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HomeMy WebLinkAboutUntitled (2456) MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 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: i a a.il., %- w ' : COMMUNITY SERVICES Amot9cAt Receivel3 ) ,,�; �\ [kidding Planning,Environmental Health.Community Health 415 N.6`''Street,(Bldg 8)-Shelton,WA 98584 W E L D-C) ZC-\ - C) b Z2___. Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT �/) �� V� fYnln, PHONE MAILING ADDRESS 1/EET,CITY,STA ,ZJP 0. kl�_ 1-0 �� - ��^` SITE ADD RE SS r)BEET,CTfY,bTATE, 3 21/ V- / r�) MA 1 8 n - —3 B I 0 PRIMARY PARCEL NUMBER(WELL SITE) `�1� 4 1 0 I' 1 U !0. I W 9 , ., -'APPLICABLE) bo«Ll�-1 SECONDA L1 `Y PARCEL NUMBER(IF APPLICABLE) 2 335---5b— oc,02-1 --- WATER-gOURCE SOURCE TYPE PAR EL t LOT SIZE PARC.cL 2 LOT STE ❑New t4 Existing IRWell El Spring 1 13 r� ,L+ PROPOSED WATER SYSTEM NAME(REQUIRED) f L,ct je--e —-rx c-- Ll L-1 ,4 q 3 PROJECT DESCRIPTION ZCMt--9 well DIRECTIONS TO SITE/CONDITIONS , L I-I-e 4h Yo01 h 1 oche r CWa11z ►n at 2 l7l N I% Q e In Vie.- 12-e\ (*{ DWOO-k RA` -eiG rea 1 PS-�cA k S 1 cj I�v isi. k e ,v e 11 y\e_a r I ct� 2- -fro 0/.. 5. Q ro c r-4-,- C o,i vt.ey Site Plan: (may also be attached) (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...) RFc, 022,o7� Fii,F0 *--.\ 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 Review Step 1: Well Site Inspection: YES NO NA El )1S.. ❑ Evidence of existing sources of contamination within 100 foot radius of water source? (drainfields, tanks, buildings; indicate distance on plot plan) El ri, El 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? ❑ ❑ Does the ground slope away from the water source site? (show slope on plot plan) ❑ El Is the well cap satisfactory? fEl.--, ❑ ❑ Screened and vented? i i ❑ The well casing extends I/ above level ground/concrete slab? (circle one) ❑ ❑ Is there evidence of a surface seal? L4 f : (i`j,`(354. 7.Z ❑ El Does the seal appear adequate? LOY) ; _ 1 3 , 02 yc",-- El Is a variance necessary for well site approval? 7-45 Comments L �- L �/lr J �. v Pass El Fail Inspector i t,4 Date 4 'V--1-7---)-((' Review Step 2: Two-Party Review: YES NO NA 7] ❑ ❑ Water Well Report with adequate pump test on file?P l43'OP1I"?f 0l) II/Y/' ?f V.10 O7Mfar (O$VYI (600901) If NO, date of Capacity Test j/ 5,'79'Z ( Driller Oatq t�'('�r GPM Zd llo lil El Received Satisfactory Bacteriological Analysis? Date of test /77( D7(1 L) ?oGPI fw 6ator 2.400101 El El Received Signed, Notarized, and Recorded Notice? AFN Zu/Yt13/ K ❑ ❑ System appears adequate to serve 2 single-family residences based on information provided? Comments - 18 2g2!1 C.011,1,„v^ / KA2ovDied Reviewer i Date V/ 1�� Zy. t 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 10, 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 elm card tad._1_99903_9 Fie Original end RreaCopy Depernwerst at Ecology "'"'" WATER WELL REPORT ut..lE WELL LD.I AAG 300 Second Copy—Owner's Copy STATE OF WASHINGTON � No i Thad Copy—DAlltrrs Copy Right Permit (1) OWNER: tare David Mayer Adder 14701 SE 232nd St. , Kent, WA 98042-3812 (2) LOCATION OF WELL: count' Mason . SW 1,4 SE tK sae 35 T. 23N_R 3W w.A. (2k) STREET ADDRESS OF WELL(or mama am.aa) NE 2161 Tee Lake Rd., Tahuya. WA 98 588 (3) PROPOSED USE: RI Domestic industrial ❑ Municipal ❑ (10) WELL LOG or ABANDONMENT PROCEDURE DES-:RIPTION ❑ IrrigationTeat WeII D Other ❑ Formation:Describe by abler.character.titre of material and structure,and show thickness of aquifers ❑ Dews Qer and the kind and natchangere of the material in each stratum penetrated,with at Mast ono entry for each TYPE OF WORK: Owner's number of well change°t'"t0f"�1 0 — (ft more than one) manfulTOM ro Abandoned❑ New wtail ( i le7 od: Dug J Bored 0 -" -- Deepened C Gable 5 Driven❑ Reconditioned C Rotary❑ wed❑ Brown congloRwrate — 0 8 (5) DIMENSIONS: Diann ter of wea 6 aches. Drilled 51 feet. Deem of completed well 51 n. Gray hardpan 8 47 (6) CONSTRUCTION DETAILS: Sand & gravel with water 47 51 Casing Installed: 6 • oiam.from 0 ft.to 46 it. MEW �• Diann.from 11.to R r Threaded ' Diem.from ft.b ft. Portoretiorfe: Yes❑ No Tape of perforator wed SIZE of perforations in.by in. perforations from ft.to ft perforations from n.to ft. perforations from it to ft Sumac Yes IS No 0 msoufacu.ers Name Cook Type tainless wire wrap Model No. m.Die Skit sae 2 from 46 -ft.to 51 fL Diam. Stet sae from It to it T Gravel pseired Yoe s❑ No a Size of gavel nn++ [� ` . �' Gravel placed from ft to IL D r E U U y Surface seal: Yes ® No❑ To what depth? 18 2 DEG {} Maeda used in seal Retoni to )EG 0 1 1997 _ ^,'— Did any most contain unusable water? Yes❑ No a — — Type of water? Depth of strata �FRh141 ASSISTANCE CCNTFr = Method of selling strata oft - . (7) PUMP: Mvwtacs Tiers Name Goulds Tape: sub_ H.P. (8) WATER LEVELS: Land-le elevation Work Started 1.0/27/97 .19. Completed 11L4 97____ .19 above moan sea level t< stave level 10 n.below top en weu Date .--- WELL CONSTRUCTOR CERTIFICATION: Meow pressure D4.per*roars inch Date Arfesten water it controlled by _ I constructed and/or accept responsibility for construction of this wet, and its (Cap,valve.etc) compliance with all Washington well construction standar is.Matenals used and (9) WELL TESTS: Drawdown is amount water level is lowered below staoc fever the information reported above are true to my best krh wfettpe and belief. Was a pump test made? Yes❑ No E tf yes,by whom? NAME _ Davis Drilling Yield: gel./rnin.with II.ckawdown after --- hrs. (PERSC&.nNA BAComano r) fl,-vE uTITAI .. Address Belfair WA 98528 (Signed) l2te.B.IZ- timitae vo. 1992 Recovery data(time taken as zero when curia)turned off)(water level measured from well (WELL Cl) top to water brief) Time Wafer Level Time Water Level Time Water Level Contractor's e Regtstra�7p���h No. L.1\VISDI1100A Date Nov. ,is 97 (USE ADDITIONAL SHEETS IF NECESSARY) Date of test _ Bailer test 10 gal./min.with 10 It.drawdewn alter 1 hrs. — Ahtost gel.;min.with stem set at _ _ n.for—__ hrs. Ecology is an Equal Opportunity and Affirmative Actin.)e ?player.For spe- Artesia,Yaeu g.p.m. Date orReso urces Program at(206) Temperet•.xa of water Was a chemical analysis made? Yea❑ No W 407-6600.The TOO number is(206)407-6006. ECY050-t-20;9/d3;••f , eci 3iotif Mason Coui"s(y DMS 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 hr 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' 5 min 12.7' 10 min 12.2' 1hr 5.6' 26276 Twelve Trees Ln NW Ste.0 Poulsbo,WA 98370 (360)779-5141 Date Sample Collected Sw le -'QM* 125/ Zt)L y ccreCOed Ana, Day Yea 5 :v6 4 J�h Type of Water System(check only one box) ❑Group A ❑Group B g•other! .-• v}f� Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): IN System Name: / / 1 7 N.E (ee �y�e 2� Contact Person: �hi e lc py v. Day'hon ) �_OI.- tj.. 7 s- CeII Phone: Email: Eve.Phone: Send results 10:(Print full none,address and zip code a.m l e for copy of mutts) DO4;s Pr-rl1,. i. © DTh- :r 011111/11111.111111.1111111111111111 Sample collected by(name): 1<,/ t Speak location where sample collected: Special instructions or comments k, fr hid • 1.❑Routine Distribution Sample(MP) 2.❑ RipW*GonpU(1urr Chlorinated:Yes 0 No (from dlstrbuSon system mar unsat.routine) Chlorine Residual:Total Free Unsatisfactory routine lab number. 3.Ground Water Rule Source Sample — — ———— S I Unsatisfactory routine collect date: J Chlorinated:Yes No ❑Triggered(A/P) Chlorine Residual:Total______Free.__ j ❑Assessment(Ail') i 1 4.Surface or DWI Raw Source Water Sample(Enumeration) ❑ E.coli ❑Fecal Filtered Yes+�___ ' S 5.grSampe Coaected for Information Only: 0 Unsatisfactory T - C64Yoim present and 'Satisfactory 0 E.coi present ❑Ecolabsent e r i Bacterial Density Results:Total Coliform �mpn/100ml.E.co6 mpN100n FecalColiform cfu/100ml. HPC cfu/lmf. Replacement Sample Required: 0 TNTC 0 Sample too old ❑ Sample Volume 0 Damaged Container 0 Date/Time Race veil:_ Lab Reference Number Receipt Temp C': 2 '''''d Codej� ���(, (SIU9223gI/or-couNTrsMs2z2D ()a In: Date Out: TMr�nrrr.d n.wgWwwv 3 �I)U 3�Z-r�zy. 1Mn1i.0l...dA^Iur.pyipvd.gaoei Ns of woir ituretatad ache foi Malin wx.pee..rosy M bordrImola.y rt 3QG77/4fe1 w DOH Lab-Sample s d"I°""'"D°'°"°'� I O�O• C fy.enW reels prybthe lams h.Ydw Ile O0felo 2 I �: [___ eMw W M lwc.by.flit rose Owe lntbe nendosed ensO in kb,o4 oe W corm water*venial by Spears loeoal res 1)011 Fme g31.31 t(.4,1n Ce/17) 2209431 Mason County WA 04108/2024 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 (3 COPY II 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 I 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 V2 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. 5. 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. 5. 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, 1 have hereunto set her hands and seal the day and year first above written. avid W.l er,Trustee oft 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 0 day of } 24, NOTARY PUB IC in and for the Stale of ! Washington,residing at etAkuv` (04,Ar My commission expires al S t1 102t'0 ROBERT W JOHNSON Notary Public State of Washington License Number 56821 My Commission Expires May 31, 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): (') David W Mayer 1.2) 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 f (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 the 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) ik,(,1> /1,1. ,((C ,P>` , (2) /.(4t0 %f 2209431 Page 7 of 8 04/08/2024 11:47:06 AM Mason County, WA State of _ ) ss County of ,n ) I, /i/7ra L`.'/[,�j47h , Notary Public in and for the S -to of Washington, hereby certify that on thi/ ,_,../,-)--/ of aetinh , 20 -2 , personally appeared before me, a s7J / a tee'-- , to me known to be the individual(s)described in and""w��h��o executed the within instrument and acknowledged to me that he/she/they signed/,tllm ro Tr.,c, rc4r .4✓a,7e >iy <-3)/6413 document as a free and voluntary act and deed, for the uses and purposes therein mentioned. Given under my hand and official seal thi �da of ij ,200, (Seal or Stamp) (Signature) Notary Public /..,rtGa /i(-11 )0`j ii State of Washington LINDA LANE MURPHY (Print riame) LICENSE#23007227 MY COMMISSION EXPIRES FEBRUARY 17,2027 Title Residing at dea.-&-e___) My appointment expires - nau-, r /(X a 2209431 Page 8 of 8 04/08/2024 11:47:06 AM Mason County, WA Mason County WA GIS Web Map 3233 550 00.D47 2141 NE TEE LAKE RD 323355000046 ---- rr- � \323352222222 . \--- _ - r y- t 2151 NE TEE LAKE RD323355000045 ` ® J` I "'f rr~ L 0 '\ o = 323355000044 2161 NE TEE LAKE RD (' howler \ ,o _� 1 _� y 323355000043 ' , 2171 NE T©E LAKE RD J'��_-— +�n l� + d�p•.� �'�C Ir� 2181 NE TEE LAKE RD 323355000042 2191 NE TEE LAKE RD o 323355000041 323355000040 3/26/2024, 10:14:02 AM 1:765 0 0.01 0.01 0.02 mi L County Boundary I .. ' ' ,1 + ', ' . l , l 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, IGN,Kadaster NL.Ordnance Survey, Esti Tax Parcels (Zoom in to 1:30,000) Japan.METI.Eso 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 httpsNwww.masoncountywa.gov/disclaimer.php Aseessuom -dook 1St- LaiK.12, 5th & Birch Thurston-Mason Health District CouNrto.House Annex Shelton, Washington DIVISION OF SANITATION Olympia, Washington Phone: 426-4407 14tplicaljoos his awany&hi yos ,d4s„ Phone: 352-41351 (Submit in Quadruplicate) DO NOT WRITE IN HEAVY OUTLINED SECTIONS j?c Owner 1,-..6e -I- , A2),,LIPhone W 2 -- >, ev ss e- i / 7 Mailing Address iiiveity .5e--- -21/Ze State Builder /3c--'47"-a-i' 113'-'1 A 6'r el-- Address fi •"--./-7.1"-.7,-)-. Sewage Contractor Address 7-e. e Legal Description .Z__ c-i-- -21 53 Parcel No. Field Book No. Directions to Property _3 . 40,40--iikr<, AA"kY'' cit-c-t--ss-c y , 1.---4,,_ ,...,,,-4.....r...,ti Intended uses of Buildings e...c"..- .A Public Sewer Wa or 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 setbavks 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. Pe , ,, irtr• c a ei,..0 4AeSt.ne'), / 2 V F7-c•-it fr 5 "-- 4E-K IS74-klar .Pre ley 11 APPLICANT'S SIGNATURE 6-27-1:1:e-2-1"— ;,.../1-aci-t,.....-- .--- DATE 4 -- 2--e" .9" Site inspection,fee $5.00 Receipt No. ••-(42 / 1 By Approved 4-4.-41 Not Approved By - 4111r7Lre291/44, SAW ' .t • DA1E SANITARIAN — r - ----•` 110.4111111' AION•MMINNIB