HomeMy WebLinkAboutWAT2024-00143 - WAT Application - 2/21/2024 WAT
MASON COUNTY
COMMUNITY DEVELOPMENT
wrmnnsslsunce unm,sWlelru.wnM�
415 N 6"Street, Bldg 8, Sharron WA 98584,
Shelton:(380)427-9670 ext 400 4 Bellarr(360)275-4467 ext 400 6 Elma: (360)482-5269 ext 400
FAX(3ri0)427-7787
Application for Determination of Water Adequacy
Instrrlcdon ,
1. Complete Part 1. No determination can be made until Part 1 is fully completed.
2. Complete only the portion of Part 2 applying to the type of water connection utilized.
I3. Submit wnipieted appliwtiuu,with any required utiauhmenis fur review.
4. An approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name.on.Applicant: Debra Triplett Date: 02/21/2024
Mailing Address: 13330 Lester RD NW, SilverdallimPhone: 360-710-4488
Parcel Number: 123065.50-01002
Type of Water System Reason for Application � /I
ElPublic/Community Water System (2 or more 0 Building permit-bleUO2-�^ W,3'Y 1
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
)BKH579 Viturtace water ❑ Other(explain)
Other(explain)
❑ Replacement or Remodel(please indicate name
Ifyou have more than one residence connected of water system below if applicable-no
to this well, check the PubliUCommunity Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
.Pubft Water System
Name of Water System: -T—rin 0 111aj
Water Facility Inventory(WFI) Number nonid
(write"none°for two-party)
❑ I am the manager of this water system.The water system has been approved for e:k services.
There are presently 0 connectiem(s)in use.This will be the Icrmnection.
❑ I am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system(.e.: recreational in full lines),Please indicate on the...lowing line the..^.a--
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 regulation.
(�, G...� 02/21/2024
Signature of Water System Manager- ..`-•-�. Date
Thlsform may be scanned and available for public view at www.co.mason.wa.us.
/1EB Fama\Dnn ,w"te Rli�.Ir1 MlN
Individual Water Well
El Water well report(attached to application). Depth 477 ft.
El Well capacity Test(attached to application) 15 gpm gpd.
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 located by the applicant or if the water well report does not have a capacity test,
a well capacity test,which provides stabilization of draw-down and recovery data, must be performed
by a licensed contractor.
El Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htto://gis.co.mason.wa.us/i)lanning 1401 t 322=
Water use or limitation recorded................................... N/AM Yes '-��`/
Well Drilled ............................................................... Date 04/21/2018
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
G 1 have reason to believe that 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
Relationship to Applicant
Part 3: Mason County Community Services Evaluation (staff use only)
Satisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the future,or guarantee compliance with all applicable WDOE water resource regulations.
Recommended approve!Indicates requirements of Sanitary Code,Title 6,Chapter 5 66.040-Detertninafion of
Adequacy for Building permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
u unsatisfactory Determination:
Applicentswater supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
gReviewer's Signatures:
Environ. Health: Date
CSD Director: Date 2.f2
RECEIVED
WATER WELL REPORT CURREtdI
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Return To 2210000e M ASON CO WA
0I3312 112S0 RMc raa s904 so P396i z, 8 P NOTCE
Debra LTriplett TRPLET 962 13330 Lester RD NW
Silverdale WA 98383
Grantor(s): (1) Debra L. Triplett
Grentee(s): (1) PUBLIC
Legal Description (1) PANTHER LAKE TRACTS BLK: A TR 2 S 45/134
(Abbreviated Form:i.e. lot, block,plat orsection, township,range)
Assessor's Tax Parcel: (1) 12306-50-01002
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA (WRIA)
I (We),the undersigned grantor(s), hereby place this notice on record that the described real
estate situated in Mason County, State of Washington is subject to water use restrictions
and conditions set by Washington State Senate Bill 6091 and Mason County Code 6.68.
These restrictions and conditions are based on location of property and/or Water Resource
Inventory Area or WRIA.
WRIA: 16
Maximum Annual Average Gallons Per Day: 960 gallons
Dated on this ��a day of _, 20�.
Signature of Gra`n�jtor(s)T:
(1)p zn OL ! ��2.Q . (2)
State of Washington )
County of Mason )
Page 1 of 2
I,the undersigned, a Notary Public in ano for the above named County and State, do hereby
certify,that on this ZZ_day f APrI I , 20L ,
bfa Q I Gpltl� El'nawh 4ffL_personally appeared before me,who is known to be
signer of the above instrument, and acknowledged that he(she) (they) signed it.
GIVEN under my hand and official seal the day and year last ab�itten.
c
,a•,1.COTT''�., Notary Public in and for the State off Washington,
vk e�� F2�� residingat I7J "P lOuorY
p 9 y
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Ding o
My commission expires:
N1PUBL1G•o Z.
O:
C
•.,�OF WAgN
Page 2 of 2
2209999 MASON CO WA
04/23/2024 12 50 PM RGREE
TRIPLETT p191 92 R00 Fee $30'1 50 Paaer 5
Return To ����������������������������������
Debra L Triplett
13330 Lester RD NW
Silverdale WA 98383
And
Degarimore Revocable Trust
John O &Dorothy/John O Degarimore Trse
861 NE Mt Myster LP
Poulsbo WA 98370
WELL/WATER/POWER USERS AGREEMENT
TRIPLETT/DEGARIMORE WATER SYSTEM
PARCEL IPS 12306-SO-01002 and 12306-50-01003
Of Mason County,State of Washington
OWNERSHIP OF THE WELL AND WATERWORKS
It is agreed by the parties that each of said parties shall be and is hereby granted an undivided
one-half Interest in and use of the well and water system to be constructed on PARCEL$rS
12306-50-01002 and 12306-50-01003 Panther Lake Tracts BILK:A TR 2 &A TR 3 Of Mason
County,State of Washington. Each party shall be entitled to receive a supply of water for one
residential dwelling and shall be furnished with a reasonable supply of potable and healthful
water for domestic purposes.
The system is to be constructed to serve properties located at Panther Lake Tracts BLK:A TR 2,
Parcel Number 12306-50-01002, and Panther Lake Tract ELK:A TR 3, Parcel Number 12306-50-
01003, Mason County,State of Washington.
COST OF MAINTENANCE OF 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. The expense of water quality
sampling as required by the State of Washington and Mason County shall be shared equally by
both parties. The parties shall establish and maintain a reserve account at a mutually agreed
upon banking institution. Each party shall be entitled to receive an annual statement from the
said banking institution regarding the status of the reserve account. The monetary funds in the
reserve account shall be utilized for the sole purpose of submitting water samples for quality
analysis and maintaining, repairing,or replacing the well and common waterworks equipment
or appurtenance thereto.
EASEMENT OF WELL SITE AND PUMPHOUSE
There shall bean easement for the purpose of maintaining or repairing the well and
appurtenances thereto,within 10 feet of the wellsite in any direction. Said easement shall
allow the installation of well house, power, pumps,water storage reservoirs, pressure tanks,
and anything necessary to the operation of the water system.
WATER LINE EASEMENT
An easement for the use and purpose of conveying water from the well to PARCEL fl'S 12306-
50-01002 and 12306-50-01003 Of Mason County, State of Washington is granted. Said
easement shall be five(five)feet in width and shall extend on, over, across and underneath
property line of Panther Lake Tracts BLK:A TR 2 &A TR 3 of Mason County,State of Washington
from designated well site. No permanent type of building shall be constructed upon the water
line easement except as needed for the operation of the well and water system.
POWER LINE EASEMENT
An easement for the use and purpose of conveying power from the Mason County PUD 3
installed Power Pole and Transformer located on Bear Creek Dewatto Road, Belfair Washington
98528 to each Parcel and the joint well system, Parcel q 12306-50-01002 and 12306-50-01003,
Mason County,State of Washington is granted. Said easement shall be 10 (ten)feet in width
and shall extend on,over, across and underneath property line between Parcel#'s 12306.50-
01002 and 12306-50-01003 Panther Lake Tracts BLK:A TR 2&A TR 3 of Mason County,State of
Washington from designated power source. No permanent type of building shall be
constructed upon the power easement except as needed for the operation of the well and
water system.
MAINTENANCE AND REPAIR OF PIPELINES
All pipelines in the water system shall be maintained so that there will be no leakage or
seepage,or other defects which may cause contamination of water,or Injury, or damage to
persons or property. The cost of repairing or maintaining common distribution pipelines shall
be born equally by both parties. Each party in this agreement shall be responsible for the
maintenance,repair and replacement of pipe supply water from the common water
distribution piping to their own particular dwellings and property. Water pipelines shall not be
Installed within 10 feet of a septic tank or within 10 feet of sewage disposal drain field lines.
PROHIBITED PRACTICES
The parties herein,their heirs, successors and/or assigns,will not construct, maintain or suffer
to be constructed or maintained upon the said land and within 100 feet of the well herein
described,so long as the same is operated to furnish water for public consumption, any of the
following: septic tanks and drain fields, sewer lines, underground storage tanks,county or state
roads railroad tracks,vehicles,structures,barns,feeding stations,grazing animals,enclosures
for maintaining fowl or animal manure, liquid or dry chemical storage, herbicides,insecticides,
hazardous waste,or garbage of any kind. The parties will not cross connect any portion or
segment of the water system with any other water source without prior written approval of the
Mason County Department of Public Health and/or other appropriate governmental agency.
WATER SYSTEM MANAGER
The owner of Panther Lake Tracts BLK:A TR 2 is designated "Manager of the water system. The
manager shall be responsible for arranging submission of all necessary water samples as
required in the Washington Administrative Code and Mason County Rules and Regulations and
handling emergencies such as system shut down and repair. The manager shall provide his/her
name, address, and telephone number to the Mason County Department of Health Officer and
serve as the contact person to the Health Officer. The Manager shall organize and maintain the
water system records and notify the Health Officer and parties,service connections and lots
that are Included in this agreement of the water quality tests that are required by WAC 246-291
and Mason County Rules and Regulations. Water System records shall be available for review
and Inspection by all parties In this agreement and the Health Officer.
PROVISIONS FOR CONTINUATION OF WATER SERVICE
The parties agree to maintain a continuous flow of water from the well and water system,
herein described in accordance with public water supply requirements of the State of
Washinton and Mason County. In the event that the quality or quantity of water from the well
become unsatisfactory as determined by the Health Officer,the parties shall develop a new
source of water. Prior to development of or connection to a new source of water,the parties
shall obtain written approval from the Health Officer. Each undivided interest and/or party shall
share equally in the cost of developing the new source of water and install the necessary
equipment associated with the new source of water.
RESTRICTION ON FURNISHING WATER TO ADDITIONAL PARTIES
It is further agreed by the parties hereto that they shall not furnish water from the well and
water system herein above described to any other persons,properties or dwelling with prior
consent of both properties and written approval from Mason County Department of Public
Health. Additional connections will require upgrades of the system to full Group B requirements
unless total connections exceed nine services, which will require upgrading to Group A
Standards.
HEIRS, SUCCESSORS AND ASSIGNS
These covenants and agreements shall run with the land and shall be binding on all parties
having or acquiring any right,title or interest in this land described here In or any part hereof,
and it shall pass to and be for the benefit of each owner thereof.
ENFORCEMENT OF AGREEMENT ON NON-CONFORMING PARTIES AND PROPERTIES
The parties herein agree to establish the right to make reasonable regulations for the operation
of the system,such as the termination of service if bills are not paid within forty-five days of the
due date,additional charges for disconnection, reconnection,etc. Parties not conforming with
the provision of the agreement shall be subject to interest charges of 18% per annum together
with all connection fees.
Datedonthis as dayof�20
Signature of Grantor(s)::
(1)
(2)
State of Washingto )
County of Mason )
I,the undersigned, a Notary Public in and forthe above named County and State, do hereby
certify that on this2Z dayofAPfil . 202L4 ,
L�P.hfa pleWA Eliaab&0YI&4Ae personally appeared before me,who is known to be
signer of the above instrument, nd acknowledged that he (she)(they)signed it.
GIVEN under my hand and official seal the day and year last above written.
.q�
ANY COTT t NONo a�n and forthe State of Washington,
�.'fi�5'E'� �utxiq Q residing at KJ-oa P (,oJ --h
3 :?NOTARY t E My commission expires: 0��25�2G
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