HomeMy WebLinkAboutWEL2025-00026 - WEL Application, Design, Letter - 9/8/2025 ira MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
BELFAIR:360-275-4467,EXT 400
f ' Public Health & Human Services ELMA:360-482-5269,EXT 400
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
oS`t' tj.\ Date Received:
r'_; , MASON COUNTY OH - I i - 2021
COMMUNITY SERVICES Amount Received: Received By.
:,� ^v� Building,Planning,Environmental Health,Community Health _ +t
_rrr "; WEL 2o2.5- 000a,
415 N.6th Street,(Bldg 8)—Shelton,WA 98584
Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400
•
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT L u> ,'� he4
nt�.�L /V //e jr PHONEst
41- ?0 ♦ -Sly `MAILING ADDRESS-STREET,CIY,STZIP
/q Imo- G /y`/
PO \AI E s-T v 4l~mp FEIzay r. ,E L m l W'A R
SITE ADDRFSS-STREET,CITY,STATE,?IP Wt S T LinV� Pill ✓ r, "Lm — WA- q q6/1/
PRIMARY PARCEL NUI
61` C0--•3 -ooc)3
SECONDARY PARCEL NUMBER(SAME AS PRIMARY IF LOCATED ON SAME PARCEL)
WATER SOURCE SOURCE TYPE PARCEL I LOT SITE(min I acre) PARCEL 2 LOT SITE(min I acre)
New existing YW ell Spring *61 1 -a;
PROPOSED WATER SYSTEM NAME(REQUIRED). N
t V
ag
Nui-etr - ier Le w1'rE,12 yszEl✓1
PROJECT'DESCRIPTION(e.g.,detached ADU,new degle-[wiliy reddens,existing monodies,etc.) APR 1 7 2025
►n Le_ ceor iAr f e4.;j nLe-
•
DIRECTIONS TO SITE/CONDITIONS/GATE CODE/KEY LOCATION/ETC By
FRaA(l W •RtSid t-I-I(tTc RER.Y j u21.1 G1.1 '14% WEST -3RL-molt' ge,Oakj
"Pro c_e e-c� -1-o *Fro p e(+1 6 iv T t+E. RR 1 tt
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.)
1 T A-Tsq
6,7 ek
APR 17 2025
1 v BY:
Required Submittals Checklist: (additional information located on the first page of this packet)
0"Satisfactory bacteriological test from within the last year
a/Well report with well tag number,well tag secured to well casing,and capacity test showing 800 gal per day
D"Notice to Future Property Owners of Private Two-Party Water System recorded with Mason County Auditor's Office
0 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
�w� -- ---- Staff Use Only ---- — --
Review Step 1: Well Site Inspection: y�� ram' / ',,-`/ E
YES NO NA Se L'f rtAy(1rf 14C YI f�� l SO`c4 t'Pi(' ' i(,
❑ ❑ Evidence of existing sources of contamination within a 100-foot radius of the water source?(drainfields,
tanks,buildings;indicate distance on plot plan)
❑ Fa, ❑ 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)
gt, ❑ ❑ Does the ground slope away from the water source site?
❑ ❑ Satisfactory well cap?
I ❑ ❑ Well cap screened and vented? 1 I
❑ The well casing extends 1 above level ground/concrete slab?(circle one)
❑ ❑ Ei Evidence of a surface seal? Lat: 47 I SS Ca 7 of
❑ ❑ Adequate surface seal? Lon: — tZ 3 - WO Lit co s
❑ ❑ 0 Variance necessary for well site approval? Tag: No --'Gt ,-
Comments: C(A42.(k cc) C �l'(3\`i ( 1 /1/q/ ,�=a 'f
yfc/207S: Seek- irrolicedt ( , pro , 5of f T'raw, ken Slew/se 0031 1
ass ❑ Fail Inspector CA 9\ Date 5 4
11
Review Step 2: Two-Party Review:
YES NO NA
❑ Water well report(well log)with a concurrent capacity test?
❑ ❑ Nonconcurrent/separate capacity test?
Capacity test information: Date 1(12 1,2 N t( Driller 044/5 O(I •
GPM i 1 t 7 Duration(minutes) 120 Total Gal 7 5)6 y
❑ ❑ Satisfactory bacteriological analysis? Date of test 7( t&(ZO2Y
b
(cr ❑ ❑ Signed,notarized,and recorded notice to future property owners?AFN Z Z C Si I$
❑ ❑ The system appears adequate to serve two connections based on the information provided?
Comments:
gaZ(ZO/5 : MSa1 Coifr OMf cFdicq( l, ( ed 04) olVeh Ui, to f 3* 2 ftr `milApproved ❑ Denied ReviewerDate f/ t(71
'
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
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`h, 2018 per ESSB 6091.
--Y__ 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 Davie'Farm lid
Beyair, '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:
26276Twelve
Trees Lit NW
Ste.0 J SPECTRA Laboratories - Kitsap
Poulsbo,WA ...Where experience mailers
98370 T COLIFORM BACTERIA ANALYSIS FORM
(360)779-5141
Date Sample Collected Time Sample County
Collected
Month 17 ' Year 1KP,, I \a.SoV1
Type of Water System(check only one box)
0 Group A 0 Group B Other
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
10#
System Name: 20W S A I Pv o n �
Contact Person:
Day Phone: Cell Phone:
Email: Eve.Phone:
Send resutls to:(PM Ili namo address and zip ceide or enact above for electronic copy of results)
SAMPLE INFORMATION
Sample collected by(name): L-et,
Specific location where sample collected: Special instructions or comments:
Type of Sample(check only one box)
1.0 Routine Distribution Sample(AN) 2.❑Repeat Sample(A!P)
Chlorinated:Yes ❑ No❑ (from distribution system after unsat.routine)
Unsatisfactory routine lab number.
Chlorine Residual:Total _Free
3.Ground Water Rule Source Sample — — — — --
1 I Unsatisfactory routine collect date:
S
Chlorinated:Yes No
❑Triggered (AP) Chlorine Residual:Total Free___
❑Assessment(A/P)
4.Surface or GWI Raw Source Water Sample(Enumeration) i S I I I
❑ E.Coll ❑Fecal Filtered Yes No_. -_
5.�d,_J Sample Collected for Information Only:
LAB USE ONLY DRINKING WATER RESULTS -LAB USE ONLY
❑Unsatisfactory Total Coliform Present and pf,,Satisfactory
❑E.coli present ❑E.coli absent
Bacterial Density Results:Total Coliform mpnl100m1.E.cob mpn/100m1.
Fecal Coliform cfu/100m1. HPC cfullml.
Replacement Sample Required: 0 TNTC ❑Sample too old
❑ Sample Volume ❑Damaged Container ❑
Date/Time Received \\Ae) Lab Reference Number
Receipt Temp Ce \` ` Method�:QT-COUNT/SM92220
`O Tree reportr Wood'dry a Is ere O Me pence or comeya
Date In. Date Out ehereekmd ayw.+ .eem o+w a derketre "'tiaw
^/IC •(,1 I n//I`7/2� red mooed islac men»d.I you boo ICIi this report h
( r ( error,*Me nobly N se rder mndehk si]EP77940i aM
deYorea repot won*/
DOH Lab-Sankt!
(j� \ Thew rere�As Walter
aey o Me r Mead erd theeemdetet as
010- \ ]� mooed toy he wormy Du report Nil not be
r Spectre exoPt
an AA*tithedpro vines
1 DOtt iam el Jt9(owe.06'17)
Spectra Labs - Kitsap, LLC (Poulsbo)
SPECTRA Laboratories -Kitsap 26276 Twelve Trees Ln NW Ste. C
...Where experience matters Poulsbo,WA 98370
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: $307.50 Pages: 5
AEGIS LAND TITLE GROUP
WHEN RECORDED RETURN TO:
Heather M Pierce
340 Garrard Creek Road
Oakville, WA 98568
Escrow No.: 2024-54561-SH
Filed for Record at Request of: Aegis Land Title Group
DOCUMENT TITLE(S): Two Party Water System Users Agreement
REFERENCE NUMBER(S) OF DOCUMENTS ASSIGNED OR RELEASED:
GRANTOR(S): Larry Dennis Nutter
GRANTEE(S): Heather Pierce
TRUSTEE(S):
ABBREVIATED LEGAL DESCRIPTION: PTN NW SW 2-19-6
TAX PARCEL NUMBER(S): Property 1:
61902-32-00020
bra_8e-04V e o(-) 't-1—)
LPB 01-05
0 4. 1
ellsgr110:F8547A20.47 ?•_F11.991A-c:::22482999C6O
TWO PARTY WATER SYSTEM USERS AGREEMENT
OWNERSHIP OF THE WELL AND WATERWORKS
it is agreed by the parties that each of said parties shall be and is hereby granted an undivided one-half
interest in and to the use of the well on parcel 61902-32-00030 and the associated
water system. Each party shall be entitled to receive a supply of water for one residential dwelling and
shall be furnished a reasonable supply of potable and healthful water for domestic purposes.The
following parcels have the right of usage of this water source:
(Parcel 1) 61902-32-00030
Legal Description: 1NAT PO('+ OF "HE SOUT 100 FEET or T-1E
-- NORTH HA+ r NZ 2) O� THE SOJTH IIY,EST OUARTI
(Sw)/4) OF SECTION Two (2). TOY(NSHI NINETEEN .._ - _.-.
(19) NORTH. RANCE SIX (6) WEST. W.M., n_YIN^� -
WESTER-Y OF THE THREAD OF 81NCHAM CREEK:
EXCEPTING -HEREFROM TI-+F WEST •150 FEET
THEREOF.
Property owner(s): Larry Dennis Nutter __.& -
(parcel 2) 61902-32-00020
Legal Description:_ <45- x '1-E r ar -HL 'f•Fs T 4x FEE-7 OF
rHAT POR1TON of I-IF SCIU Irl 100 FEI. + '-)F THE
NORTHWEST QUARTER (NWI/4) OF THE Ss-K./THY/EST
QUARTER ,Sw1/4) Or SECTION Two (2), TOWNSHIP
NINETEEN (12) NORTH. RANGE S:x (6) VEST. W.r1.,
_YINC wE.STERI_Y OF THE 1$-REAP OF UINCHAM
CREEK.
Property owner(s): Heather Pierce &
=.::t of Maintenance of Water System
par.;;: ereto covenants and agrees that they shall equaUy ..hel she maintenance and operational cc_ of the
well and water system herein described.
Water Line Easements
Larry Dennis Nutter, 61902-32-00030
(o:-''r name.and parcel#, name of subdivision, and lot number containing fLe well)
GRANTS
_ Heather Pierce, 61902-32-00020
(owTner name,parcel#, name of subdivision, and lot numberadJacent to well)
2 Party Shared Well Users Agreement 1 of 4 I i' a g
Autnents.pn tD:F354 A20-a792.E 't.991A-)C2248289C60
An easement for the use and purpose of conveying water from the well to the property of
Heather Pierce, 61902-32-00020
(owner nme,parcel#,name of subdivision,and lot number g_da en •
ermanent type of building shall be allowed to be constructed
Said eLLac.nent shall be five(5)feet in width and sall extend on,over,across,and underneath said strip of land from
designated well site to shared property line.No newp
upon the water line easement except as needed for the operation of the well and water system.
Maintenance and Repair of Pipelines
All pipelinesmycute the water system shall bwa maintained
or injury,or damage to persons or property.Cost of repairing Cor defects
which may cause contamination of theb hc,til parties. party in''.tis agreement shall
maintaining common distribution pipelines shall be born equally by thl n .Each om the c,.,t s er
fWater pipelines waterhall not be i:tstnllou within 14 feet
be responsible for the maintenance,repair,and replacement of p., �, Y' g
distribution piping to their owe particular dwelling and property.
of a septic tank or sewage disposal drain field lines.
Prohibited Practices grpotential source of cantarnination,
The parties herein,their heirs,successors and/or assi ,5,will not construct any c _fc l source ti
maintain or suffer to be constructed or maintained t ineupon to furnish t theer saidor land
and+ domestic within
100 feet of the
p e well hereinof
on, o long s the s e s snot lie
contamination may include but is not limited to: septic tanks tend
e�Umulut tCenclosures lines,
maiunderground
fowl ord. animal
ad stations anoror grazing animalsr pins where manure
manure, aste
age of
liquid or dry chemical storage,herbicides,insecticides,hazardouste potential or
bof contamination.The
structures and/or barns shall meet required setbacks and not harbor any p
parties will not cross connect any portion or segment of the water system with any other water source or waste water
p 3ealth District and/or other
disposal outlet without prior written approval of the LW')on`
appropriate governmental agency.
Provisions for Continuation of Water Service herein described in
The parties agree to maintain a continuous flow of water fiorn the well andAter
C ttnry•
In the ethe
v event that
accordance with water supply requirements of the State Washingtond ge shall develop a new source of water.
quality or quantity of water from the well becomes unsatisfactory the parties
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.
2of41Pag�:
2 Party Shared Well Users Agreement
Autnenta'9n to.Fas47A20.4762-EF11.991A,X2248299C61)
Restriction on Furnishinh Water to Additional Parties
It is further agreed by the parties hereto that they shall not furnish water from the well and water s)stein herein
above described to any other persons,properties,or dwelling without prior consent of both property owners and
written approval from the Cl t ou Health District.
k Restriction on Water Use
State water right laws prohibit this system from using more than 5000 gallons of water rur indoor domestic use on
any day will-fiat first obtaining a permit from the Washington State Department of Eculogy.Also each parcel may
irrigate no more than 1/4 acre of noncom"ercial lawn or garden. In order to remain in,:ompliunce,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 1/4 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
of the
shall require the property owners•,provide: 1)proof of a notarized revocation of this agreement and 2)proof
potable water source for each property to the GretttHealth District for review and approval.After,review and approval by the health district thelproperty o 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 45on
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.
-i--)
Signed:
Owner(s)of Property with the Well
A- y WSJ _____
Print Names �'
State of Washington )
iLiGLSs
County of ar )
? Party Shared Well Users Agreement
3of4Ih,:;;c
7-EP '-39•A X;a4,o23GCE)
I,the undersigned,a N tary Public in and for the above i:ained County and State,do hereby certify that un this �tN1i1111I1�����
` 20..E personally appeared before me
S day of _ to me known to be the individual(s)describe tP D u N^l/'����G
not, signed and sealed the samy* ........
,,4.**.,/l•
and voluntary act and deed,for the uses and purposes therein mentioned. t :v 0 OTARY ° .Z
GIVEN under my hand and official seal e ••y and year last af.b ye w-i___ ritten. /,^ =N: =
NotaryPublic d for t e fate of Wa lnn �,
p
%0A'co t
Residing in: -`;/1�t W - �/�eLx 'i�91''3°Nurnb°•At10��.
My Commission Expires; _ Li :_ _------ "I�,,OF tWAS ‘`%
-------- __ -���._.�. �•���--
Signed: —n��ner(s)of Second Property Served by the Shared Well
Print Name:
I,the undersigned,a Notary Public in and for the above named County
y ande State,
do hereby certify that on this
_day of__ t::__,20 Personally appeared c�_��� fme
to me known to be the individuals)described in
slit (they)signed and sealed the same as free
and who executed the within instrument,and acknowledge that he(she) ig
and voluntary and deed, for the uses and purposes therein mentioned.
GIVEN un..c Land and official seal th day and year last above written.
1
Notary ublic in and for the State of W shington.
Residing in:_. ril42 _1\_
My Commission Exp es 5 c --
KAREN HURLEY
'%, NOTARY PUBLIC#101167
STATE OF WASHINGTON
COMMISSION EXPIRES
JULY 15, 2025 _
4 of41P:,sue
2 Party Shared Well Users Agreement
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'` S� O 1200 Gallon Septic Tank
i 6� 2-Compartment with
I5, Effluent Filter
d
� -, O 1000 Gallon Pump Chamber
1Cb� in
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3b J• AAULA JOY JOMNSON.
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EJfPIRES /7
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APPROVED
N
A DEC 2 6 2024
MASON COUNTY ENVIRONMENTAL HEALTH
DJA
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