HomeMy WebLinkAboutWEL2025-00026 - WEL Application, Design, Letter - 9/8/2025 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
J L SHELTON:360-427-9670,EXT 400
BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT400
FAX:360-427-7787
09/08/2025
NUTTER LARRY DENNIS
80 WEST SALMONBERRY DR
ELMA, WA 98541
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2025-00026
80 W Salmonberry Dr
619023200030
The 2-party water system, Nutter-Pierce Water System (619023200030/619023200020), 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: z.
V I 1 1 . 202 J'J5/
' ; COMMUNITY SERVICES Amount Received:EnvironmentalReceived B.
\\ f C` `�•v Building.Planning,Environmental Health,Community Health NeO
415 N.6t°Street,(Bldg 8)—Shelton,WA 98584 WE L 2 02.5- (5b0Be
Shelton: 360-427-9670 x400 Belfair.360-275-4467 x400 Elm:360-482-5269 x400
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT \ � /4 e PHONE s ?0 Z S�i 2_
MAILING
ADDRESS-STREET,CI)t"Y,STt17E,
PO \AI es-r SAUni1n ELRay 1) r• 'ELLmA VV,4 q 5"/
SITE ADDRESS-STREET,
CITY,STATE,ZIP
{ q6 J
PRIMARY PARCEL NUMBER(W'I•II SrI �-S(+L 1 Cn i DP, t ✓ r• Lm 4 Y Y i //
615(}Z.,3(W)003 4
SECONDARY PARCEL NUBER(SAME AS PRIMARY 1F LOCATED ON SAME PAR EL)
WATER SOURCE SOURCE TYPE PARCEL I LOT STUE(ink 1 sere) PARCEL 2 LOT SITE(mla I acre)
New NSxisting iYWell Spring 1 .c ,-j ■�� 11;1
PROPOSED WATER SYSTEM NAME(REQUIRED). !� C V
Eg
Nu ,r - i e r Le w trCER., EM L _
PROJECT DESCRIPTION(e.g.,detached ADU,new dngie-family residence,e:iftieg eoenatloe,eta) APR 1 7 2025
tJ ea) S i‘n l.e -ccornAr f fSi rte n ce
DIRECTIONS TO SITE/CONDmONS/GATE CODE/KEY LOCATION/ETC. By
fQUn(\ w ItSI# Ht4TCJE12y 'PO&p .3.4 k1 toss WESQ 5At-molt) SUP-9
Pro 'Fro peir+1 6 J T+E R 1a,tt-T
Site Plan: (may also be attached)
(property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,water lines,property easements,etc.)
(0.7 M APR 1 7 2025 M
IJ
� 0 BY:
Required Submittals Checklist: (additional information located on the first page of this packet)
a Satisfactory bacteriological test from within the last year
7We1l report with well tag number,well tag secured to well casing,and capacity test showing 800 gal per day
CI-Notice to Future Property Owners of Private Two-Party Water System recorded with Mason County Auditor's Office
Septic Records(additional locating requirements may apply if there is a lack of septic records on file)
This form may be scanned and made available for public viewing on the Mason County website. Revised:01//2025
Page 1 of 2
Staff Use Only ----------------------
Review Step 1: Well Site Inspectionf y,. �+'' p /,����
YES NO NA Sef1rC Sporf 141/ Yf�4 SC)`c4'' t kvec,
❑ ❑ Evidence of existing sources of contamination within a 100-foot radius of the water source?(drainfields,
tanks,buildings;indicate distance on plot plan)
❑ fp, ❑ Are there roads within a 100-foot radius of the water source?
Is the road Private,County,or State?(circle one) Distance to the road(s)
�, ❑ ❑ Does the ground slope away from the water source site?
l
❑ ❑ Satisfactory well cap?
❑ ❑ Well cap screened and vented? L I
❑ The well casing extends above level ground/concrete slab?(circle one)
❑ ❑ g Evidence of a surface seal? Lat: CR, I S$ Co 7'
❑ ❑ Adequate surface seal? Lon: (73 - WO Lit Co S
❑ ❑ �] Variance necessary for well site approval? Tag: 4zv T Q
Comments: ( ( k-a ( �}e e
` '' 7.n43 et Y` Ge_
y/Sf ZUZ5' Se* imilStiott la le/ Mooed to 5of f !from ill SwGuns 003)
1
(A '4 ` S-�%F...yass ❑ Fail Inspector ( Date
Review Step 2: Two-Party Review:
YES NO NA
VI ❑ iM Water well report(well log)with a concurrent capacity test?
❑ ❑ Nonconcurrent/separate capacity test?
Capacity test information:Date 1(I l IP bZ l Driller 044/4 J arr`` •
GPM 1 (t 7 Duration(minutes) I?o Total Gal Z 5 Y
ti ❑ ❑ Satisfactory bacteriological analysis? Date of test ?(1&(`Ot t(
cia ❑ ❑ Signed,notarized,and recorded notice to future property owners?AFN T Z(51 I
X ❑ ❑ The system appears adequate to serve two connections based on the information provided?
f
Comments:
q<zt(ZotS : 640501C00117 Open/1/Othi�l, 1C4 01(�►tt lof Sit Z 1
r 9/g(zo?....7-
Findings Approved ❑ Denied Reviewer Date 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
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 191h, 2018 per ESSB 6091.
w
Revised:02/04/2025
This form may be scanned and made available for public viewing on the Mason County website.
Page 2 of 2
Davie Pampa, Inc.
340 we Davta`Farm lid
Belfair,`Wa 98528
(360)801-6107
Project 80 W Salmonberry Dr,
Elma, WA 98541
Capacity Test TAG:NA
Date 07/12/2024
Pump 1 hp
Well Depth unknown
Static Water Level 49.5'
Draw Down Recovery
Time Water Level GPM 0 52.4
0 min 49.5' 1 min 49.6'
5 min 52.4' 21.5 2 49.5'
10 min 52.4' 21.5 3 49.5'
15 min 52.4' 21.5 4 49.5'
30 min 52.4' 21.5 5 49.5'
1 hr 52.4' 21.5 10 49.5'
2 hr 52.4' 21.5 20
3 hr 30
4 hr 40
45
Capacity Notes:
26276 Twelve fAA
'Frees Ln NW II
Ste.0 (i SPECTRA Laboratories - Kitsap
Poulsbo,WA ,.,where experience'naivete
98370
(360)779-5141 COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
Collectedct
LA
month r wear t :+aY ��►+ l" GISOVI
Type of Water System(deck only one box)
❑Group A ❑Group B Other
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name: $D W 5 4 1►'`n o n b-c-rYtJ�
Contact Person: d
Day Phone: Cell Phone:
Email: Eve.Phone:
Send results to:(Print full rune,address and rip code or wail above for Nactronic copy of mutts)
SAMPLE INFORMATION
Sample collected by(name): Let,
Specific location where sample collected: Special instructions or comments:
f11 if\ c v \*--
Type of Sample(check only one box)
1.❑Routine Distribution Sample(AIP) 2.❑Repeat Sample(A/P)
Chlorinated:Yes El No El (from distribution system after unsat routine)
Unsatisfactory routine lab number.
Chlorine Residual:Total Free_
3.Ground Water Rule Source Sample — —
S I I I Unsatisfactory routine collect date:
•
I I
Chlorinated:Yes No
❑Triggered (A/P)
Chlorine Residual:Total_Free
❑Assessment(A/P)
4.Surface or GWI Raw Source Water Sample(Enumeration) I S 1 I I
❑ E.cols ❑Fecal Frlsred Yes rio_
5.V_Sampte Coffected for Information Only:
LAB USE ONLY DRINKING WATER RESULTS .. LAB USE ONLY
❑Unsatisfactory Total Coliform Present and satisfactory
❑E.coli present ❑E.coli absent
Bacterial Density Results:Total Colilorm mpal100m1.E.coli mpnl100m1.
Fecal Coliform cfu/100ml. HPC cfu/tml.
Replacement Sample Required: 0 TNTC ❑Sample too old
❑ Sample Volume ❑Damaged Container 0
Date/Time Received: \\�\c� Lab Reference Number
\—\\cm-2`'\ . \\C->WC 0\
Receipt Temp C': Method Code: .2E,. aT-COUNT/SM9222D
Thar wort is issued whey for N ire d N paw iv arsrp.y
Dale In: / r/► Date Out/ .rom�r m.yea*mow« a aw
cwyamw..or. ,yn.
^
!/L7/2q menses wore s vW/vnid II you l rieshai thisreboil h
.na,plwe retry N order srnrMWy at Ys0.779611 I and
DOH Lab-Sample C am%
` (( These mulls Was arty e N hens W40 arrd N sari Se(a)re
010• waned by N labasrry.Ths spat snag not bs revodlna amp
in IAA.*SW Ira WIGS w1n.n wus U a SO.ras L*reUrsa
OCM Form.731-3191.nE*..ONt 71
Spectra Labs - Kitsap, LLC (Poulsbo)
SPECTRA Laboratories -Kitsap 26276 Twelve Trees Ln NW Ste. C
Poulsbo,WA 98370
...Where experience matters
Phone: (360) 779-5141
www.spectra-lab.com
Spectra Labs - Kitsap, LLC (Poulsbo) received samples for Davis Pumps on Tuesday, July 16, 2024 at
11:45 am. Unless otherwise noted, all samples were received in good condition and were tested in
accordance with the laboratory's quality control procedures. A summary of the samples received are
outlined below.
Sample No. Description Location Sampled
241946-01 80 W Salmonberry Yard Hydrant 07/15/2024 16:30
This report package contains laboratory sample results and any attachments listed below. If you have any
questions please call (360)779-5141 or email us at www.spectra-lab.com.
Attachments
01)
This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other
than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at
360-443-7845 and destroy this report promptly.
These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced
except in full,without prior express written approval by Spectra Laboratories.
07/18/2024 Page 1 of 1
2215198 Mason County WA
08/29/2024 03:46:26 PM AGREE
eRecorded #201066 RecFee: $307.50 Pages: 5
AEGIS LAND TITLE GROUP
WHEN RECORDED RETURN TO:
Heather M Pierce
340 Garrard Creek Road
Oakville, WA 98568
Escrow No.: 2024-54561-SH
Filed for Record at Request of: Aegis Land Title Group
DOCUMENTTITLE(S): Two Party Water System Users Agreement
REFERENCE NUMBER(S) OF DOCUMENTS ASSIGNED OR RELEASED:
GRANTOR(S): Larry Dennis Nutter
GRANTEE(S): Heather Pierce
TRUSTEE(S):
ABBREVIATED LEGAL DESCRIPTION: PTN NW SW 2-19-6
TAX PARCEL NUMBER(S): Property 1:
61902-32-00020
1-6L8e/n4. e k r()
LPB 01-05
l
•
,enlirsgn ID:F8547A2G•47 .1-EF11-991A402248299C60
TWO PARTY WATER SYSTEM USERS AGREEMENT
OWNERSHIP OF THE WELL AND WATERWORKS
It is agreed by the parties that each of said parties shall be and is hereby granted an undivided one-half
interest in and to the use of the well on parcel 61902-32-00030 and the associated
water system. Each party shall be entitled to receive a supply of water for one residential dwelling and
shall be furnished a reasonable supply of potable and healthful water for domestic purposes.The
following parcels have the right of usage of this water source:
(Parcel 1) 61902-32-00030
_ HAT POR'i0N OF ?HE SOU 100 FEET Orr T•IE
Legal Description._ NqOt•RTHI HAS_, (N172) THE SOUT►IYATHEST CUARTf:i+
(SW1/4) OF SECTION TWO (2), TOWNSHI= NINETEEN T`
(16) NORTH. RANGE SIX (6) WCST. W.t.t.. L�'1NC
WESTERLY or THE THREAO OF BINGHAMr REEK;
EXCEF11NO -HEREFROkA TFF WEST 450 F
ET
THEREOF.
Property owner(s): Larry Dennis Nutter
(Parcel 2) 61902-32-00020
Legal Description: FEE;T'HDFE
_ r-ATROf OTHE ST45C
NORTHWEST QUARTER (NWI/4) OF THE SVUTHWr$''
QUARTER ,$W1/4) or SECTION TWO (2), TOWNSHIP
`YINCL WESTERLY OF THE A YO RE AO or O NGH'AM•;•fi.•
---
Property owner(s): Heather Pierce
t of Maintenance of Water System
I aar,;t ereto covenants ar.d agrees that they shall equally'Aare?he maintenance and operational costs of the
well and water system herein described.
Water Line Easements
Larry Dennis Nutter, 61902-32-00030 _ _+
(og -Tr nam•r anr.5arcel#,game of subdivision, and lot number containing the well)
GRANTS
Heather Pierce, 61902-32-00020 �-
(owner name,parcel#,name of subdivision, and lot number adjacent to well)
2 Party Shared Well Users Agreement i of 4 l P a g e
_. — -------
_.. -
•
•
A..nnem.agn tO:F8547A20-4762.E •991 A-0C2248299C60
An easement for the use and purpose of conveying water from the well to the property of
Heather Pierce,61902-32-00020
(owner name,parcel#,name of subdivision,and lot number adi_acentlQ—x- •
Said =e.nent shall be five(5)feet in width and shall type over,
o building and underneath
be alath said
usbee of land
dteom
d
desigt�at.d well site to shared property line.No permanent
upon the water line easement except as needed for the operation of the well and water system.
Ma_ intenance and Repair of Pipelines
All pipelines c in e the waterntam systemnation shall f the e water,
orinjuryed ,tor damage to persons or property.Cot that there will be no leakage or e of repairing defects
which may cause contamination of both parties. party in::tis agreement shall
maintaining common distribution pipelines shall be born equally byI in water Each the !n water
be responsible for the maintenance,repair,and replacement fpie. ,te'Ipi ngzes shallrfrom not e i•. l�n ..item 10 feet
distribution piping to their own particular dwelling and property.
of a septic tank or sewage disposal drain field lines.
Prohibited practices �, potential source of contamination,
The parties herein,their heirs,successors and/or assigns,will not construct any t'^l source contamination,
maintain or suffer to be consnuctederamaintaineda os�water for said land
a d nd domestic 100 feet of
the well hereinof
o o long s the same is op end contamination
may include but is not limited to: septic re cansaccumulate,enclosures lines,
maintergro�fowl ord �ane imal
manure,feed stations liquidand/or grazing animals os storage,p where
chemical herbicides,insecticides,hazardous waste or garbage of any kind.New
or drypotential source of contamination.The
structures and/or barns shall meet required setbacks and not harbor any
parties will not cross connect any portionwaste
or segment of the water system with any other water source or aste waterdisposal outlet without prior written approval of the lean District and/or other
a��o'�'
appropriate governmental agency.
Provisions for Continuation of Water Service described in
The parties agree to maintain a continuous flow of water Rom the well
and nd`'wateer .> rutty.herein the event that the
accordance with water supply requirementsec tees unse of Washingtonatisfactory ry the parties shall develop a new source of water.
qulity or quantity of water fromo the well
Each undivided interest and/or party shall share equally in the cost of developing the new source of water and
installing the necessary equipment associated with the new source.
•
2o4jI' ag '
2 Party Shared Well Users Agreement
Aulnentaln ID Fa54'A20-4762-EFt 1-95tA-(224a299C60
•
Restriction on Furnishing Water to Additional Parties
It is further agreed by the parties hereto that they shall not furnish water front the well and water system herein
above described to any other persons,properties,or dwelling without prior consent of both property owners and
written approval from the G t ou ly Health District.
on I�KQJ\
Restriction on Water Use
State water right laws prohibit this system from using more than 5000 gallons of water for indoor domestic use on
any day without first obtaining a permit from the Washington State Department of Ecology.Also each parcel may
irrigate no more than 1/4 acre of noncom"^ercial lawn or Barden. In order to remain in wmpliance,each proposed lot
61902-32-00030 ___ __-., _ _and lot 61902-32-00020 _is
prohibited from using more than 2500 gallons of water on any given day for indoor domestic use. Further,the total
amount of yard,garden and other irrigation used by each property cannot exceed I14 acre or 10,890 square feet.
Termination of this Agreement
This agreement may be revoked at anytime;however,it may not be revoked without each property obtaining a
sufficient acceptable potable water source and prior consent of both property owners.Termination of this agreement
shall require the property owners'^provide: l)proof of a notarized revocation of this agreement and 2)proof of the
potable water source for each property to the avert Health District for review and approval.After,
review and approval by the health district the property ers shall then file: 1)the notarized revocation of this
agreement and 2)proof of the potable water source approved by the health department for each property at the G 4 i
County Auditor's Office as a recorded document that runs with the title of the land.
Heirs, Successors, and Assigns
These covenants and agreements shall run with the land and shall he binding on all parties having or acquiring any
right,title,or interest in is land described herein o any part hereof and it shall pass to and be for the benefit of
each owner thereof. 4-3
Signed: —
� Owner(s)of Property with the Well
Print Name: L F}'agy 12e.nn t 5 v_J tre---
State of Washington )
)ss
County of MIS o Y )
•
2 Party Shared Well Users Agreement
3 of4if.: +;
A. --:D =2F47A2,:-4762.E,'•.9�:A.X:2248239:6)
1,the undersigned,a N tary Public in and for the above named County and State,do hereby certify that on this 11,ttlttll////
S day of !< / 20_62 personallyappeared before me
r nes _ to me known to be the individual(s)describ t1� //
P ( ) V / /
��. O N�y� �,,
and who ex cuted the within instrument,and acknowledge that he(she)(they)signed and sealed the sam`c`�.�R/....sion.•• ret 4„
and voluntary act and deed,for the uses and purposes therein mentioned.
`� oFo.�1'2 0c?tB�'�i.0
(ITVEN under my hand and official seal J c y and year last a ve written. =_:V *WARY :Z=
,fig-0-e,V_249 ritni
Notary Public d for e tate of Wa hin h, f� ID
Residing in:, _ GU i'�A.9.��eNumd°�',.1�`��
My Commission Expires: ._ _l i=ate. ,_------ 11... OF WASN� �?
///1I11,1I I ltN0
—
Signed: _ Q.`__
Owner(s)of Second Property Served by the Shared Well
p y
Print Name: eC Q-2c(''P_ ------
I,the undersigned,a Notary Public in and for the above named County and State,do hereby certify that on this
day of . t._,2024,personally appeared before me
to me known to be the individual(s)described in
and who executed the within instrument,and acknowledge that he(she)(they)signed and sealed the same as free
and voluntary and deed, for the uses and purposes therein mentioned.
GIVEN=Lei hand and official seal th day and year last above written.
Notary ublic in and for the State of W shington.
Residing in. �_.-_
� tS •2 -
My Commission Exp es:: •
�
KAREN HURLEY
NOTARY PUBLIC#101167
s STATE OF WASHINGTON
COMMISSION EXPIRES
%,,� JULY 15, 2025
2 Party Shared'Well Users Agreement
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d � � S� 01200 Gallon Septic Tank
�. 2-Compartment with
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d
O 1000 Gallon Pump Chamber
5.
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pa #6200i-32-0003o
At"f..3-.s It PC,
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C) �y_ PAULA JOY JOHNSON.7
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APPROVED
9
o ai DEC ? 6 2024
al MASON COUNTY ENVIRONMENTAL HEALTH
IDJA
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