HomeMy WebLinkAboutWEL2023-00054 - WEL Application, Design, Letter - 10/9/2023 At MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
BELFAIR:360-275-4467,EXT 400
i Public Health & Human Services ELMA:360-482-5269, EXT400
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
Sincerely,
David Anderson
Environmental Health Specialist
Mason County Environmental Health
j+
/
• oC
R x a , 2222
-' zlc t MASON COUNTY Oate Rna.N4 l ) 3 6764F
d' =) COMMUNITY SERVICES O
w ..,- mountR0 ,
aBP �� ,a n� � � NdIR F`sc'TRtt�
Shelton 360-427-9670 x400 Bdfir:360-275-446x400 Elmo:360-482-5269 x400 WEL 3 O 0 1
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT ,
a c2C\ y1L.6)0) PHONE ` 015 -no- iI9.L
MAILING ADDRESS-STREET,CITY;STATE.9P
co1d.-C) NL rv2-fi.- Stn r€_ 2a . &Ic.;r w4\ 95;at
SITE ADDRESS-STREET.S\TREE^T,CITY.STATE.ZIP
PRINARRTPARCEELLNUNEE (WELL silt,
,� S t� 'KLel , 9)cI <,;f , wP- 9 sad
02_fle9 — SH— CIaaS-k
SECONDARY PARCEL NUMBER LIE APPLICABLE)
?2. C>`1 - 54 - C10cSb
WATER SOURCE SOURCE TYPE ELT LOT 56E PARCEL 2 OT s¢E
0 New Existing Well ❑Spring 0Cfll, aCrri$ EL - 1S E
401.43
PROPOSED WATER SYSTEM KANE(REQUIRED �Unilly R r/Et'I
o+ r P DESCRIPTION
Nz1oi SFik
DIRECTIONS TO SITE/CONDITIONS
CC klar.. WA-) N hsta VA rats/ 0ot+a\ &tkixn O. .'ti& -kr AAn 11 LeCh -hi
��1��+en c.,.. Ina-?i,l ,.c j.; 1 7:ntl+C , tO. N-_N 1„Tnr`L c.- An: t. Sl/ts.'.4 ,CLI' dis.A,, RCM e- Ci+/—
Site Plan: (may also be attached)
(property boundaries,structures,well site wit Oa'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
bee . (A.1 roLL Cl
•
l -
Submmittals Checklist:(these additional items will be required for approval)
Q/�atisfactory Bacteriological sample(this may be deferred if well is not yet drilled)
f9 ell Log with pump test or 4-hour capacity test performed by driller(this may be deferred if well is not yet drilled)
Oof�bce to Future Property Owners recording (record with Mason Co.Auditor,supply copy of recorded document)
ptic 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/I 3/2021
Page 1.of
;, ----- ._— ____.___—Staff Use Only — — .._.._._ —..
,
)l pc)
Review Step 1: Well Site Inspection: ,; e� I
u YES� NO NA ,r
F ❑ ❑ Evidence of existing sources of contamination within 100 foot radius of water sour ? J �3.3
(drainfields,tanks, buildings; indicate distance on plot plan) ! I®
❑ V ❑ 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?
2 0 0 Does the ground slope away from the water source site?(show slope on plot plan)
❑ ❑ ❑ Is the well cap satisfactory? 2 ovf of'1 mevs f tXil B fedV,
(1 0 0 Screened and vented? t .
,�z ❑ The well casing extends r 6 above level ground I concrete slab? (circle one)
IX 0 D Is there evidence of a surface seal? tof c'II 1106101
tg 0 0 Does the seal appear adequate? eu,:— (zz- 731WO
❑ 941 0 Is a variance necessary for well site approval? Tay, Bs,elf;
Comments -ctea vp "Ka 4,67.0/5
Pass ❑ Fail Inspector (9 2N .._ Date 10//7/ Zo Zj
Review Step 2: Two-Party Review:
iS NO NA
❑ ❑ Water Well Report with adequate pump test on file? /�� I� �w',, x-, p
M If NO, date of Capacity Test 7/z/let1 Driller 4O`"vOtr, OalliGPM I0
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test IO/26/AM
pir 0 0 Received Signed, Notarized,and Recorded Notice? AFN 2/7$171
Or ❑ 0 System appears adequate to serve 2 single-family residences based on information provided?
Comments 7�
Approved ❑ Denied Reviewer ly% Date (0!/LV7/N Z3
Findings in this review reflect observed conditions as they existed an the day of the site inspection. No claim is made, express
or implied r f 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 Janumy 19"' 2018 per f_S'S116091.
Revised: 10/13/2021
This form may be scanned and available for public view on the Mason County Web site. page 2 of 2
t•tpd,4ed
WATER WELL REPORT I. 0!PARTINEIHT OF R0541004166143.WE45751
ECOLOGY Unique640b Wei 10T29NQ BME 355
Tao 011 1; Rota of Washington
Site Well Name(thwart than coe well):
O DeR4041amdl Caea
Wnon ry',_Onp'v,YinmwahonNDl Ne - Water RippLYermiVCeM1iScom No.
Prcpaed Urm Pl Demotic ' pbduibul OMuN=lal;. Ylopedy Owar Nemo REI CONTRACTORS
pNW+dq tiYrdpdpe gtl'rsp'en ❑Od•r• Wall Sots{Addmr M SHORE RD •
41wW tlep;pTal 0.15dv C(tyr BELFMR County MASON
b NM14610 titi*_ OOp8 ❑logo pMdaTom n 4 f 2
�f]Dapmw� OY)pmt�, ODpd dAS. OMud 2otmy Tex Pucel Na�,21 ✓'�� 9b
Dlamldgm:UlaW,motW:ms a Iml b 193 )c V8a avantee approved fortbtsweu? O Yei O N0 _ •
Otto aea(tPl=ad wnll 105 n
If yet whet was WenD cf t(
Last LOonten.m Wall
LMIOR L1nof 1:44maler. Freq. 'Cu Tnmna. Steel PVC Folded Thread _ 1
'W I ! ti •1 1m s59 In R I ❑ R I ❑ Location(nee mnnunon6 onPPe 2): 0WWeicorI EWM
❑ I ❑ N — _Lb ❑, I O ❑ I ❑ NE %-h of the.SE ?Section 9 •1'awns6ip.2EN ]tmgo y. .
-... o I 0,—in 1. O 'I E ❑' 10. La4tlde(Bmmplat1.12345)
-.❑ b in.. a. ❑ ❑ O.. Longitude(Example:'-120,12345)
n ra0p1. 0Yon RNo 'Typo of;cadmic,.used •DxDl sLagfC ¢t FSan or Aeeomldssa YSaas4n
6E N oLtofrom _. Slayow grouWM „ Iry by—tm Po bnD lvbYOl hand 6wgfm•Itlel eedatato dlltb M'ndund
�a �Perf mtia SamG.Io�O.bgbw plpmMnvO=a aatoto flm m l intib layer no0emd with at least one of fereach abnnsa of
Seaaoa: F Ya dNe O[akm b pooh information.Utz•ddWopel Nap Ifaetth•ry.
;;'Ma{allot F1Um .:; To
Tu .er.5 ' Etn. Mrttomm CLAY&GRAVEL:BROWN p .I 40
m RWdpb6 D. 41o1Nm 12 NPpm 1WM1ta LL 4Q- 59
Dlawtea; A. $rM.im b tbm G W__tt CLAY&P2 VEL BWNRO
c CLAY&GRAVEL'BROWN
-'Ue dil 1p d?ro,u n e o Bue dfp'd Nalma GRAVEL H2O.BROWN el 105
..ff.... :MMR1Plad Bnm' ft. . R.
eb SU!M her ®Yea ORa 1o4.IE141W 20 £
o MaDn IWM meat BENTONITE
oi--. Dldaayal3aamajttattt%Oleanl! ❑Ye WNg
'TrotTtatat Pepmbrmats RECEIVED
M16od aialing,Sgf -
EF - , ! egpDiOa' pki em GOU1D9 1`/p SUB JPHASE
WELL QONSTRUCTION AND
n° ae,1 FomPw..k•uepa:ps rt. pulped mwak 10 ®m LICENSING OFFICE
a ptetLevN.Luleawfi dop etbe= rboPo mea aea WYgl_R
a sbkapotteporwdlaedo '1r ft.ahoy.ground wrlbea SEPT 222021
Ca - sybg pkdawl 65 1441ow top otWelleastng Patc 0-10,21
f Maio Wmaruo v lbs.➢errgevemeh:. Dam
14iaM1 water 669atimlcalQ' colvtaivv.
cc.}.
m NNI Tao /+r��C
o5 W e mpinpmlluiej13 rdi Iwo 1%Yn 4 bYw1wm? RECEIVED
; " Yt ,! 18 rW1pe tdaW4i0 etbr<M. RECEIV E
lT ld "ewam m: __N0YL 2022
toptwifrkirlryg- bmSumRunnled f1 ter Im d mwcLL
ua% Plewete=INeh....
po - Time Wawa/oral Tune w.ntal...m Tune watmre.ec •
Department of Eonlcay
We" fkitiing-httr,a
oW
t too atpumplegmt
1-4- Bail tvTtam with ttitatdota eta tn}.
glrWt pnIthkw M t_Rf ar 0
ATI4I OoW__W
El Tmpearpm9Pwgbr l F Was•ckmlm nonlools undo/ 0 Ws ❑No Ewa Dato 8-3121 CompltdPl 9-221Ets .
.. WY,LLCONSTRUCf{ON CE$TBICATION: l aopstmckedand/or accept responsibility far consryaunodds welt and Its compliancnwith of WasWnglan wall
bot couspueMpstandµdiNu mat used.a ad roe tnfommmprcporterd above are two to myhMtknowlcdge and belief.
❑Dag,c 7talncu OPE PrintNorpcMADl TROTTER_—, Ds Company C00LWATER,RRILLING INC
r _ Adds 10021NW HOLLY RD
B
SPyatwa ¢ 4✓!s ` " — CIlyshm,Zip BREMERTON WA 90312
]lcmeeN9.5Q07 Cangamw-5.
1P TYA W EB.SPopsa'¢Lcrosd No.1773.
SpaNdt6 Signature Itc®s5d4on No COOLW0194WM Dato 92221
BCY 050-1-20(He d1(10) 1/3311 aced 1163 document in an ply of!Moot RIcase callt Euler 1168mates Program cal
3664076872 ?mans wentbearing ass can call 711Aoorr Wasbil4Ln Relay$enlce.Pcnam with aspc h duu6110v Cab call
1186 SE Mile
HLII Or,Pon
Orchard.WA 'I SI'E("I'R.1 LDAorBwries imap
98166 - - esaedw.ewmr.n
(I60)181]845 COLIFORM BACTERIA ANALYSIS FORM
Data Sample Collected Time Sample County
12111 202z aDm' Nlu50A,
WA Dig v.
rpm ci Water System(check onlyonebox) 1 1,,
❑GWPA ❑Group s 2TNa f2nvgfelAfell
GoupA and BMW B Systems-Provide hen Water Ermines Inventory OWE
System ID8
SystemName
Confad Person: al nt 5 n'L e,-(
Day'mane:2rt'S ceriphonc 25321'11C&SS'
Em& 5 e.l tilt r Lt 5;;a lv5lJ,CagePhpne
Sell reset p pLa Nawar..seems ne ebumall.bnM[�'S�Pmnkeery el neuN)
.E.�e•AiS..S.�y..M er L S4err-Ar.en m
..
r2cn Sid_
l_a1S I Lk:
('Lace.
SAMPLE INFORMATION
Sample mlected by(name) !
5_1 S h en e r
Spade°location where sample colksled'. Special Estruceone«comments.
i0150 Shore.
B el f'c.lk WA 9 4.51-51
Typo of Sample(chock only one box)
1.0 Routine BINAntlan Sample(AR) 1.0 Repeat Sample(AIPI
• CNwnaled:Yes No Ileomdmasonsynemsnerunsa cannel
Um sbsfadoy routine lab amber.
Clarice Residual:Total_Free__ •
].BMIYnd Wader Rule Source Sample UnSetiedOry roudnecollect dale:
ISI I I
O*dnatal Yes_ No.
_--
❑Thsgnred(NP) CLbnne Residual Tod_.._Fie__
❑nuassmuR(AP)
4.Surface or OWl Raw Source Wad Semple(Enumeration) ISI I
❑ Ecol ❑Fecal tame r.._w_
500empe Comma(or intwmellm miry
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Tod Codlam Present and Ikelackey
❑E.cog present ❑Ewpeh and
Bacterial Density Results:Total Ctlilom _mpnlloCml.E.cM_hp&IODS.
Fecal Cryform_ _ F'tllgml. NEC_ _..._cluilml.
Replacement Sample RquIn1 ❑TNTC ❑Sample tw old
❑ Semple Vdume 0 Damaged Crnbiner ❑__ _ _ .--
Lab aepmrca Namta
orriai /Los ;II SDK -('I
Receipt Ttrnpc•. Method Codt sMe223BIlT-CgMnSM9T13D
Oa Ponied: n.,"Thw,yde,sn.w.etap~ammadv/La
tall tebsanIex
/n��I p � n ..
JLP I1-h V tyW
mvrmm aced w Yha.wln
bLO a0a3 -cCClCo
2175372 Mason County WA
012w2o2201:53:48 PM AGREE
eReeertled M70326 RooFee:$2u€50 Pages:4
LAND TITLE CO
ENVIRONMENTAL /I
HEALTH
tor,
Relurn Address:
Winifred Enterprises LLC In \Iri IV:Irr lfr>,oi
15560 Orwelke Rd NW
Pre rbe,WA 98370
031130n LTC
DOCUMENT TITLE-Shred Well AP resmenl
REFERENCE NUMBERS OF RELATED
pq£DMENTS:Auditor's Pik No.388452
COURTESY RECORDING ONLY...
GRANTORS:Winifred Enterprises LLCup James R Whigan NOOABILT'FOR VALIDITY
GRANTEES:SamCnIOI Skim end dolour A.wino LAND TITLE ACCURACY
mesonDOWSE.
LEGAL DESCRIPTION:Abbreviated Deseripllom LOT BOP 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
AO9'SSOR'S PROPERTY TAX PARCEL NOS. 22209-54-90057&222119-54-90058
WATER] REDEEM AGREEMENT
This Agreement dated the VW dhy of January,2022 by and between Winifred Enterprises LLC,<lo
James It Whltsett hcrelnagcr referred tow the Pasties.
WHEREAS:Winifred Enterprises LLC,do James It Whit ctt is the owner of the following described real
property siemted in Mason County,Washington:
LOTS A&B OF SHORT PLAT NO.993,RECORDED MARCH 19,1931 UNDER AUDITORS FILE
NO.383452,BEING A PORTION OF LOTS 57 AND58 OP CLIFTON BEACH UPLANDS ADDITION,
AS RECORDED IN VOLUME 4 OF PLATS, PAGE 31, RECORDS OF MASON COUNTY.
WASHINGTON
WHEREAS:Story Carol Stagg and Johnny K.Stagg am Wmhmmg the following described reel property
situated in Mason County,Washington:
LOT R OP SHORT PLAT NO.993,RECORDED MARCH 19, 1981 UNDER AUDhTOR'S FILE NO.
335452,BEING A PORTION OP LOTS A AND 58 OF CLIFTON BEACH UPLANDS ADDITION,AS
RECORDED IN VOLUME4 OF PLATS.PAGE 31,RECORDS OF MASON COUNTY,WASHINGTON
WHEREAS:There is a well that serves die above described cold real espte which is located at the base of
the slope on the NW saner or Let 58
NOW T11E112E0101 THE PARTIES AGREE AS FOLLOWS:
I. OWNERSHIP AND NUMBER OF SHARES.There shall be two shares or interests in the well end water
system,one share being appurtenant to each of the parcels of real rotate described above Each share shell
be a pan°Et a title to said parcels of rent estme. Pur hermom,GRANTEE Stacey Carol Stagg.is aware that
GRANTOR Winifred Enterprises LLC,intends to sell Lol 58 and this agreement will be assumed by new
pure ascr.
2. RIGHT TO WATER;ONE RESIDENCE ONLY. Each shore in the water system shall include the right m
nneive water but only for one single family residence per share. The water MUM be used on the parcel of
real estate to which the share In the water system Is appudenanl 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 Ne Well Site,water system site,pump
house,tanks and waterlines including access for ingress,ogres,and utilities foroperalloo,maintenanceand
repair are hereby declared,aeaded and established,and also including a I00'protective radius around the
well as required by the Health Department. The owners of the parcels of real estate dull comply with this
protective radius and any other applicable legulatlora of the Health Department or other governmental
egwcy.
4. MANAGEMENT.The owners of shares matte watersynan shall have the responsibility for its mnnagoment.
All matters shall be decided by mutual andlor unanlmour consent.
5. COSTS SHARED EQUALLY. Tficre is a separate meter to supply*conical power to the Water System-
Each party hereto covenants and ayes that they shall equally share the maintenance and operational costs
of the well and water system herein described.
6. ASSESSMENTS. At a future lime,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 end 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 payment was due,it shall bear interest at the same rate as
charged by Mason County on delinquent axes. Also,any unpaid assessments shall be a lien against the
property and a Notice of Claim of Lien may be flied with the Mason County Auditor,
11. LIEN SUBORDINATE CERTAIN MORTGAGE AND DEEDS OF TRUST. The asmamenls fur the
maintenance of the well and water system shall be junior and subordinated to the lien of any firs lien pnehaee
money mortgage or fiat lien purchase money deed of cost(hereinafter referred to ar"mortgage")only to the
extent that the assessment subordinated becomes due after the dale of recording of said mortgage and prior
to the date of issuance of Trustee's or Sheriffs Deed.Sale or transfer of any let 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 wile or transfer shall relieve such
It 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 inn with the tubs 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 recording of the Deed of Lot B from Winifred Enterprises
LLC do owner,lames Whitson to Stacey Carol Stagg and Johnny K.Stagg.
2175372 Page 2 of 4 01/28(202201:53:48 PM Mason County,WA
ni. la
DATED THISemr Ely ofJanuary,2022.dVWinined Enterprises LLC
d o owner.Junes R Whitson
y�/
Stacey Carol Stagg Joh ny 14!Sugg
STATE OF WASHINOTON
COUNTY OF MASON
On thin day personally appeared before me,James R WhIIedL•single person,as owner of Winifred Enterprises
LLC to me known to be the individual,or Individual.described in and who executed the within and foregoing
Inssbment,and acknowledged that he signed the some as his free and voluntary act and deed,for the uses and
purposes therein mentioned.
Dated /-a(0-aa- 0
NOTARY PUBLIC Notary Public' Curth fWuhingt nn
STATE OF WASHINGTON[
COLLEEN HOWNGSWCITIN
printed name:Residing at: : !f $)A)-�**L
HY COMMISSION DAMES
JULY tl,10tg My Commission Expires 7-/7'lb
COMMISSION 0143272
2175372 Page 3 of 4 0128J202201:53:48 PM Mason County,WA
STATE'OF W ASHINGTON
COUNTY OF MASON
On this day pergQP ntl geared before me,Slang Carol Stagg end Johnny K.Sings,to me known to be the
iRdividoel,e�dividu,r described i11 and who mated the within and foregoing Instrument and
acknowledged Nat , signed the same esJwr free and voluntary act and deed,for the uses and purposed
therein mentioned. da nee
Dated CII -a(o -aoaa
[BRENDA JACOBS NyPubhd nnh�Portsmre of Washington
TAOUCI21N05 Printed ppTATT OF WAHGTON Resimimn t:
OMMISSION EXPIRES
FEBRUARY 10,2025 My Commission Expires rya-Ice-8095
2175372 Pagel of 4 01/2B/2022 01:53:48 PM Mason County,WA
'SITE PLAN at 6120 NE North Shore Rd, BeNair, WA 98528
Parcel#: 22209-54-90057
TOTAL AREA. 21,500 SOFT 8376'
SCALE. 1"=30 FEET
I..r_ S
_ 0' 10' 20' 30' 40' 50' 60'
`� Existing
curtain drain
o.0P,04 � ep.____ NORTH
OT .Stec ^Y - Construction road&
90'ELEV. -- --g6<1a1e� aet\ ----- __
• '' CA f.5 on=P-- - -- Parking
w E
80'ELEV. ' - ,{ ��� 1a56 •
2-party well
(100'mdius) ZGxaGO s
70'ELEV -
Single family residential � ` / PprcsµN� _ THE NATIVE SOILS ARE IDENTIFIED AS AN
Me on west side of property '' EVERETT VERY GRAVELLY SANDY LOAM
. \MTHAINFILTRATION RATE FROM 2 TO
Proposed 5'high reinforced' -- INCHES PER HOUR. (Ref: USDA Natural
concrete retaining wall wl ,- , Su
ch - 13 Service-
Conservation Ser -Vkb Soil Survey).
"cut lineshown behind it -
a - 4"dia x 10'PVC pert
60'EL --'- �L0.\5j\NO zn Zgs c spoouipe�Co�e3)connected
own
'0 ,n'-p' �? placed in 2'wide by
'Existing 5' If - G ea 8"deep trench&mapped
2 to 3-man rack retaining wall(2) f, - V Meter aN,.ap with filter fabric per Min.
to provide adequate building foot- s Se �.j p Reouiremonr#5.
pond for single family residence N V4 O
0
,Per
-
,
6120 NE NORTH SHORE ROAD 50' ELEV_ a�
BELFAIR,lW+98528
, E
,
w
'• 40'ELEV -
•
g•
Legar Descr. Clifton Beach Uplands Addition TR 57&NE 1/2 of TR 58
TRB of SP#003542/144 1_ — - - --
.
Prepared for:John and Stacy Stagg I qr.11,2023 SHEET 1.0