HomeMy WebLinkAboutWAT2025-00140 - WAT Application - 7/8/2025 WAT 2623 - ()OHO
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MASON COUNTY 415N.6t'Street
Tai Shelton.WA 98584
Shelton:360-427-9670,Ext.400
•�` ""`_. Public Health & Human Services Belfair:360-275-4467,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 mus accompany this application.
E- IrY1 et.c. - j& - Ec,1 t L.13 E .(mc�cJ�,
Part 1: Applicant/ Parcel Identification)
Name on ApplicantdLc ',Q, k&v1o(}rn Date: --f3-2Oz S
MailingAddress: 7 , ).3(06.`-60 ' 0593�(' �(✓� `J'�r�Ci�liCc.k�'C�. 1 Phone:
Parcel Number: ' �lj,(,Tr1YL .1))A ciSsn4 (20, Id -52. - a5� C� �'�
g-(9. I 52 -6' IO Ic.)4tu
Type of Water System Reason for Application
Public/Community Water System (2 or more )21 Building permit,.6l(12626 •-
connections) 0 Division of land: (X 1 i 4
❑ Individual water source (one connection), #of Parcels? SPL
0 Well ❑ Boundary line adjustment
0 Spring/surface water 0 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 �/T(�Ua. �•��i W n' /
Complete the section appropriate for the type of water connection being evaluate
Public Water System c2 . 60LP
Name of Water System:
Water Facility Inventory (WFI) Number: (write "none" for two-party)
0 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.masoncountywa.gov
J:\EH Forms\Drinking Water Revised 05/08/2024 Page I of
immoisoimmoommor
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
Water well report (attached to application). Depth \., , I ft.
Well capacity Test(attached to application) (9'0 gpm 71/4'0 0 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.
Satisfactory bacteriological test within last year (attach to application).
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)
J/i) 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).
Reviewer's Signatures:
Environ. Health: \ " \��' Date 0t('(ZA
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
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WATER WELL REPORT arErne atVl (..1tinsa1MrertlMn.WF _ —
ECOLOGY onedue kology Well ID 1as Na 800302__
TvpMWiwi Strit 71 wars Stan
® Careasbm Sift Well Name(it moue than one wail► _ _
CI osnanmen t=a o osii..04.ea1tt11Htea Water Right Pan++(CtrttricawNu -
fun;NUa. 14 I emaiei 17 hlr nd tJ nbwe*d plapeny Owner Vane Q11SI_I<C►tkaiAL_
u er w..r 11 hrprw t t tre Well a Odin._.____---_-.- 201
wall 6uas Amama---E.Wit D►Ia _ ---------
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n napaint i)ca.. a or. E1 Ah. ❑ldttfAIIepy ttu Hard No.222126201010
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Myape� �Yall Irvin,who WS.rht ear..art fix?Car. Lbw Ota.eue Inn T. node.= >oss.l PVC% Wei Meted
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4 St IuN re A.kLta 34Q NE QAV18 FARM RD
lan•eet No 0797 Cwy,C+w.,_7gr BNhir Ws 95528
IF TRAINEE Sponaor'.I.icatec No Contactor'.
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Vanguard Laboratory
2635 Parkmont Lane SW, Suite A
Olympia WA 98502
vexaaVB 360-967-7010
GNU'/F04 COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
Collected
08/ 04 125 14 : 30 °AM Pierce
Month Day Year
Type of Water System(check only one box) Future
❑Group ❑Group B 6f]Other Group B
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name: Wellington's Water
Contact Person: Lacey Davis
Day Phone:(360 ) 329-2699 Cell Phone:(
Email:davispumprepair@gmail.com Eve.Phone:(
Send results to:(Print full name,address and zip code or e-mail)
Davis Pump Repair
davispumprepair@gmail.com
SAMPLE INFORMATION
Sample collected by(name):
Lacey Davis
Specific location where sample collected: Special instructions or comments:
Lot #1 of Lakewood Plat C
SO1
Type of Sample(select only one type of sample from types 1 through 5 below)
1.❑Routine Distribution Sample(AIP) 2.❑ Repeat Sample(AIP)
Chlorinated:Yes No (from distribution system after unsat.routine)
Unsatisfactory routine lab number:
Chlorine Residual:Total Free_
3.Ground Water Rule Source Sample
Unsatisfactory routine collect date:
S
Chlorinated:Yes No
❑Triggered(A/P) Chlorine Residual:Total Free
❑Assessment (A/P)
4. Surface or GWI Raw Source Water Sample(Enumeration)
S
❑E.coli ❑Fecal Filtered Yes No
5.®Sample Collected 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 Coliform /100m1. E.coli /100m1.
Fecal Coliform /100m1. HPC /1 ml.
Replacement Sample Required: ❑TNTC ❑Sample too old
❑ Sample Volume ❑Damaged Container 0
DaterTime Received: Lab Reference Number
08/04/25 16:00 V250804-18
Receipt Temp C°: 5.2 Method Code:
SM9223B
Date Reported to DOH Lab Use Only:
08/22/25
DOH Lab-Sample#
285-80418
DOH Form M131-319(effective 06117)-It you need this(meetarae in Cl altemaeve faunal WI 800.525.0127)TDDtTTY cat 711).
2230213 MASON CO WA
09/03/2025 01:47 PM EASMT
111111Il101IIIIIII111111I111111IIIIIIIIIIIIIIIIIIIIIIIIIIII11111111111111I111ges: 3
AFFIDAVIT
NO
WA R.E. EXCISE TAX
SEP 0 3 2025
EXEMPT
Return to: MASON COUNTY TREASURER
Davis Pumps Inc.
340 NE Davis Farm Rd
Belfair,Wa 98528
WELL EASEMENT AGREEMENT
THIS WELL EASEMENT AGREEMENT("Agreement")made and entered into by parcel owner(s):Tru North
Investments,LLC,hereinafter referred to as"Grantor"
and
Jayce Dietz Kadoun,hereinafter referred to as"Grantee"
Grantor.Tru North Investments,LLC
Grantee:Jayce Dietz Kadoun
RECITALS
A.Grantor is the owner of certain real property,located in Mason County,Washington,identified as Assessor's Tax
Parcel No.
Parcel#22212-52-01010
LAKEWOOD PLAT C PCL 1 OF BLA#23-41 AF#2208542 S 52/212-217 S 54/114-119
(SE V.of SW'h Sec 12 T 22N R2W)
B.The well with Unique Ecology Well ID No.BQC302 (the"Well")and associated water facilities(including but
not limited to pump,pump house,lines,and related improvements)are located on Grantor's Property.
C.Grantee is the owner of that certain real property("Benefited Property")identified as Assessor's Tax Parcel No.
Parcel#22212-52-04025
LAKEWOOD PLAT C PCL 4 OF BLA#23-41 AF#2208542 S 52/212-217 S 54/114-119
(SE'V4 of SW'/.Sec 12 T 22N R2W)
201 E Dietz Drive Belfair,Wa 98528
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D.The parties desire to establish and record an easement for the benefit of Grantee to allow for the use,operation,
maintenance,repair,and protection of the Well and associated water facilities.
AGREEMENT
1. Grant of Easement for Well and Water Facilities.
Grantor hereby grants and conveys to Grantee a perpetual,non-exclusive easement in,to,and across
Grantor's Property consisting of a 100-foot radius around the Well,together with the pump,pump house,
and all facilities necessary to produce,monitor,maintain,and distribute water to the Benefited Property
(the"Easement Area").
2. Purpose.
The Well shall be designated as a private domestic well for the exclusive use of the Benefited Property
(Parcel No.22212-52-04025LAKEWOOD PLAT C PCL 4 OF BLA#23-41 AF#2208542 S 52/212-217 S
54/114-119(SE'/4 of SW'/4 Sec 12 T 22N R2W)201 E Dietz Drive Belfair,Wa 98528).The Well shall
continue to serve solely as a private domestic well for such property until such time as the Well is permitted
and approved as a Group 13 Water System by the appropriate regulatory authorities.
3. Use Rights.
Grantee shall have the right to enter upon the Easement Area at all reasonable times for the purpose of
installing,operating,repairing,replacing,monitoring,and maintaining the Well and related facilities,so as
to keep the water system properly functioning.
4. Grant of Access Easement.
Grantor further grants to Grantee a perpetual,non-exclusive easement over,across,and upon the following
portion of Grantor's Property:Parcel#22212-52-01010 LAKEWOOD PLAT C PCL 1 OF BLA#23-41 AF#
2208542 S 52/212-217 S 54/114-119 (SE'/4 of SW'/4 Sec 12 T 22N R2W)for the limited purpose of
providing access to the Well,pump house,and associated water facilities.
5. Ownership and Responsibility.
All improvements and facilities associated with the Well shall remain the responsibility of Grantee.Grantee
shall ensure that all work conducted within the Easement Area is performed in compliance with all
applicable laws and regulations.
6. Running with the Land.
This Easement shall be appurtenant to and run with the Benefited Property,binding upon Grantor and
Grantee and their respective successors,assigns,heirs,and legal representatives.
2
IN WITNESS WHEREOF,the parties have executed this Property Easement Agreement effective as of the date of
the last signature below.
GRANTOR:
By:
Tru North Investments,LLC(Parcel Owner(s))
GRANTS
By:
Jayce Dietz Kadoun(Parcel Owner(s))
NOTARY ACKNOWLEDGMENT
.jtj�,eyndersign a otary Public in and for the named above Co ty and S do here y certi tat n this
Kd day o ,202.E personally appeared before meCOPer e WWI� ee to
be the individual described on and who executed the within instrument,and acknowledge that he(sh. .igned
and sealed the same as free and voluntary act .•: •eed,for the users and purposes herein mentioned.
•
GIVEN under my hand •/ official seal th. day • a year last above written.
ik
MIii L. /4 0 • MICHELLE C.GOODS
w IN Nor
N: Public' t e S of Washington, Notary Public
ajC� to of Washington
residing �14[!if Ji.A)/64- Comm N I328
res
My commission expires: • i October 01,2025 G
3