HomeMy WebLinkAboutExempt - WAT Application - 1/31/2024 I / , ,I
WAT ,SL'-s "- eaci'a
415 N.6t"Street
MASON COUNTY Shelton.WA 98584
1 .4 COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
Belfair:360-275-4467.Ext.400
^z Molding.Planning Environmental Health.Community Health Nina:360-482-5269,Ext.400
Application for Determination of Water Adequacy
Instructions
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.
3. Submit completed application, with any required attachments for review.
4. An approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Dustin Theoharis Date: 1/31/2024
Mailing Address: 2073 East Scorpio Place Phone: 253-335-1283
Parcel Number: 322205003050
Type of Water System Reason for Application
)4(
Public/Community Water System (2 or more fed Building permit E12Y2Oa-4-0OP28
connections) ❑ Division of land:
Z1 Individual water source (one connection). #of Parcels? SPL
Q7 Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
0 Replacement or Remodel (please indicate name
If you have more than one residence connected of water system below if applicable— no
to this well, check the Public/Community Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System:
Water Facility Inventory (WFI) Number: 4
(write"none" for two-party)
❑ I am the manager of this water system. The water system has been approved for services. There
are presently connection(s) in use. This will be the connection.
0 I am the manager of this system. This connection will be to upgrade or change the use of an existing
connection on this system (i.e.: recreational to full time). Please indicate on the following line the nature 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.
Print Name of Water System Manager Phone
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Fonns\Drinkine Water Revised 4/27/2021
Individual Water Well
❑ Water well report (attached to application). Depth ft.
❑ Well capacity Test (attached to application) 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.
1 Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planninq 14_ 15_16_22_
Water use or limitation recorded N/A Yes
Well Drilled Date
Individual Spring/Surface Water
❑ WDOE permit (attach to application)
❑ Method of disinfection
❑ I 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 approval indicates requirements of Sanitary Code, Title 6. Chapter 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
4:;:4/-
Reviewer's Signatures:
Environ. Health: refl t
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
_ Thurston County Environmental Health
412 Lilly Rd NE
Olympia, WA 98506
360-867-2631
'THURSTON COUNTY
® t
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
i I i Di 0 Collected
���'y///1t��//�l �)
Monti Day Year P0.� S
Type of Water System(check only one box) ❑ Private Household
❑Group A ❑Group B IQOther' Gl
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
ID#
System Name:
Contact Person: N-e1 d ; A t It.cy5
Day Phone:(3( ) 3 ).z ;;i� Cell Phone:(
E-mail: j'1 ,l Iepr-kd w jve.Phone:(
Send results to:(Print full name,address and zip code or email address)
SAMPLE INFORMATION
Sample collected by(name): J�. ,� i L\ ` 1/ _ c
t�l 1 , [•E h
Specific location or address where sample collected: I Special instructions or comments:
I 113 I Nc Nora: Shute
-re% Lki A
Type of Sample(must check only one box of#1 through#4 listed below)
1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes No ❑Distribution System
Chlorine Residual:Total Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total Free
❑E.coli—GWR(A/P)
❑Fecal—Surface.GWI.spnngs(numeration) Unsatisfactory routine lab number.
Filtered:Yes No
❑Assessment Monitoring(AIP) Unsatisfactory routine collect date:
['Other•
S
4.0 Sample Collected for Information Only
Investigative_ Construction/Repairs \< Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and $Satisfactory
❑E.coli present ❑E.coli absent No Coliform detected
Replacement Sample Required:
❑Sample too old(>30 hours) El TNTC ❑
Bacterial Density Results:Total Coliform 1100ml. E.coli /100m1.
Fecal Coliform /100m1 Enterococci /100 ml.
Method CodeXSM 9223E [ISM 9222D IT* Z1
❑SM 9215B ❑Enterolert0 41'C.3
1 Date and Time Analyzed: 21 2 Z4 Date Reported:2124 L 1
Sample Number(DOH number plus.ve digits) Lab Use Only:
0 8 0 1 '' 3 e,
fXYI Gnaw/114.110 AA,,C1 1 • 1
l
'Davie Pwnpo, Inc.
340 WC Dada`Farm td
'delfair,'Wa 98528
(360)801-6107
Project 17131 NE North Shore Rd.
Capacity Test TAG: N/A
Date 8/9/2024
Pump % hp
Well Depth unknown
Static Water Level 10'-6' fluctuating
Draw Down Recovery
Time Water Level GPM 0 32.3
0 min 7' 0 1 min 28.9
5 min 32.3' 13 2 25.8
10 min 32.1' 5 3 23
15 min 32.4' 5 4 20.6
30 min 32' 5 5 18.4
1 hr 33.2' 5 10 12'
2 hr 32.1' 5 20 7.5
3 hr 32.4' 5 30 7.6
4 hr 32.1' 5 40
5 hr 33.3' 5 45
6 32.4' 5
Capacity Notes: well subject to tidal fluctuation
2214702 MASON CO WA
08/19/224 CIPM
:AVIS PUMPS :NC65200664LRec Fee $306 50 Payes 4
ill!IIIIiIliIll!Illlfll1IIIIII!1''IIIIIIfIIIIII11!IIIIlls4N!
Return To:
Davis Pumps Inc.
340 NE Davis Farm Rd A.
Belfair, Wa 98528
((----;
Declaration of Wad reement
Theohar-` Wa ystem
Pri 2 P
ABBREVIATED LEGAL DESCRIPTjorIS ANDJ'ARCEL_N_UM@ERS OF TRACTS BEING SERVED;
The well and water system being situated on� j f
Parcel#32220-50-0350 __Legal Description: ,
GREAT BEND WATEH O BRACTS BLK:3 TR 38&T.L.SLY OF RD
Range:3W,Townsbip:,222N`'Sec '\:29
SE'/,of the NW f": `u
17131 NE NORTHrrSHOR D.TABU YA 98588
Grantor(s):Dustin i��
Own
Parcel#. ?20-50-03.50
■!Description:
AT BEND WATERFRONT TRACTS BLK:3 TR 38 &T.L.SLY OF RD
e;3W,Township:22!S,Section
:20
C/.`ot the NW `/.
NE NORTH SHORE RD,TAHUYA 98588
1 rantce(s): Rachel Perkins
1
Owner of
Parcel#32220-50-0349
Legal Description:
•
GREAT BEND WATERFRONT TRACTS BLK:3 TR 38 N OF RD
Range:3W,Township:22N,Section:29
NW V.of the NW `/A
17122 NE NORTH SHORE RD,TAHUYA 98588
1
•
\\
Has been designated to serve a source of water to the following parcels si Mason County,State of
Washington;herein described: OParcel
N.;>
�220-50-0350#3_ _
Legal Description:
GREAT BEND WATERFRONT TRACTS B1.K:3 TR,38li F RD
Range:3W,Township:22N,Section: 20 i
NW '/.of the NW '/.
17131 NE NORTH SHORE RD,TAIICYA 98 --2
& `
Parcel#32220-50-0349 C'..
Legal Description:
GREAT BEND WATER FRONT„TR/LK:3 TR 38 N OF RD
Range:3W,Township:22N; t
NW V.of the NW ''h
17122 NE NORTH SH D,;A MSS
88
v1 C______))
OWN ERSHIP4 WEZ21,;vlpID WATERWORKS
It is agreed by tie parties that each of said parties shall be and is hereby granted an undivided one-half interest in
and to the use ofthe±:well and water system. Each Party shall be entitled to receive a supply of water for one
residentikl dwOing'and shall furnish a reasonable supply of potable and healthful water for domestic purposes.
C M4 4TENANCE OF WATER SYSTEM
h hereto covenants and agrees that they shall equally share the maintenance and operational costs of the
l and wr system.
_ •f ETO FUTURE PROPERTY OWNERS
�--`fht�vater system is to two services. design be
\obtained from the focal healthdesigned jurisdicprovidetionfor prior to expandingAdditional beyond this number
planningand of services.approval Designmust flow
Standards account for domestic use and watering of a typical lawn andior garden space only. The design assumes
that all residences will be equipped with ultra low flow plumbing fixtures and that all users will keep conservation in
mind whenever the system is used. Additionally,a water right,obtained from the Department of Ecology, is
required if the water system exceeds exemption standards. This system has not applied for or been granted any
waivers from specific provisions of the regulations.
EASEMENT OF Val.I,$ITE AND PLMPHOIISF
There shall be an easement for the purpose of maintaining and repairing the well and components to complete and
maintain a properly functioning water system and appurtenance thereto,within 100 feet of the well site in any
direction of both properties listed. Said easement shall allow the installation,maintenance or repair of the well,
2214702 Page 2 of 4 08/19/2024 01:56:08 PM Mason County, WA
irommissimmommar
water system,pump house,pumps,water storage reservoirs,pressure tanks,waterline, utility lines and/or anything
necessary to the operation of the water system.
MAINTENANCE AND REPAIR OF DISTRIBUTION LINES
All pipelines in the water system shall be maintained so that there will • • leakag .t'lf seepage,or other defects
which may cause contamination of the water, or injury,or damage t. . rsos)or property. Cost of repairing or
maintaining common distribution pipelines shall be borne equally bi• ii, brties. Each party in this agreement
shall be responsible for the installation,maintenance,repair,and ropl\acets*et of pipe supplying water from the
common water distribution piping to their own particular dwalng and pefty. Easement shall be granted on both
lots to repair,replace or maintain the waterline as needed for`dIstributiourposes. Water pipelines shall not be
installed within 10 feet of a septic tank or within 10 fee; fsevwaggN disj'sal drainfield lines.
UPROHLBITED 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 drainfields,sewer lines,underground
storage tanks,county or state roads,railro8d:tracksyv. hicles,structures,barns, feeding stations, grazing animals,
enclosures for maintaining fowl or atii maittt�e ifiquid or dry chemical storage,herbicides, insecticides,
hazardous waste or garbage of any 12it
The parties herein,their heirs,Suess and/or assigns are required to keep the water supplied from said well free
from impurities which might_beinjjlriou the public health. It is the purpose of these grants and covenants to
prevent certain practices liefeiriafterftd?'nerated in the use of said grantor(s)land which might contaminate said
water supply. l.`
Exhibit A NOW,THEREFOREAlip'grantor(s)agree(s)and covenant(s)that said grantor(s),his(her)(their)heirs,
successors and astigns'v� not construct,maintain, or suffer to be constructed or maintained upon the said land of
the grantor(s);arid within tifty(50)feet of the well herein described,so long as the same is operated to furnish water
for public coriStttpt.iSn,ANY POTENTIAL SOURCE OF CONTAMINATION INCLUDING BUT NOT LIMITED
TO:cess,p(j 1s,seiPeis,,privies,septic tanks,drainfields,manure piles, fenced pasture,garbage of any kind or
description,nriy"encloslire or structures for the keeping or storage of non biodegradable fertilizers, liquid or dry
chen isytis; iiibicides or insecticides as well as any enclosures or structures for the keeping or maintenance of fowl
of trials such.;3ts barns, chicken houses,rabbit hutches,pigpens,livestock sheds, and further agree(s)not to use,
ly,disp,),$)e or suffer to be used,applied or disposed,non biodegradable fertilizers,any liquid or dry chemicals,
hcidegt insecticides within the above described protective radius.These covenants shall run with the land and
0 be-binding on all parties having or acquiring any right,title,or interest in the land described herein or any part
'bf,7and shall insure to the benefit of each owner thereof.
WATER SYSTEM MANAGER
'N.` l The owner of Parcel#32220-50-0350 Legal Description: GREAT REND WATERFRONT TRACTS RI.K:3 TR 38&
`� T.L.SLY OF RD Range:3W,Township: 22N,Section:29 NW V.of the NW V. 17131 NE NORTH SHORE RD,TAHUVA
98588 is the designated"Manager"of the 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 shutdown and repair. The Manager shall provide his/her
name,address and telephone number to the Health Officer and shall serve as a contact person to the Health Officer.
The manager shall organize and maintain the water system records and notify the Health Officer and all 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 Regulation. Water system records shall be available for review and inspection
by all parties in this agreement and the Health Officer.
ii 2214702 Page 3 of 4 08/19/2024 01:56:08 PM Mason County, WA
HEIRS.SUCCESSORS AND ASSIGNS (1
These covenants and agreements shall run with the land and shall be binding on '\I parties having or acquiring any
right,title,or interest in this land described herein or any part hereof,and ' ' s to and be for the benefit of
each owner thereof. //� —~� '
1
ENFORCEMENT OF AGREEMENT ON NON-CONFORMINOAMES AND PROPERTIES
The parties hereto agree to establish the right to make reasont �regulationsifor the operation of the system,such as
termination of services if bills are not paid within 45 days of( • due date,additional charges for disconnection,
reconnection,etc. Parties not conforming with the prov,isioi s\o(Zhis agreement shall be subject to interest charges
of 18%per annum together with all collection fees. i'i&----- 7'-----------------
g-i fiao,a_y*
Theoharis Water System Owner / Date
I
D
i y.tl ., JEsus saw 1
' ,,^► Notiry Publk•Af!TWA '
•-�J1 Marxopa County
4c, ---„N...„, ILdcommissla+/6na677State of �d PI,A , t My Comm .Ex tres Oct 23,2026
County,W >f0t,C.—es?ck
I,the undtt�`signed,a Notary Public in and for the named above County and State, do hereby certify that
otrjhis<1 .'day of 4w?ns4 , 2024, personally appeared before me 'Segos /,,e
(me kriovr to be the individual described on and who executed the within instrument, and acknowledge
.• he(stfe (they)signed and sealed the same as free and voluntary act and deed, for the users and
herein mentioned.
VFsN under my hand and official seal the day and year last above written.
-3 le °-7- -eldo C
N Notary Public in and for the State of 9( Core�. _ . __
residing at 2/75 E OCOT(h O 120 5/1 d
My commission expires: (0 .1 S- 20Z G
2214702 Page 4 of 4 08/19/2024 01:56:08 PM Mason County, WA
. Mason County WA GIS Web Map
Tate NORTH SHOREIRD
17120 NE'NORTH SHORE'RD
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8/14/2024, 10:23:56 AM 1:383
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• Site Address (Zoom in to 1:3,000)
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