HomeMy WebLinkAboutUntitled (2455) MASON COUNTY 415 N 6TH STREET, SHELTON,WA 98584
•r• •- SHELTON:360-427-9670,EXT 400
` BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA: 360-482-5269,EXT 400
FAX:360-427-7787
David Mayer
14701 SE 232nd St
KENT, WA 98042
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2024-00022
2161 NE Tee Lake Rd
323355000044
The 2-party water system, Tee Lake Tract 44 & 43 (323355000044/323355000043), 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
MASON COUNTY Date Received: a , 1,4„.
II`
ltill"f. � COMMUNITY SERVICES Amo � v � Recoiv
1
\ Building,Planning,E mnronmental Health.Community Health
/ 415 N.6" Street,(Bldg 8)—Shelton,WA 98584 W E L fj il ZZ-
C\
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 D,c)
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
as ,amyrmnsc.nzra:,•avmm.,-- :::,m.�a..., - -n:;»,.._,_,,..,:_..
APPLICANT l`� \`�/�vIY/�Y/�� PHONE �j�
MAILING E33�STREET.CRY,STA ,ZIP- c -AK- l_o - 16_3 -`,0�-C-
SITE ADDRESS-S m...
R EET,CM,STATE. 3 V-n -, �1 1 8 n 1 3 B 10
PRIMARY PARCEL NUMBERLIRE) L '- . ' 1 a 11 v\ I IN 9s e
SECOND AY PARCEL NUMBER(IF APPLICABLE)
02
WATER SOU O SOURCE TYPE PAR EL 1 LOT SIZE PARCEL 2 LOT SIZE
❑ New I$(Existing L�We11 0 Spring 1. 3 S L ! :
PROPOSED WATER SYSTEM NAME(REQUIRED)
1' LcIje—e_ kraC- i/z-I jL 3
PROJECT DESCRIPTION
7 , pot r`ry we I
DIRECTIONS TO SITE!CONDITIONS
lei( c e-,--) 1--i-e_ -+11 Y 05h \ocke 61,lwl t- 1n I I 1 N
f ee I —' \2 e\ °MO- 16 10 ,1.� oleic\ reel eSin-ke i cp v isl e
\ v-- I Y Ic ' �F v r o�vim-
�,v._ r��a 1k� 20 - a l� S. P o -1-� I
Site Plan: (may also be attached)
(property boundaries.structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...)
ki,
RFC, o22��
01,Fo
Submittals Checklist: (these additional items will be required for approval)
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)
Notice to Future Property Owners recording (record with Mason Co. Auditor, supply copy of recorded document)
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
Staff Use Only
1
I
Review Step 1: Well Site Inspection:
YES NO NA
❑ fsi.,. ❑ 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.
I What is distance to ROW?
❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan)
❑ ❑ Is the well cap satisfactory?
TT.,
❑ ❑ Screened and vented? i
❑ The well casing extends I/J above level ground/concrete slab? (circle one)
❑ ❑ Is there evidence of a surface seal? Lot: (i7, `(354 72.
❑ ❑ Does the seal appear adequate? Lan ; _ R_3 • U,2 yc ?c
471-
❑ Is a variance necessary for well site approval? 745 �J
Comments \ 7 ' ! .
" ° A-0 U r "
1 � , •(/—(7�((
} Pass ❑ Fail Inspector `, 66 LAbritN___,, Date
///6
Review Step 2: Two-Party Review:
YES NO NA
❑ ❑ Water Well Report with adequate pump test on file?DiATDfil, on UU/`l/fq'.10 ti/NI'foi 60,441 ( 0yo1)
If NO, date of Capacity Test jfigc/Z ( Driller 9 tq ti((e GPM 20 00
❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test 179� dr7' L) 206P0I 'Or 60r'),-0 el
❑ ❑ Received Signed, Notarized, and Recorded Notice? AFN ZW?Ili(
[f ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided?
Comments
A-PR i 8 2024
,:f Approved ❑ Denied Reviewer ! Date V/ 5h laZY.
`
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 19',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
l
Butt caw No._ti2)9903_9
Flie Original and FireeCopy Depressant of itcologywith
WATER WELL REPORT UNIQUE WELL LD.T AAG 300 •
Second Copy—ems Copy STATE OF WASHINGTON
Third Copy—Drlaers Copy Wiser Right Perrrtlt No.
(1) OWNER: P1WYe David Mayer Acts 14701 SE 232nd St. , Kent, WA 98042-3812
(2) LOCATION OF WELL: County Mason . SW t/a SE iu sec 35 T23rk,R 3W wit.
(2a) STREET ADDRESS OFWELL(or noires:aaew) NE 2161 Tee Lake Rd. , Tahuya, WA 98588
(3) PROPOSED USE: W Industrial CI «ta Muni ❑ (10) WELL LOG or ABANDONMENT PROCEDURE DE&:RIPTION
O
❑ DeWater Test Well D Other ❑ F.orrnttbn:Describe by oobr.dwscbr.sine of material and structure.end stair 1Ndnas of egotists
-
and the bad and nature of the material Si each stratum penetrmd,with a least ono entry So(each
(4) TYPE OF WORK: Owr1er's number of well charge of shbmhsmorh
(„mote itharh one) YATEAtAL FROM TO
Abandoned 0 New well [S Method: Dug 0 Bored 0 — r
Deepened 0 Cobh)g Driven❑
Recondrponed 0 Rotary 0 Jetted 0 Brown conglomorate 0 8
(5) DIMENSIONS: Diameter of wee 6 Inches.
Drifted 51 feet Depth of con feted wee 51 it. Gray hardpan 8 47
(6) CONSTRUCTION DETAILS: Sand & gravel with water 47 51
Casing installed: 6 • Dlam.from 0 tt.to 46 ft.
Otani.from R.to R. ^�
Tlhrsadsd • Otani.from R.b ft.
psttpfaiiOns: Yes❑ No
Tips of perforator used
SIZE of perforators in.by in.
perforations from R.to ft.
perforations from ft.to 1t
perforators from R.to ft.
Screens: Yes[� No ❑ h
Manufacturer's Nettle Cook
Type tai nless re wrap Model No.
ours.5 Slot size 2 from 46 ft to 51 ft.
Diem._Sid site from ft to ft. rrrn111 ���r(( (�
Gravel pecked: Yes ❑ No EJ( size of gravel i
U {
Gravel placed from ft to ft �� l�
JJ
Sorts saai: Yea ® No 0 To what depth? 18 ft. DEG 1,yy(} -.
Material used in said Betonite 1 DEC 0 1 1"" ^'
Did any strata contain unusable water? Yes❑ No®
—
Type of water? Depth of strata -,FRM(( ASSISTANCE CENT i:
Fr
Method of sealing strata off
(7) PUMP: Manufacturers Name Goulds
Type: Sub_ H.P. k
/ /n / /
(8) WATER LEVELS: L w elevation Woes elevati Woes Started 1.0!2719L. te. C«rwlered 11.LG!97 - .19
above mean sea bvel R- �^
Stack ter,,, 10 ._._---- n.below top of woo Date WELL CONSTRUCTOR CERTIFICATION:
Aneµan fxesaun Ibis.per square inch Date
Artisan water*controaaC by I constructed and/or accept responsubiltty for constructor 01 this wet, and its
(Cap.valve.etc.(_ compliance with all Washington well construction standar is.Materials used and
(9) WELL TESTS: orawdown us amount water fowl is krvered below static level
information reported above are true to my best i rt wletige and belief.
Was a pump test made?Yea❑ No E3 if yes.by whew"? NAME Davis Drilling
Yield: gal./rain.with ft drawdown after_-_ hrs. :PERSON.mak di CORPORATION) n,V5 uPAW—
.,
Address Belfair WA 98528
(Signed) I te�. . e 10.- 1992
Recovery data(time taken as zero when pump turned of)(water level measured from well - teal. R)
top to water level)
Time WaterLevet Tune Water Level Timo Water Level Contractor's
Registration
No. VISDI1100A Data Nov. 19 97
(USE ADDITIONAL SHEETS IF NECESSARY)
Date of test r_
Baiter test 10 Sale min.with 10 ft.drawdown after 1 hrs.
Alrtest get;min.with stem set at _ ff.for hrs. Ecology is an Equal Opportunity and Affirmative Action e Iptoyer.For spe-
Artrsian tow g.p.m. Date cial accommodation needs.contact the Water Resourats Program at(206)
Temperer-se of water Was a dlernlcet analysis made? Yes Q No 407 6600.The TDD number is(206)407-6006.
ECY 050.1.20 tspam•-iYv itlieLl i;!K i )V,riso!t r virl l ;r'WAS
DAVIS DRILLING
340 NE Davis Farm Rd
Belfair, WA 98528
Test pump for: David Mayer
Well address: 2161 NE Tee Lake Rd, Tahuya WA 98588
Pump: 1/2 hp
Well Depth: 51'
Static Level: 5.6'
Date: 3/25/2024
Well ID: AAG 300
Draw Down
Time Water Level GPM
0 min 5.6' 0
5 min 30.8' 25
10 min 35.5' 20
30 min 37.1' 20
1 h r 37.1' 20
2hr 37.1' 20
Recover
Time Water Level
0 min 37.1'
1 min 21.8'
2 min 16.6'
3 min 13.1'
4 min 12.9'
S min 12.7'
10 min 12.2'
1hr 5.6'
x
26276 Twelve
Trees Ln NW
pay
Poulsbo,WA
98370
(360)779-5141
Sample
Date Semple Collected Time -
3 1 Z51 2.D 1, Collected
AMA D+N Yea , :`d 411u " "4t.Jv 41
Type of Water System(check only one box)
❑Group A ❑Group B g'6ther/ I-, V?it'
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name:L'6 / N.t %e e y e
Contact P,errson: .h1, %- Per✓,
I
I " _Day Pfwn`�. U.� �:D(- c1 7 S" Cell Phone:
s:
Ema : Eve.Phone:
Send media b:(RM M nan.,.etr,.e Ind zly cods or mall r„ k of mutts)Oa4 J p, . 1..1, 0 at'Y+t.
•
Sample collected by(name): icf,iC
Specific location where sample collected: Special instructions or comment
1-,..ell he j
1•0 Routine Distribution Sample(A/P) 2.❑ Repeal Sample(A/P)
Chlorinated:Yes 0 No.81-- (from distribution system after urine routine) i
Chlorine Residual:Total Free Unsatisfactory routine lab number.
3.Ground Water Rule Source Sample —— —————
SI I Unsatisfactory routine collect date:
/ /
Chlorinated:Yes No
i ❑Triggered(A/P)
Chlorine Residual:Total Free_
❑Assessment(A/P)
4.Surface or GWI Raw Source Water Sample(Enumeration) S I I
❑ E.coil 0 Fecal HaredHaredYob No
5.Wimple CoMcted br Infenaation Only:
❑Unsatb{eetoty.T brillormfsieaentanti Satisfactory
! 0 E.coi present 0 E.col absent
Bacterial Density Results:Total Colifonn. mpn/100m!.E.coi mpn/100n
FecalColifonm du/100mt- HPC cfu/lml.
Replacement Sample Required: 0 TNTC 0 Sample too old
❑ Sample Volume 0 Damaged Container ❑
Date Time Received:, Lab Reference Number
1�2y iDco 2302-S--c- 1
Receipt Temp C': Method Code
i 3 a SM9223 /0T-COUNT/SM9222D
I D12(011
In: Date Out �} / TMrw+ra.e n.us.ptrp,q,p�p„rn y 3 f r V *hark Mtltrr.d A^ru..d Its a oulairditMpy� 1.
NM. N.A.,'
.."rory1, r�W' 7e4710e1tt nM
DOH Lab-Sample# °nk°r '°,11,.01.5
Noy moio moo*ory n M Am.o bowl do M nevi.(.)a
010. 1 2 S C: —6.4 by turithaviery,H.nowt.ti ooltoroaw.e.,a,
in U.*Aka Pb WM.►eMln Spor.l by*cry Utordaiw,
DW ramr O3131 D Wm*.Odin
2209431 Mason County WA
0410812024 11:47:06 AM AGREE
eRecorded #196459 RecFee: $310.50 Pages: 8
ROBERT JOHNSON
Return Address:
Robert W.Johnson P.L.L.C.
Attorney at Law
P.O. Box 1400
Shelton,WA 98584 COPY
DOCUMENT TITLE: Road and Well Maintenance Agreement
GRANTORS: David W.Mayer,Trustee of the Elisabeth Mayer Marital Trust u/w dtd 6/15/2020,
GRANTEES: David W.Mayer,Trustee of the Elisabeth Mayer Marital Trust u/w dtd 6/15/2020,
LEGAL DESCRIPTION:Tee Lake Shore Acres Tr 43,and Tee Lake Shore Acres Tr 44
ASSESSOR'S PROPERTY TAX PARCEL NOS:32335-50-00043&32335-50-00044
Declaration of Road and Well Agreement
David W. Mayer, Trustee of the Elisabeth Mayer Marital Trust u/w dtd 6/15/2020,
(Declarant) for the purpose of providing for maintenance agreement of a common access
road and water system Declares as Follows:
WHEREAS,Declarant is the record title holder in and to the following described tracts
of land situated in Mason County,Washington:
Parcel A: Tee Lake Shore Acres Tr 43, Parcel No. 32335-50-00043,and
Parcel B: Tee Lake Shore Acres Tr 44, Parcel No. 32335-50-00044
WHEREAS,there is located on the above-described Parcel B a common well and
associated equipment (Water System) which will serve both Parcel A and B.
WHEREAS,there is located on Parcel A and Parcel B a driveway that serves both
Parcel A and Parcel B as shown on that certain survey of record dated June 1997 and
recorded on June 26, 1997, under Auditor's No. 648705, records of Mason County,
Washington.
WHEREAS, Declarant desires to set for the Agreement for the purpose of reducing
to writing the respective rights and obligations pertaining to said Well and water
distribution system and road shared between the two lots.
TERMS OF AGREEMENT
NOW THEREFORE, in consideration of the promises and covenants herein
contained, it is agreed that that the water distribution system shall be used by the parties
Road/Well Agreement- 1
to this Agreement,as well as by all future owners and occupants, upon the following terms
and conditions:
I. EASEMENTS
1. WATER SYSTEM.
The Owner of Parcel A, for the benefit of Parcel A shall have a perpetual non-
exclusive easement over and across Parcel B as is reasonably necessary for
the installation, maintenance, operation,and repair of the Water System.
The Owner of Parcel B, for the benefit of Parcel B, shall have a perpetual non-
exclusive easement as is reasonably necessary for the installation,
maintenance, operation and repair of the Water System.
2. ROADWAY.
The Owners of Parcel A and Parcel B shall have a perpetual, non-exclusive-
easement for ingress, egress and utility purposes, over the other's parcel
twenty feet in width the centerline of which is as established by that survey
of record dated June 1997 and recorded on June 26, 1997 under Auditor's
No. 648705, records of Mason County, Washington.
II. WELL MAINTENANCE/REPAIR
1. OWNERSHIP OF WELL.The owners of the two parcels described herein shall
own the well and well infrastructure on a fifty-fifty (50-50) basis between
the two above referenced parcels.
2. MAINTENANCE/REPAIRS WELL. Assessments for improvements and repairs
necessary for the continued operation of the well shall be in two parts, one
for each lot. Major improvements and repairs may include (but not be limited
• to) pump replacement,pump house repairs, etc.This provision shall not
apply to each party's underground water distribution lines. The parties are
responsible for their own lines.
3. POWER COSTS.The power source for this well/waterworks is on Parcel B.
Each lot owner shall contribute ih of the power costs in the amount of$5.00
per month. This fee may be increased from time to time based on increased
utility costs but shall always reasonably relate to actual utility costs.
4. WATER SUPPLY. If the water system shall ever fail to supply adequate
domestic supply of water pressure to the properties,these two residences
shall act together in a diligent manner to cure the problem and to maintain the
Road/Well Agreement- 2
2209431 Page 2 of 8 04/08/2024 11:47:06 AM Mason County, WA
water system in good and orderly repair according to applicable laws and
regulations.
S. SERVICE LINES. Each property owner shall be responsible for the repair,
maintenance or replacement of the service lines serving the respective
properties. The well has been approved for single family residential use only
and the future owners will not be expanded to serve any other users without
mutual agreement and approval by Mason County. Additionally,a water
right, obtained from the Department of Ecology, is required if the water
system exceeds exemption standards.This system has not been granted one
or more waivers from specific provisions of the regulations.
III. ROAD MAINTENANCE/REPAIRS
1. MAINTENANCE. The Parties shall each share in the maintenance of the road,
each parcel paying an equal share of normal maintenance costs if any.
Normal maintenance shall include but not be limited to filling of chuck holes
and provision for drainage or as the Parties may otherwise agree.
2. DAMAGE/CONSTRUCTION.The Parties understand that the road may be
damaged as the result of construction or installation of water or electricity
lines, or other activities undertaken by either Party, their successors,and
assigns.The Party whose activities result in damage to the road agrees to pay
the reasonable cost of restoring the road to its condition before the damage.
If the actions of more than one Party damage the road, then each damaging
Party shall pay equally for the reasonable cost of restoring the road to its
condition before the damage.
3. ROAD IMPROVEMENT.
a. Notice. Any improvement to the road by a Party including, but not limited to
the grading,widening,or paving thereof shall not be undertaken without
written notice first being given to the other Parties.Such notice shall
describe the improvement to be made and shall be given no less than thirty
(30) days prior to the improvement contemplated being undertaken.The
notified Parties shall have the right after such notice to take such action,
including, but not limited to surveys or other review to determine to its
satisfaction that the improvement does not violate the easement or conflict
with any other covenant or restriction or for any other purpose.The cost of
any such action shall be borne by the notified Parties.
b. Consent/Cost. Any improvement undertaken without the consent of the
notified Parties shall be at the improving Party's sole expense. If the notified
Party consents to the improvement, then the Party consenting as well as the
Road/Well Agreement-3
2209431 Page 3 of 8 04/08/2024 11:47:06 AM Mason County, WA
Party initiating the improvement shall each equally share the reasonable cost
of such improvement.
IV. GENERAL PROVISIONS
1. BINDING EFFECT; Running Covenants.This Agreement shall be binding on
any successors in interest to the Declarant.The Declarant intends that the
covenants in this Agreement shall run with the land.
2. DISPUTE RESOUTION.Any claim between the Parties under this Agreement
shall be determined by under the American Arbitration Association (AAA)
Arbitration Rules.Any issue about whether a claim must be arbitrated
pursuant to this Agreement shall be determined by the arbitrator.The
arbitrator shall apply substantive law and may award injunctive relief or any
other remedy available from a judge including attorney fees and costs to the
prevailing Party but shall not have the power to award punitive damages.
3. WAIVERS. No waiver of any terms, provisions,or condition of this Agreement
whether by conduct or otherwise in any one or more instances shall be
deemed to be or construed to be as a further or continuing waiver of any
such term, provision, or condition or as a waiver of any other term, provision
or condition of this Agreement.
4. SEVERABILITY. If any term, provision of this Agreement or any
application thereof to any person or circumstance shall to any extent be
invalid or unenforceable, the remainder of this Agreement or the application
of such terms or provisions to persons or circumstances other than those to
which it is held invalid or unenforceable shall not be affected thereby and
each term and provision of the Agreement shall be valid and enforceable to
the fullest extent permitted by law.
S. ATTORNEY FEES. In any controversy, claim or dispute arising out of or
relating to this Agreement or the method or manner of performance thereof
or the breach thereof, the prevailing Party shall be entitled and awarded in
addition to any other relief, its attorneys' fees.
IN WITNESS WHEREOF, I have hereunto set her hands and seal the day and year
first above written.
h/i.
avid„0.04
yer,Trustee of t e Elisabeth Mayer
Marital Trust u/w dtd 6/15/2020
Road/Well Agreement- 4
2209431 Page 4 of 8 04/08/2024 11:47:06 AM Mason County, WA
STATE OF WASHINGTON
) ss.
COUNTY OF MASON
On this day personally appeared before me David W. Mayer,Trustee of the Elisabeth Mayer Marital
Trust u/w dtd 6/15/2020,to me known (or proven on the basis of satisfactory evidence) to be the individual
described herein and who executed the within and foregoing instrument,and acknowledged that she signed
the same as her free and voluntary act and deed,for the uses and purposes therein mentioned.
GIVEN under my hand and official seal this day of �all- 24,
NOTARY PUBIC in and for the Sta;e of
Washington,residing at tf G-4
My commission expires 61 Al S 4 ZLIZfi
ROBERT W JOHNSON
Notary Public
State of Washington
License Number 55821
My Commission Expires
May31, 2026
Road/Well Agreement- 5
2209431 Page 5 of 8 04/08/2024 11:47:06 AM Mason County, WA
EXHIBIT A
Mason County Notice to Future Property Owners
Road/Well Agreement-6
2209431 Page 6 of 8 04/08/2024 11:47:06 AM Mason County, WA
Return To
David W. Mayer
14701 SE 232nd ST
Kent, WA 98042-3810
Grantor(s): (1) David W Mayer (2) David W Mayer
Grantee(s): (1) PUBLIC
Legal Description (1) TEE LAKE SHORE ACRES TR 44
(Abbreviated form:i.e. lot, block. plat or section. township. range)
Assessor's Tax Parcel: (1) 32335-50-00044
NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM
I (We) the undersigned grantor(s), certify that the water source located on the above-described
real estate under Legal Description (1) and Assessors Tax Parcel (1) situated in Mason
County, State of Washington, has been designated to serve a source of water to the following
parcels situated in Mason County, State of Washington; herein described:
Tax Parcel: (Connection 1) 32335-50-00044
Tax Parcel: (Connection 2) 32335-50-00043
The system owner is responsible for keeping this system in compliance.
The name of:he water system is: TEE LAKE TRACT 44 & 43
This system is designed to provide for two service connections. Planning and design approvals
must be obtained from the department prior to expanding beyond this number of services.
Additionally, a water right, obtained from the Department of Ecology, is required if the water
system exceeds exemption standards.
This system (has'has not been granted one or more waivers from specific provisions of the
regulations.
Dated on this 22 day of March , 2024 .
Signature of Grantor(s):
(1) ,,,,7 �1��. �� �� , (2)
2209431 Page 7 of 8 04/08/2024 11:47:06 AM Mason County, WA
State of /r1 )
)ss
County of „-a9 )
1, Z.n(4 A_/ 1-2hy , Notary Public in and for the S to
of Washington, hereby certify that on thi '^"day of az.icA , 20 .2 ,
personally appeared before me, ,21.4.1 c2-i- to
me known to be the individual(s)described in and who executed the within instrument
and acknowledged to me that he/she/they signed 7 „c, *
7- o-44y Sys -hi
document as a free and voluntary act and deed, for the uses and purposes therein
mentioned.
Given under my hand and official seal this"day of a_re.j) 20�7'"
(Seal or Stamp) (Signature)
Notary Public 4/oc a ��Uc..-pAti
State of Washington (Print n ame)
LINDA LANE MURPHY
LICENSE#23007227
MY COMMISSION EXPIRES Title �c. -171
FEBRUARY I?,2027 /
Residing at v QQ-(2�
My appointment expires, .LL2 t t,s7/•0c'
2209431 Page 8 of 8 04/08/2024 11:47:06 AM Mason County, WA
Mason County WA GIS Web Map
323355000
2141 NE TEE LAKE RD
323355000046
\3 23 3 5 22 222 2.
�5
2151 NE TEE LAKE RD
323355000045 - -- \
0
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323355000044
t
2161 NE TEE LAKE RD {toNl°
1 f' P""`�'
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3 23355000043 , t"
2171 NE TEE LAKE RD +4n{� a(C4 •�
0 —���
2181 NE TEE LAKE RD
323355000042
2191 NE TEE LAKE RD
3233 55000041
323355000040
3/26/2024, 10:14:02 AM 1:765
0 0.01 0.01 0.02 mi
L County Boundary I ' ' ' 'I + ` ' '
0 0.01 0.02 0.04 km
No Filled
° Site Address (Zoom in to 1:3,000)
Sources:Esri,HERE.Garmin.Inlermap.increment P Corp..GEBCO.USGS,
FAO. NPS.NRCAN,GeoBase, ION.Kadaster NL. Ordnance Survey. Esri
Tax Parcels (Zoom in to 1:30,000) Japan.METI,Esri China(Hong Kong).(c)OpenStreetMap contributors.and
the GIS User Community
Mason County WA GIS Web Map Application
Mason County disclaims accuracy,reliability,or timeliness of website info,not liable for losses from reliance on it.https/)www.masoncountywa.gov/disclaimer.php
J
Thurston-Mason Health District No.
5th & Birch Court House Annex
Shelton, Washington DIVISION OF SANITATION Olympia, Washington
Phone: 426-4407 4 licatiem ios hodelja,Site yaireciithos Phone: 352-4851
(Submit in Quadruplicate)
DO NOT WRITE IN HEAVY OUTLINED SECTIONS
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Owner
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Mailing Address __.� AV-City
Builder
Ber-Ll ' /3•.+/./ar w'-- Address fic�/-"*"- ir
Sewage Contractor Address
Legal Description -re; e if E
Parcel No. ? Field Book No.
Directions to Property
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Intended uses of Buildings` �...+ Public Sewer Wa er Supply
No. of Bedrooms No. of Bathrooms Basement Septic Tank
Type of Soil Lot Size
Soil Drainage: Good Moderate Poor None
DRAW SKETCH in blank space or on separate sheet indicating the following:
1. Property lines and location of house on lot and indicate minimum and maximum setbacks plus
dimensions of lot and all buildings.
2. Location of house and sewage disposal system in relation to streams, lakes, wells, patios,
driveways, underground tanks, water supply lines and easements.
3. Location of all interception drains or french drains.
4. Proposed fill, including depth, area, porosity and amount.
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APPLICANT'S SIGNATURE ...CJ " ✓2e-c'Cam DATE 7--`' '
Site inspection fee $5.00 Receipt No. a(47 11 By Ago
Approved .4-4. 4 Not Approved By .-.
DATE -''f}r) • DATE SANITARIAN