yALfM, 114, residing ``'W..O/\9q o"syak�u, /r% My mmmIsabn expires: )I aq a03-9 fir • I 9 1 Z 13 _ ,/i d'T''ro, s•29',.��� ? c ///r�9rF OF Wr- I.." rn ` Page oft 2175372 Mason County WA 01/26/2022 01:53:46 PM AGREE • eRecorded #170326 RecFee: 4206.50 Pages:4 I ' LAND TITLE CO SLOa0 00 aL12 ENVIRONMENTAL RECEIVED Return Address: HEALTH MAY 11 2023 Winifred Enterprises LLC 615 VV, Alder S �uu 15560 Orweiler Rd NW Poulsbo,WA 98370 JUL 2 0 2023 Q211360 RECEIVED DOCUMENT TITLE: Shared Well Agreement REFERENCE NUMBERS OF RELATED DOCUMENTS: Auditor's File No.388452 COURTESY RECORDING ONLY... GRANTORS:Winifred Enterprises LLC c/o James R Whitsett NO LIABILITY FOR VALIDITY GRANTEES:Stacey Carol Stan and Johnny K. Stem, AND/OR ACCURACY BY LAND TITLE OF MASON COUNTY LEGAL DESCRIPTION:Abbreviated Description: LOT B OF SHORT PLAT NO.993,RECORDED MARCH 19,1981 UNDER AUDITOR'S FILE NO.388452,BEING A PORTION OF LOTS 57 AND 58 OF CLIFTON BEACH UPLANDS ADDITION,AS RECORDED IN VOLUME 4 OF PLATS,PACE 31, RECORDS OF MASON COUNTY,WASHINGTON ASSESSOR'S PROPERTY TAX PARCEL NOS. 22209.54-90057&22209-54-90058 1 WATER SYSTEM AGREEMENT This Agreement dated the 2(!f' -day of January,2022 by and between Winifred Enterprises LLC,c/o James R Whitsett hereinafter referred to as the Parties. WHEREAS: Winifred Enterprises LLC,do James R Whitsett is the owner of the following described real property situated in Mason County,Washington: LOTS A & B OF SHORT PLAT NO. 993, RECORDED MARCH 19, 1981 UNDER AUDITOR'S FILE NO.388452,BEING A PORTION OF LOTS 57 AND 58 OF CLIFTON BEACH UPLANDS.ADDITION, AS RECORDED IN VOLUME 4 OF PLATS, PAGE 31, RECORDS OF MASON COUNTY, WASHINGTON WHEREAS: Stacey Carol Stagg and Johnny K. Stagg arc purchasing the following described real property situated in Mason County,Washington: LOT B OF SHORT PLAT NO. 993, RECORDED MARCH 19, 1981 UNDER AUDITOR'S FILE NO. 388452,BEING A PORTION OF LOTS 57 AND 58 OF CLIFTON BEACH UPLANDS ADDITION, AS RECORDED IN VOLUME 4 OF PLATS,PAGE 31,RECORDS OF MASON COUNTY,WASHINGTON WHEREAS:There is a well that serves the above described said real estate which is located at the base of the slope on the NW corner of Lot 58 NOW THEREFORE THE PARTIES AGREE AS FOLLOWS: I. OWNERSHIP AND NUMBER OF SHARES.There shall be two shares or interests in the well and water system, one share being appurtenant to each of the parcels of real estate described above. Each share shall be a part of the title to said parcels of real estate. Furthermore,GRANTEE Stacey Carol Stagg,is aware that GRANTOR Winifred Enterprises LLC, intends to sell Lot 58 and this agreement will be assumed by new purchaser. 2. RIGHT TO WATER;ONE RESIDENCE ONLY. Each share in the water system shall include the right to receive water but only for one single family residence per share. The water must be used on the parcel of real estate to which the share in the water system is appurtenant for personal or domestic use only and cannot be extended or transferred to any other real estate. 3. EASEMENTS FOR OPERATION. All necessary easements for the Well Site, water system site, pump house,tanks and waterlines including access for ingress,egress,and utilities for operations,maintenance and repair are hereby declared,created and established,and also including a 100' protective radius around the well as required by the Health Department. The owners of the parcels of real estate shall comply with this protective radius and any other applicable regulations of the Health Department or other governmental agency. 4. MANAGEMENT. The owners of shares in the water system shall have the responsibility for its management. All matters shall be decided by mutual and/or unanimous consent. 5. COSTS SHARED EQUALLY. There is a separate meter to supply electrical power to the 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. 6. ASSESSMENTS. At a future time,the owners may by mutual consent set a maintenance fee each calendar year or monthly payment into a fund for the power bill and maintenance of the well and water system. 7. LIEN. If any owner shall fail to pay any assessment for their share of the maintenance of the well and water system,then beginning thirty(30) days after the payment was due, it shall bear interest at the same rate as charged by Mason County on delinquent taxes. Also, any unpaid assessments shall be a lien against the property and a Notice of Claim of Lien may be filed with the Mason County Auditor, 8. LIEN SUBORDINATE CERTAIN MORTGAGE AND DEEDS OF TRUST. The assessments for the maintenance of the well and water system shalt be junior and subordinated to the lien of any first lien purchase money mortgage or first lien purchase money deed of trust(hereinafter referred to as"mortgage")only to the extent that the assessment subordinated becomes due after the date of recording of said mortgage and prior to the date of issuance of Trustee's or Sheriff's Deed. Sale or transfer of any lot shall not affect the assessment lien. However, the sale or transfer of any lot pursuant to mortgage foreclosure or any proceeding in lieu thereof shall extinguish the lien of such assessments as to payments which became due subsequent to filing the action to repossess the property and prior to such sale or transfer. No sale or transfer shall relieve such lot from liability for any assessments thereafter becoming due or from the lien thereof. 9. CONVENANT RUNNING WITH THE LAND. The provisions contained herein shall benefit and burden the parcel of real estate and shall run with the titles to the parcels of real estate described herein,provide that in the event a public water system shall serve all the parcels of real estate, then this agreement shall be null and void. 10. This agreement shall become effective upon the'wording of the Deed of Lot B front Winifred Enterprises LLC c/o owner,James Whitsett to Stacey Carol Stagg and Johnny K.Stagg. 2175372 Page 2 of 4 01/28/2022 01:53:48 PM Mason County, WA • DATED THI �day of January,2022. rt t t✓ (d Enterprises LLC c/o owner,James R W hitsett Stacey Carol Stagg Joh ny Stagg STATE OF WASHINGTON COUNTY OF MASON On this day personally appeared before me,James R Whttsett,a single person,as owner of Winifred Enterprises LLC to me known to be the individual,or individuals described in and who executed the within and foregoing instrument, and acknowledged that he signed the same as his free and voluntary act and deed, for the uses and purposes therein mentioned, Dated I0aa— fr NOTARY PUBLIC Notary Public i anp for th of Washington STATE OF WASHINGTON Printed name: / /n flSWC COLLEEN HOWNGSWORTH Residing at: MY COMMISSION EXPIRES JULY 17,2025 My Commission Expires COMMISSION 4143272 2175372 Page 3 of 4 01/28/2022 01:53:48 PM Mason County, WA STATE OF WASHINGTON COUNTY OF MASON On this day per all'a peered before me,Stacey Carol Stagg and Johnny K. Stagg,to me known to be the individual, -o individua s described in and who executed the within and foregoing instrument and acknowledged that resigned the same as.her free and voluntary act and deed, for the uses and purposes therein mentioned. flea - Dated nl —. c "90o�r� BRENDA JACOBS ' Notary Publit-i and for,the State of Washington iNOTARYPUBUC121008653 ; Printed name: gF da Urac STATE OF WASHINGTON Residing at: Pnrf r'Orr has-A COMMISSION EXPIRES FEBRUARY 16,2025 My Commission Expires —r9 &5 2175372 Page 4 of 4 01/28/2022 01:53:48 PM Mason County, WA