HomeMy WebLinkAboutWEL Application, Design, Letter - 10/9/2023 . MASON COUNTY 415N 61H STREET,SHELTON,WA 98584
SHELTON.360-427-9670,EXT 400
BELFAIR:360-275-4467,EXT 400
Public Health 8t Human Services ELMA 360-082-5269, EXT 400
FAX'.360-427-7787
STAGG STACEY CAROL & JOHNNY K
6120 NE North Shore Rd
BELFAIR, WA 98528
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2023-00054
6120 NE North Shore Rd
222095490057
The 2-party water system, Sunny Hill Water System (222095490058/222095490057), 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
Sincere(��
David Anderson
Environmental Health Specialist
Mason County Environmental Health
/
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II <) MASON COUNTY �,R,=� I O ( ��
: COMMUNITY SERVICESllr
A"untR�Zk - I Receiret�
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Shelton: 360-427-9670x400 pdGin360275-4467x400 ElmoM360-4825269 x400 WEL 3,0 - a6 p 5Lf
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT
PHONE
S-I-RECL\ 91-H�61d�S 1 ri)S - 20- II �O,L FILING ADDRESS-STREE LP ET,CITY:STATE,
M Mac) NC ti:- Sh1„rv- �:1 . N.1c,;( , t.JJt 96-,ay
SITE ADDRESS-STREET,C/TY,STATE.ZIP
L L) NE iVLr�,. AVR S1ae l�.c,\ , c)e1 z•( , uJPc 98Sab
PRIMARY PARCEL NUMBER(WELL�SITEI
2.t at - S-I' CIDQ )1-
SECONCARY PARCEL NUMBER CIF APPLICABLE)
;W.-0 A- 54 - `Ioc S5
WATER SOURCE G��� SOURCE TYPE / PARCEL I LOT SZE PARCEL 2 LOT SIZE
❑New LYEzisting fd Well ❑Spring O-NA acc+5 U -»gEmcS
PROPOSED WATEREKTFM NAME(REQUIRED)
? unity 101
DESORPTION
PROJECT
SFIk
DIRECTIONS TO SITE/CONDITIONS
c 1..7R--') 61 l M lrC> n;>v Del.") C>twn 0.a nt 4,4(n LerF
S?-ti <, ln(A-?J::i; w j. �-nvlrc �t�+1,`L9� c.- Ail' N_J1iiL Si.La-t c4i' <l;>);\944 .4. Co,- al11}.
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septicsewer components and lines,easements,etc...)
5ea2„ cA:Lrack, e4
ltt—
Submittals Checklist: (these additional items will be required for approval)
Iatisfactory Bacteriological sample(this may be deferred if well is not yet drilled)
LE ell Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
lit otice to Future Property Owners recording(record with Mason Co.Auditor, supply copy of recorded document)
a'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
---- Staff Use Only
09 .. -
Review Step 1: Well Site Inspection: >Ide
xrlews
yevreJl-
fI1Y(�ES NO NA `❑ 0 Evidence of existing sources of contamination within 100 foot radius of water sour j VS'
(drainfields,tanks, buildings; indicate distance on plot plan) r j
giD❑ ri ❑ 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?
II ❑ 0 Does the ground slope away from the water source site? (show slope on plot plan) _�-
❑ ❑ ❑ Is the well cap satisfactory? Z Owl Of Y 1MOS If VI U (odV,
V0 0 Screened and vented? /t .
❑ The well casing extends / (9 above level ground I concrete slab?(circle one)
MR ID Is there evidence of a surface seal? Leif La.4(06 4 0y
W 0 ❑ Does the seal appear adequate? LGn:- (i Z• 73I 6570
❑ ❑ Is a variance necessary for well site approval? T ej' 3M S 355
Comments ^C('W((C Up ( fCdos
Pass 0 Fail Inspector ‘,AC_i Date "0//7/ Zo Zj
•
Review Step 2: Two-Party Review:
E NO NA
0 0 Water Well Report with adequateat pumpl test on file? /�� Poke Ia 1
777��� If NO, date of Capacity Test (/2.�to Z( Driller COO''wok( 0al1/_IjpGPM `r
hr ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test IC9/Z6(?VZH
fir 0 ❑ Received Signed, Notarized,and Recorded Notice? AFN 205772
X ❑ 0 System appears adequate to serve 2 single-family residences based on information provided?
Comments � 7�r
Approved 0 Denied Reviewer l��' l�^�- Date (0/707Zf 73
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 668.
Water usage restrictions and additional fees may apply to all new wells drilled after January 19', 2018 per LSO 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
IApASSeJ
WATER WELL REPORT oePARTMEI4t By Noticed l HO9./b.WE4ST51
ECOLOGY Omepmt'Golbgy via ro ra$NP BME 355
)i Ccof
V,Iqtk; SWte alw .0i4CSon SIN Well None(Imare tha
n one well):
o capp�pdaa
❑DwpcmWRW C} aaww INI990.060091R0 Welerltghtpami7CeriMeateNo.
tropwbd Use, "Pl:Pewnte 1161439.el ❑IyoeleIp.I property OfArName REI CONTRACTORS
b nedakueg nLdgPaN. 10490990941790
t ❑oukr- .. -Well 6hact Addtca�N SHORE R➢ ..
CP909909 p'lyym M0399 Clry EELFAIR Comty MASON
pNewM41i RA'llamNPn ondwo q)and 0MH oOPI 13 u2D9S
"'M Pmm4 O'Gyba []WS dA0. ❑Mddaawv TaxPaitel % y�IDDp
bhaentic Y]Hwsh(btba meal 3,3106 rt. .. Wes a vMeocaappcowd forth0 well? Yes OO No
,Myth dfM0310M wall I05 y,
CaPirya'gon,elallu Wall If ye;what was Wave, foe/
0313c ylnbvpmner Prom To Teuknoso scot TVGWuMtd Tamed
Q I p.",e_, !^. 1 I09 .290 W. ❑O I ❑ O I ❑ Location Nee stnlcH do aa page 2): 17WWf4or0 HWM
CI ❑ In , — �m II I El ❑ I ❑ NE Y4dihe SE '/•;Seion 9 Twh 2N Bac e y
in N . c2
• ❑ q _ in
a I O ❑ I ❑ immda(B%ampla 4$12345)
Longitude(punalylc-126,13345)
PorgaltIogp ID Ws 19 No S799 Izgotpnf to wad DPBI LP C n t hoRorA WWawtesld4Prettlptb
Loi.t,, NA1alclat ov._u E.
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L� :Pttfinel{d tmm.,.. �,t1-lo flbobw�awdxeGw nets of!ha y,_ INmh lay p to d,yMe at km ow envy tin echcbonee or
W "SF6eosl BYcs U No p&Hut,b'Pcoj, g, ialmmwd UN rddflotl 006 ltattfsaryy..
a .M nmmint.rA w` • ---- ::'Nokrlal F1Vm+:. To
;.,Typo r1,6 •90 pf,ptm CLAY&GRAVEL BROWN 0. • 40
re. DI dc In.'Sbtmo R It(rom 1W It.te]OS..il. 4Q 69
o .nrlm,MNt_,•_.>& :Slotaiae In from It.to W CLAY&GRAVEL BROWN 69 97
` CLAY&GRAVECBROWN
en W II&pk t)(: m_ p)Ne Sim efpwtwt<ml_;o: GRAVEL H2O BROWN 97 1.5
MWlilsehMMdr;'._RIo�• tt—
gSnrfac So L ®•Xp o'Fo To mita&pat 20 S
€ -4rmm Ia 4 1ed'aENtoNRE
mdaw 0499 tM no LlPwaer] 0 Y4 ',r9Na Ls RECEIVED
'ryWPtwplw] I}iyih efsueh
Mead twMIIMfl ff -
82 •yy Lrei p MPP6WIwr'4Nan GOULDS'. Type SIIBJ PHASE WELL CONSTRUCTION.AND
ILE,1 yumpmul{edwpt;95' R ntdPed flow tate:10 Pm LICENSING OFFICE
t n WmeyLwtloornoi m If I., b verve swroLOVOIm
cIt. us .
o sta4 tt a xorw;n S t a flaw Mea uw r w SEPT 22.2021
KSIpO IM lev<1 B9 R betal.rep orwtg n pate 0-10-21
Ade1N Werewe , IN P Woaeiw4'. n e
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tb i5 'ATHkI
wi pioetas Yci wed1 ❑No 0 Ym 4 bywhom^ y L L
; Ylto fd le 18 y'yb6 0.dwwdywneaw< Ers
} Y Id 4 @mMh RMwdwtiafw lue
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x nmwtdae- n nn^ xhe,.miod i d as dr Aw.n t 1 1
22
o lento vx Mw0
ap lime Wyatt/net Than NuKrn a Tito w nt.vel -. ut e . .,nl
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a8 _
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oO - WIELLco[YSTRUC3'(ON CEI¢IBICATION: I conslmctedand/or meptraspncbtLty for co6st0u0o9 Pfads waII and Its compllanaowiih all Washington well
c0 wbehnah69,961d*4dtM^Ima]sUced:30thdia1oA11003 reported eboveam sic to myben lmowkdgeagd bclicP.
um ❑➢riIlcri Tfralnec 0 PB PrintNamc MAGI TROTTER D If RCompaliY 000LWATER➢RILLING INC.
Si d� f _ Address 10921 NW HOLLY RO
'^—fir _ City,Slute,Zip BREMERTON WA 96312
U.rkANPM'Sp " 4 Caegemoib
so orgSi naiorc ink LleemnNo.'1723
Spa'mdY8Si8natmc RcgwSaGw No.CO0LWD19410M Dam 92221
ECY 950-)-20(Row 11118) Ifyou need this&ailmentn Pn Pile r alefnhrm.Rtease gall the Wuml RPa 404Perant al
360404872, Per'SOW wiOJwonng1Nsl con on Y11for 1WlshrhOa Relay Army,ns with aspeclr&ability Map roll
42243J 6341.
17865E Mile
till Dr.Pon
Orclmd.WA 'I SI'EC't'R.1 L11190rntifries Riteap
98366
.••' eyrrlm Dian
(360)443-7e45 COLIFORM BACTERIA ANALYSIS FORM
GateRampo collected Time Sample county
101241AD2 illededfl M4Sn�
Tor
mot DA
TypeewaterSysem(Melt only one box) ((JJ 1 LOCI
❑Creep A ❑Group8 2rather rr\VCarLOCII
Group A and Gmq B Systems-Pro de from Water Feciilies ImenWy(WFIT
IDA —
System Nana
Cooled Pinar ,JTt n'1 Eta Y.1nI e.1(
Dal Phpna:2F', Gel Phane:2532n Ic($
Emet S eJ1�r7^,r r L�`)48TIW51JiuC rhona.
Seal Anvils seminal woe samba...PI.bonw MememmOWm noun.)
idL:n1:.-aCtS+J"1 es Li 5a.
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G R r Z: �i.11gi,Lgt74.' ( Lace.
SAMPLE INFORMATION
Semple collected by(name)-. [`
SFedec location whore sample Callededi Spatial.tstu bans m comments:
00150 Plc r4h Share. g5za
Be.) {-c.J.-
Try.of Simple(check coly one boo)
1.0 Rouun.OI.trlbufwn Sample(AP) 2.0 Repeat Sample(MP)
Chlornated:Ya❑ No atom eiurouew system alter mat malt)
Onsatislvfory routne lab number.
CMmine Residual:Total Free_
S.Ground Water Rule Source Sample Unsalalfaclwy rouana collect date:
IBt I I
chbnnaIed:Yes NO
❑TdggerS(AIP) Chlorine Raelduel:Total Free
❑Aumsmenl ADP
'a.Surface or GM!Raw Source Water SemM.(Enumem0a.) 15
❑ EE coat 0 Fecal Tired Yu_e_
526empe Commtar lnrwmMon any
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsathsfodory Total Colton Present and at'sfaclory
E.cog present 0 EEO absent
Bacterial Density Results:Total Cdifomt _mpd100ml.E.ro, m001100ml.
Foul Colton_ cell00inl. HPC_ __„_ctllml.
Replacement Sample Required: ❑TNT[ 0 Sample taodtl
❑ Sample VWme ❑Damaged Container ❑.
Near
er R. ed W Wrce Planter1bn
i02. 1) 1LOS- itf Kb< - Cl
Receipt Temp C` mood Cab:
SM9123BIOLCORITfSM91830
left immm'm'grfr.
Ow RIM .ewS.thI
/Ul zWi22 saw Os.ea.u.,. ,.u. ..me.un.,
DOH tmsompaa
Ths HA vPar.v.n1•10rt N-
bL.O a03 -co
2175372 Mason County WA
01t2W202201:S3:40 PM AGREE
eRecerded 8170326 Rocree:$20650 Pages:£
LAND TITLE CO
ENVIRONMENTAL • ,I
HEALTH
'a Y
Return Address:
Winifred EaterprIen LLC I n VAI AIt{nr Sll L!�'.l
15560 Orwelkr Rd NW
Poubbo,WA 98J70
Q3313da LTC
DOCUMENT T'ITI E.Shared Well Arreemeel
REFERENCE NUMBERS OF RELATED
DOCUMENTS:Auditors File No,386452
GRANTORS:Winifred Enterprises LLC tic James R Whitsett COOLIABIirr FoRuRTERY INGONLY...
pr NO TWOIRRAACCURA'AYHM IT
GRANTEES:Savor Carpi Spvv and 3ohnar E.SW" 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 51 AND 58 OF
CLIFTON BRACH UPLANDS ADDITION,AS RECORDED IN VOLUME 40F PLATS,PAGE 31,
RECORDS OF MASON COUNTY WASHINGTON
ASSESSOR'S PROPERTY TAX PARCEL NOS 37209-54-9009&22209-54-9110M
WATER SYSTEM AGREEMENT
��
This Agreement dated the any of January,2022 by and between Winifred Enterprises LLC,do
James R whltsen hereinafter referred to as the Parties.
WHEREAS:Winifred Enterprises LLC,do James R WhiLeti is the owner of We following described rent
property shunted in Mason County.Washington:
LOTS A&B OF SHORT PLAT NO.993,RECORDED MARCH 19, 1981 UNDER AUDITORS FILE
NO.388452,BEING A PORTION OF LOTS 57 AND 58 OP CLIFTON BRACH UPLANDS ADDITION,
AS RECORDED IN VOLUME 4 OP PLATS. PAGE 31, RECORDS OF MASON COUNTY.
WASHINGTON
WHEREAS:Stacey Carol Stagg end Johnny K.Sings are purchasing the following described real property
stormed in Mason County,Washington:
LOT B OF SHORT PLAT NO.993,RECORDED MARCH 19,1981 UNDER AUDI'IOR'S FILE NO.
388452,BEING A PORTION OF LOTS 57 AND 58 OF CLIFTON BEACH UPLANDS ADDITION,AS
RECORDED IN VOLUME 4OF PLATS.PAGE 31,RECORDS OF MASON COUNTY,WASHINGTON
WHEREAS:Then is a well that serves the above described said real estate which is located at the base of
the slope on the NW caner of Lot 58
NOW THEREFORE THE PARTIES AGREE AS FOLLOWS:
I. OWNERSHIP AND NUMBER OF SHARES.Thera shall be two sham or interesb in lie well and water
system,one share being appurtenant to each of the parcels of reel estate described above. Each share shall
be a pan ofthetide to said parcels of rent eaten. Punhcnnert.GRANTEE Stacey Carol Stngg.is aware that
GRANTOR Minified Enterprises LLC,intends to sell Lot 58 and this agreement will be assumed by new
purchaser.
2. RIGHT TO WATER;ONE RESIDENCE ONLY. Each shire in the water system shall include the right to
receive water but only for one single family residence per shoe, The water must be used on the parcel of
real estate to which the share In We water system Is importer nt for personal or domestic use only and cannot
be extended or transferred to any other real estate.
3. EASEMENTS FOR OPERATION. All necenery easements for the Well Site,water system site,pump
house,tanks and waterlines inclwWg access for ingress,egress,and utilities for operations,maintenance and
repair are hereby declared,anted and established,and also including a 100'protective radius around the
well as required by the Health Department. The owners of the parade of real estate shall comply with this
protective radius and any other applicable insulations of the Health Department or other governmental
agency.
4. MANAGEMENT.Theownas of shares in thewaessystom shall have the responsibility for Itamenagemad.
All metiers shall be decided by mutual and/or unanimous consent.
5. COSTS SNARED EQUALLY. There Is a separate meter to supply electrical power to the Water System.
Each party hereto covenants end agrees that they shall equally sham the maintenance and operational rasa
of the well and water system herein described.
b. ASSESSMENTS. At a future time,the owners may by mutual consent set a main ,unce 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
Ntarged by Mason County on delinquent texts. Also,any unpaid assessments shell be a ken against the
property and a Notice of Claim of Lien may he flied with the Mason County Auditor.
S. LIEN SUBORDINATE CERTAIN MORTGAGE AND DEEDS OF TRUST. The assessments for the
maintenance of the well and water system shall be junior and subordinated to the lien of any first lien purchase
money mongage or first lien purchase money deed of Wstt(horehWler inferred to as"mongage')o ly to the
extent that the aasGam01 subordinated becomes due alter the dare of Reading of said mortgage and prior
to the date of issuance of Trustee's or Sheriffs Deed.Sale or tram fer of any lot shall not affect the assessment
lien.However,the sale or foster of any lot pursuant to mortgage foreclosure or any prooeeding In lieu
thereof shall extinguish the lien of such assessments as la payments which became due subsequent to filing
the action to apemen the property and prior to such sole or ransfer. No sale or transfer shell relieve such
lot from liability fanny assessments thereafter becoming due or from the lice thereof.
9. CONVENANT RUNNING WITH''TIE LAND. The provisions contained herein shall benefit and burden
the parcel of real estate andshall run with the tides to the parcels of real anon described herein,provide that
in the event a public.water rynem shall serve all the parcels of real state,then this agreement shall be null
end void.
10. This agreement shall become effective upon the recording of the Deed of Lot B front Winifred Enterprises
LLC c/o owner,Jena Whlaea to Stacey Carol Stagg and Johnny K.Stagg.
2175372 Page 2 of 4 01/213/2022 01:53:48 PM Mason County,WA
DATED TIus?6 day ofJanuary,2022.
VWiniRW Enterprises LLC
do owner,Jamas P.Wham
Stacey Coral Stagg lob ny .Stagg
STATE OF WASHINGTON
COUNTY OF MASON
0n this day personally appeared before me,lames II.WhItset,a single person.as owner of Winifred Enterprises
LLC to me known to be the individual.or Individuals daulbcd In and who executed the within arid foregoing
Instrument,and acknowledged that he signed the scone es his free and voluntary act and deed,for lie uses and
purposes therein mentioned.
Doted /—d(O'a'a' n
NOTARY PUBLIC Notary Yubilo )Ifor Ng5�49 ofWuhing tyn
STATE CP WASHINGTON
ORTH printed nnine:{,��,(y[�
1W C M OOt MOIRES
NotReairing b: ' an kf
MY COMMISSION MOIRES
OOMMI99bNI♦ad212 My Commission Expires 7—(7'1S—
2175372 Page 3 of 4 01/28I2022 01:53:48 PM Mason County,WA
STATE OF WASHINGTON
COUNTY OF MASON
On this day pc It scared before me,Stacey Carol Stagg and Johnny K.Stagg,to me known to be the
tndiwduel,a dividus described In and who executed the within and foregoing Instrument and
_
acknowledged Nat ; Igned the same esAav free and voluntary act and deed,for the uses and purposes
Marcie mentioned. el Thee
Dated nl —d(o -;oa
JACOBS NotayPubh pd for the State of Washington
TN%YRUCI2100053 Primed name:$fp[BRENDA
TATE OF W45NINm10N Residing $-A- Orr r —OMMISSION EXPIRES
FEBRUARY 16,2025 My Commimion Expires oa—I(a—8Q'35
2175372 Page 4 of 4 01/28/2022 01:53:48 PM Mason County,WA
'SITE PLAN at 6120 NE North Shore Rd, Belfair, WA 98528
Parcel#: 22209-54-90057
TOTAL AREA 21,5005Q.FT
83.76' --
SCALE: 1"=30 FEET
a a _ aaa� raaa�
I ■ a O O
Existing Er 10' 20' 30' 40' 50' 60'
100'DATUM ELEV _- curtain draw
pe �Ys\oPe� � NORTH
90'ELEV -- -491-ia'tl Construction road&
&SW B�e\a-_ -- -- parking
80'ELEV. Wes- - w 4 E
- - �" ' 3a66
2-party well
(100'radius)xx - pto O S
70'ELEV. ' _, _.2aoM .
Single family residentlal PAO� - THE NATIVE SOILS ARE IDENTIFIED AS AN
site on west side of property '; - EVERETT VERY GRAVELLY SANDY LOAM
5'high reinforced' i. WITHA INFILTRATION RATE FROM 2 TO 6
Proposed g INCHES PER HOUR (Ref. USDA Natural
concrete retaining wall w/ �e15 -'-13' Conservation Service-Nkb Soil Survey).
"cut line"shown behind it 0� ) ` `5 �
' Nn 'q__ 4"dia. x 10'PVCped
60'EL ,-.'" Fy'\Sp� 2a G0C '� ipe spoutsconnectetl to down
i(3)canners,
Existingplaced in 2'wide by
2 to 3-man rock retaining wall(2) V Meer s ery 6-; qF µ 8' deep trench&wrapped
to provide adequate buildingfoot- N� .dr1a\ f� with filter fabnc per Min.
gird for single family residence N BAP Cl4 '(e' `�/ �� Requirement Mh.
6120 NE NORTH SHORE ROAD 50' ELEV. "- pie 91
BELFAIR,VW 98528 -
I \ , ,,
des'
V/
tu
• • 40'ELEV,,'-
•
,ti p��
jOra \e,ao�
Legar Descr: Clifton Beach Uplands Addition TR 57 8 NE 1/2 of TR 58
TR B of SPit003 S 42/144
Prepared for:John and Stacy Stagg Ann 11,2023 -1 SHEET 1.0