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HomeMy WebLinkAboutWEL2025-00116 - WEL Application, Design, Letter - 2/3/2026 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 • SHELTON:360-427-9670,EXT 400 krippris;e. BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 02/03/2026 VAN BUSKIRK KENNETH A & PEGGY 61 NE DAVIS FARM RD BELFAIR, WA 98528 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2025-00116 1080 NE Sand Hill Rd 123203300010 The 2-party water system, Two-Party Well (SFR +ADU): Peggy's Water (123203300010/123203300010), 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 DateRecei,,e - _. _ .. - COMMUNITY SERVICES l Amount Received' Received By. F•, \V-71. ::,.g. ; Mang.Ruining,Encunnnu.0,.l Health,C:•un,unny Hralili i -5(0. beDie_Or '____. ykJ 7 ,�e\0 i 415 N.6' �g l 'Street,(Bldg 8)—Shelton,WA 98584 g �J C�E L a.6 - U 0 ) I Shelton: 360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT PHONE .4.NN "4.e" .- e cry v S i 1L- cr) U Z7 5 MAILING ADDRESS-STREET CITY,STATE.ZIP ", fiV N v`% .e\ c, W Pr C1�E 28 Y Sll'I:ADDRESS-S FREI,.'I',CI•rY,STA•UF:.ZIP 1 CDg<� .N1 a sU‘(\At!-\'A 2-ek \3e\2 rt ,Q, is,- cki �2p-, � PRIMARY PARCE1.NUMBER(WELL SITE) 2 2-c0-- 3- <.'-)CJ\p �Nss SECONDARY PARCEL "NUMBER(SAME AS PRIMARY IF LOCATED ON SAME PARCEL) V222-0- " -- o00\ o (So%V, �M\e.. WATER SOURCE SOURCE TYPE PARCEL.I LOT SIZE(no minimum) PARCEL 2 LO E(no mining New Existing Well Spring S // PROPOSED WATER SYSTEM NAME(REQUIRED).l PROJECT DESCR!PTIO, (e.g., etached ADO,new single-family residence,existing connection,etc.) '2—. ...\ d—Q- C( ' ■ DIRECTIONS TO SITE/CONDITIONS/GATE CODE/KEY LOCATION I ETC. . . , 0 IC—A—e c S 0"c9‘ 1k t\\ SLAt\or-\ 1 %r,A\-ci-6 SS - 12.e i 1 .-4-- 1 A6��-�c� O'ic \i ___,( C.'f�S S NV� COQ 0 U C U�1 �. . 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.) S—e--e_ C)I ._ .. Required Submittals Checklist: (additional information located on the first page of this packet) flZ1 Satisfactory bacteriological test from within the last year gi Well report with well tag number,well tag secured to well casing,and capacity test showing 800 gal per day IfI 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 are no septic records on file) This form may be scanned'and made available for public viewing on the Mason County website. Revised:07/23/2025 Page 1 oft S �t'1. Use Only _ J Review Step 1: Well Site inspection: ; : YES NO N/O ` v Er E ❑ ❑ Evidence of existing sources of contamination within a 100-foot radius of the water source?(drainfields, tanks,buildings; indicate distance on plot plan) ❑ ,9 J ❑ 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) oegitit ❑ ❑ Does theground slope away from the pwater source site? �� ❑ Satisfactory well cap? WiS�')'lf>A0014-r ct 60 HT I«6S 1( tt q601/e-- 4 76 ❑ ❑ Well cap screened and vented? A`,7 ❑ The well casing extends /0 above level _roan concrete slab? (circle one) rii ❑ ❑ Well tag attached to well casing? m Lat: 97.c4 MS VS ❑ '— ''Evidence of an adequate surface seal? Lon: —t 22,e if pt' ❑ ElVariance necessary for well site approval? I ag: (j( cti 10 Contes: '110f...Sat eta{ �j1�0(/YIGt law(, V9l` lV V i f fr 1nr4,l"� ...t1of kla, tli�T"\ WI( ty rW i-Seavt. lhrW !Me h!/rd4fG 90, 1 ss Fail Inspector Date ( -r le/ c rc Review Step 2: Two-Party Review: YES NO N 1 — ri/Q Waal, kid-1 ; ❑ ❑ Water well report(well log): Date Completed 01/0?/ { Driller 1. tve ( , ❑ ❑ Satisfactory capacity test showing a minimum of 800 GPD wit i full recovery to static level within 2 hours? Capacity test information:Date (l (z( /705Driller/Pump Installer PQ43 kY1 n GPM 33 Duration (minutes) 1? Total Gal 3760 Recovery Time(minutes)to Static C J. X ❑ ❑ Satisfactory bacteriological analysis? Date 0-6(03 AR5Testing Lab / l /kL 1 f b t(`w-gp. if lZl Nis ��y vurr,{to 0Aptitf4 ,r)_6 ❑ ❑ Signed,notarized,and recorded notice to future property owners?AFN Z?)G/3ie ❑ ❑ The system appears adequate to serve two connections based on the information provided? Comments: aecfiv d keg ferf 4 I (1t(1016 rwih repots b Vottr helltb 4 Approved ❑ Denied Reviewer r Date _2" 3/ 2,4, ,.., 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 Jammu), 19''', 2018 per ESSB 6091. Revised:07/23/2025 This form may be scanned and made availabie for public viewing on the Mason County website. • Page 2 bf2. A File Original and First Copy with Department of Ecology WATER WELL REPORT Application No. . Second Copy—Owner's Copy . Third Copy—Drillers Copy STATE OP. qt", ,QI}IQ"fl+®N Permit No. ...- .w+ (1) OWNER: Name loti z...�� 1��g Addrers P..>.1J-. firlx.....& ....Ee. ,rai II....444,-94528— ® (2) LOCATION OF WELL: county Mason) - _5W i .,S ...,,...!d Sec T 23 rr.. OW IRA. CL Bearing and,distance from section or-- subdivision corner — mom. — Ce (3) P1 OFISE USE: Domestic D Industrial ❑ 1 uniclpe1 p (=.0) WELL LOG: Tii Irrigation O Test Well O Other Q l"ormetion-Describe by color,character,size of material and structure.and dhow thickness of aquifers and the kind and nature of the material in each etr•atmft penetrated, with at least one entry for each chancre of formation. (4) TYPE OF WORK. Owner's number of well in (if more than one),.,. MATERIAL FROM TO New well 1g Method:D„,f p Bored 0 if OP SD1 ;S Deepened p - Cable q• I7tiven 13-- -. "- c Recondialoned ❑ Rotary❑ jetted p_ �o l d Q n g I m %2rs t ® _. ..�.,�_ ` n g r a v e c (5) DIMENSIONS: Diameter of well . .1��6a inchea. - - goon -cong!orn rat2 78 92- O Drilled...........CI 9 . ......_.et. Depth of completed well. ._.........__ - _. £l-a &&gravo1water 92 105 . :F+ _ ..1.i�2 -:3i ia .- .- - ---- .-- ._ - Casing installed: ti ., Diem. from ..r .dwi.. ti, to .i9... ft. ., --- e® Threaded p Di m:fsmra : _::.:._.:. tt. to — it _. --- Welded® '' Diem. from .. ft. to-...-•-------.. ft. . Federations: Yea o No _..-... - _. _ .._. -_. -- - - -- ,i•+ Type of perforator used _.........--••-- ---.-- __--........______.—.,. . ._. • •- - 0 SIZE of perorations in. by . , . in. . 15 perforations from ft. to ft. - = perforations from ft. to- • ft: 11 CZ .._................... perforations (tam !••- ft.to ft. 1 -__,. CO ' tfS gee. F: Yea O No, j _. . . - -- i ® La nnEactaarer'a Name- I _ ' T,tic Model No.. _ ;'lot size Erom ...i -.... � Diem. to- - -. H. Minn. ................ Slot al trOrf7-...1.,...-..an• :to v....._......a - - - _. - .• 99 C gravel packed: Yes❑ No p Size of gravel: - • — COGravel placed from 'ft.to" -' - ft. _ Surface seek Yes R No ipt To what depth? ¶l- ....._._.. ?t Material used in seal.......... B�.C�:arid E�. _. Did any abrata contain ua,.aable.-mater? Yea p No a- . . O Type of water? Depth of strata - .. - Z Method of sealing strata or2 di (7) PUM?: Manufacturer's Narao _ --L . . _ . .. . -- 0 type: $.h..._......_... ..__. . `>a (8) WATER, LEVELS: r^^d-aur4ace ele�tr., _._ . •. --- ... - -----. .. - . EYDOV a ir]4`Y9n L:_.9-.kYvel.:..'....+ '� _•DIRR ._ppe�'gg. ® Static level . ft. below top of well.Dwt,e...9..9,rf_7..9,;.... . ® Artesian pressure lbs. per square inch Date .. --- 0 Artesian water Is,controlled by 6.I ,-.. _ -. -- _(Cap,valve,ate.) . .. ® ,t' m . Dratvdown is amount wet .level Is -- (9) �� a� °� � lowered belbw sxa�c level i _ _.122 e 78 IL......_. 79 Work started...._._..._.. i8._......... Completed.................--. _ 18........ Was a pump test made? Yes D Non If yes,by whom? • C CDYield:' Ital./min. with ft.,dravrdovrn aPPer bra WELL DETI1.L 'S STATEMENT: E -� ."_ " This well was drilled under my jurisdiction and this report is s=o ., ,. •• true to the best of my knowledge and belief. I— CU Recovery data (time taken es zero when pump tamed'eh'l fwAter lever --. a if a We l i. D ra f l i ng Co D Inc. a. measured from well top to water level) 'NAliiv Time Water .Level Tarns Water Level. Time Water Lapel _ ... lPersorl, firm,or corporation) (Type or print) dif I . . • Address P 00 • Sox' 3O A1iynv Was, 98524 l .t 1 x !//**- /3cDate of to~R __ _....-- (Signed °�^ LL 1 C t"'�r Bailer teat.....,. . ...oai.lmin. v ith ft. drawdovrn after 1 Iris- `' /(Weil Driller) Artesian ROW f;Pal Date..._............. .............._._._._ __..- /� Temperature of water.........._....Was a chemical analytic made? Yea 0 No cia1 LICSn?e No 0.g.5t `''' Date q.r4, . 1S79-- (OsE A.nl srXONAL aT I Ys i NrcEssARY) ECY oral-20 3 • • WATER WELL REPORT €.- ( DEPARTMENT OF Notice of Intent No. WE61892 ECOLOGY Unique Ecology Well ID Tag No. BQC410 Type of Work: iill State of Washington N Construction Site Well Name(if more than one well): • ❑ Decommission b Original installation NOI No. BQC410 Water Right Permit/Certificate No. Proposed Use: O Domestic ❑Industrial ❑Municipal Property Owner Name Ken&Peggy Van Buskirk 1 / :.-2.' "'"'' . ❑Dewatering ❑Irrigation ❑Test Well ❑Other / :.-.' Well Street Address 1080 NE Sand Hill Rd ,, G Construction Type: Method: 'f'"+ City Belfair County Mason a ❑New well ❑O Alteration ❑::;Driven ❑Jetted ECable Tool ❑Deepening ❑Other ❑Dug ❑Air- ❑Mud-Rotary Tax Parcel No. 123203300010 t Dimensions: Diameter of borin 6 in.,to 113 ft .„ 'Was a variance approved for this well? El Yes 0 No ./1/6`O Depth of completed well 113 ft. • Construction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread 'III ❑ 6 in. +8" 113 1/4 in. O ❑ ❑ ❑ — � Location(see instructions on page 2): ID WWM or❑EWM DID in. — — in. ❑ I ❑ DIE SW '/-A of the SW V4;Section 20 Township 23N Range 1W DIE in. — — in. ❑ I ❑ DIE ❑ I ❑ in. in. ❑ I ❑ DID Latitude(Example:47.12345) 47.46489 Longitude(Example:-120.12345) -122.84119 Perforations: ❑Yes a No Type of perforator used No.of perforations Size of perforations in.by_in. Driller's Log/Construction or Decommission Procedure Perforated from ft.to ft.below ground surface Formation:Describe by color,character,size of material and structure,and the kind and nature of the material in each layer penetrated,with at least one entry for each change of Screens: ❑Yes E No ❑K-Packer b Depth ft. information. Use additional sheets if necessary. ' Manufacturer's Name Material From To . Type Model No. Diameter in. Slot size in.from ft.to ft. extension and surface seal to complete former Diameter in. Slot size in.from ft.to ft. pit completion Sand/Filter pack:❑14s No Size of pack material in. Materials placed from ft.to ft. 6"casing welded on +8" 4' 10"+bentonite surface seal 0 2' Surface Seal: ❑Yes ❑No To what depth? 275 ft. 10"+cement surface seal 2 5 Material used in seal bentonite/cement Did any strata contain unusable water? ❑Yes 0No " Type of water? Depth of strata Method of sealing strata off Pump: Manufacturer's Name grundfos Type: sub H.P. 3 Pump intake depth:110 ft. Designed flow rate: gpm Water Levels: Land-surface elevation above mean sea level ft. Stick-up of top of well casing .66 ft.above ground surface Static water level 92 ft.below top of well casing Date 11/21/25 • Artesian pressure lbs.per square inch Date - Artesian water is controlled by (cap,valve,etc.) ' Well Tests: Was a pumping test performed? N No ❑Yes => by whom? Yield gpm with ft.drawdown after hrs. ' Yield gpm with ft.drawdown after hrs. Yield gpm with ft.drawdown after hrs. Recovery data(time=zero when pump is turned off—water level measured from well top to water level) Time Water Level Time Water Level Time Water Level Date of pumping test Bailer test gpm with ft.drawdown after hrs.} Air test gpm with stem set at ft.for hrs. Date Artesian flow gpin Temperature of water °F Was a chemical analysis made? ❑Yes ❑O No Start Date 1/17/26 Completed Date 1/17/26 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well construction standards.Materials used and the information reported above are true to my best knowledge and belief. O Driller❑Trainee❑PE—Print Name Mike Davis Drilling Company Davis Drilling Signature Address 340 NE Davis Farm Rd License No. 0797 City,State,Zip Belfair Wa 98528 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.DaviSDl110OA Date 1/21/2026 ECY 050-1-20(Rev 08/19)If you need this document in an alternate format,please call the Water Resources Program at 360-407-6872. . Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. Di 1.S `uI B, TIM- 340 W1 Davis farm iid `3elfaitr,'Wa 98528 (360)801-6107 Project Ken & Peggy VanB Capacity Test TAG: BQC4I0 Date 11/21/2025 Pump 3 HP35GPM Weli Depth 109 Static Water Level 92.0' Draw Down Recovery I Time Water Level GPM 0 100.5' , I 0 min 92.0' 0 1 min 92.2' 5 min 100.4' 33 2 92.0' 10 min 100.5' 133 3 15 min 100.5' 33 4 30 min 100.5' 33 5 1 hr 100.5' ' 33 10 12 hr 100.5' d 33 . 20 i Capacity Notes: , Vanrivard Laboratory s 2635 Parkmont Lane SW. Suite A ' Olympia WA 98502 ,60-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected Type of Water System(check only one box) 0 Group A 0 Group B ❑le Other ._ _ Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: 1. .' , •y• Contact Person:arcadia Drifting:-Inc Day Phone:-(,36O•-(426-3395 Cell Phone:I ) Email: Eve.Phone:I Send results;0::':dt till nacre address and on r:ie e-e-ma I . arteta:dvrcadiamilling.cum AND rune i,parc d,adriltin0.com SAMPLE INFORMATION Sample collected by(name) Specific location where sample collected: Special instructions or comments •( Type of Sample(select only one type of sample from types 1 through 5 below) 1.❑Routine Distribution Sample(A/P) 2 0 Repeat Sample(A/P) Chlorinated:Yes___ No Iron distabLr or; ;;_m atter uncut.roctmei Unsatisfactory routine lab number: Chlorine Residual:Total__ Free,__", • 3.Ground Water Rule Source Sample S Unsatisfactory routine collect dale: Chlorinated:Yes __No." 0 Triggered(A/P) Chlorine Residual:Total Free ❑Assessment (AJP) 4. Surface or GWI Raw Source Water Sample(Enumeration) IS ❑E.cols ❑Fecal l 1 5.0 Sample Collated to Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Colifomi Present and 1I1 Satisfactory 0 E.coli present 0 E.coli absent Bacterial Density Results:Total Celiform /100ml. E.coli _/100ml. Fecal Colitorm /100ml. HPC 11 ml. Replacement Sample Required: 0 TNTC 0 Sample too old ❑ Sample Volume ❑Damaged Container ❑_ _ Ca:e,'TimeReceived. Lab efere.cceNumber tl /.21/2'") l6 . 1 5 _ ,/c7_3 ? I — •2c Reme.pm Temp C..° rna 5• C O 5i�t 6 "2 2 Date Reported to DOH Lab Use Only: DOH Lab-Sample:: 285- 2.i 2 9 1 roc,1.11 SPECTRA I_abclraloric, Kitsap t'c,ulshrl,WA o\:"'ll ...Where eapenrnce matters COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County l�- /.. - . I Collected O b.;rtr Goy ,,If Type of Water System(check only one boot ❑Group A ❑Group B ❑Other___ Group A and Urnup r.4yoi .-.Pn„se rme.t!'J?ter r:--.tidies 1..._n'.er;(WFli 1ID5 • System Narir_, f r ti' x r' ;C. Contact Person: Day Phone_ ' .i;'• ;;„_ —' 1 Cell Phone Email. , Eve.Phone _end r-jsulk;n Pr ei'.;II riafr,,a•ic .,-.1•,.c , v eria!I above for electronic copy of results, SAMPLE INFORMATION Sample collected by tname:.' 1 t�.,..1/' 1.. Specific location where sample collected Special instructions or comments: j j Type of Sample(check only one boot 1.❑Routine Distribution Sample(NP) F2.❑ Repeat Sample(NP) —! 'from d eS rbi don cistern after linen;Rmtlnr•' Chlorinated:Yes ❑ N0 O Unsatisfactory routine tab number Chlorine Reslaual Total Free 3.Ground Water Rule Source Sample Unsatisfactory routine collect date. • S — — — Chicrir.ated Yes No ❑Trig:oeren tA!P> Chlorine Residual Total Free _ El AssessmenttA'PI 4 Surface or GWI Raw Source Water Sample(Enumeration. j ❑ E col: ❑Fecal • <a"eii C!,I'c-!e:'tl, Information Only • LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Colderm Present and fn Satisfactory ❑E rot>present ❑E.ro'i absent • Bacterial Density Results'Total Conform____mpn lbOml.E.colr_r—_—mpnitDOnTl. Feral C;ticsrr cfu IOOmI. HPC cfu+Tort Replacement Sample Required: O TNTC ❑Sample Ion old ❑ Sample Volume O iiamageo Container O D.aie'llmz Received--- -- r..., T Lab Rererenc€Number ' Recslp:T«,:,.,C' Method Code i�.�. ¢f 922 sd)41 COON T t.1?2,12D ilia-Ian- , �_r"'-- - -- - ----"-- 010 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, June 3, 2025 at 3:45 pm. 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 2521.87-01 1080 NE Old Belfair Hwy Lawn Hydrant 06/02/2025 17:36 • 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. 06/06/2025 Pagc 1 of 1 Well Tagging Form DEPARTMENT OF 7DQt�IAJnt ECOLOGY Unique Ecology Well ID Tag Number: l ��� State of Washington Use this form only if a well report is found. Attach original well report to this form. If a well report is not available, contact the Well Construction and Licensing Office at: „,c:.Ic. SJ a_ '`a :c or 360-407-6650 to request a Well Report for an Existing Well form. Well Ownership First name Last name ?e-foJ`( I vcXv\�U1/{-4rk Street Address to N�1�c i`� �—cc tr w\ 1-2,1 City State Zip Code Location of Well Well Address t 05. NI-; 6 d City County s ,:4 ► %-0-'/¢ '/4 Section Township Rane' l g Th� �V 2 1 \vv❑ EWM or❑ 0(WM (check one) Latitude Degrees Tax Parcel Number 1 ° � CPL[ I IZ? Zo - 33--coot 0 Longitude Degrees Report in NAD 83 or WGS 84 �- 1 Elevation at land surface 2..� 1 feet ❑meters(check one) Well Characteristics Location of Well Identification Tag UQ' D CBA Indic to t�����to ation r /� E F G H o iceiu 11 lotthe Section by drawing a M L ; K J dot representing that location. N P Q R Section Number Comments: Certification:The information reported above is true to the best of my knowledge and belief. ❑Consulting Firm t Driller ❑ Engineer ❑Property Owner Name Drilliina Compan i fD C2-t/ 1 os I k Vie 4 ek U S 03 Driller License Number Address of per n completin tis form o7cr l t&Xt A L-ow Engineer License Number City, State,ZIP S{VaCtk, Lk of)75 • 2234383 MASON CO WA 12/09/2025 02:16 PM NOTCE DAVIS PUMPS INC #216972 Rec Fee: $304.50 Pages: 2 IIII II MI II 11111111111111111 IIII I!H IIIII II II III III III IIIII 11111111!Nil IIII Return To DO1/4v‘ mp5 111L 3r-1D W.E. 13.8- or, LAJP agS2� Grantor(s): (1) V-eY e A- flan av\tJsl-‘'r\(- -Grantee(s): (1)PUBLIC Legai Description(1) \c2-- -Of s JSj } Tz\J 23N 5 ec,'Zo 5uJ f iJ (Abbreviatecl_form:i.e. lot,block,plat or section, township, range) Assessor's Tax Parcel: (1) 1? - Z O ' — O oO 1 O NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM I (We)the undersigned grantor(;), certify that the water source located on the above-described real estate under Legal Description (1) and Assessors Tax Parcel(I) situated in Mason County, State of Washington,has been designated to serve a source of water to the following parcels situated in Mason County, State of Washington; herein described: Tax Parcel: (Connection 1) \23 Z35--OO0 1 O Tax Parcel:(Connection 2) \Z 2x)- - (Doc-pi() The system owner is responsible for keeping this system in compliance. The name of the water system is: e This system is designed to provide for two service connections. Planning and design approvals must be obtained from the department prior to expanding beyond this number of services. Additionally, a water right,obtained from the Department of Ecology, is required if the water system exceeds exemption standards. This system(has/has not)been granted one or more waivers from specific provisions of the regulations. Dated on this I I day of G ,20 . Signature of Grantor(s): /1 (1) 77 • (//gel 646, (2) V • Page 1 of 2 • • State of Washington County of Mason I,the undersigned, a Notary Public in and for the above named County and State,do hereby certify that on this 9 day of Oe.c.ewileer ,20a5 , Bent, TA 1/AvalitiSti:rk -Pe oo y Vav+bgeP rsonally 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 above written. oyi 11 44444. 140.64__ gAsiza6 \\‘ i •LEAN/�F �i% Notary Public in and for the State of Washington, ��_p cO on 1�2,744 O 0 �, residing at Vi:-}SG f 000 0 N. = vO:c.,VARY N�.m= My commission expires: D-1 -�Do2CP PUBOCI 14 'j .?Numbs . \�. //i O •• I FWAS \`��' Page 2 of 2 "tr' la O4(2.___ _.---- . i R'Vet_ .;,. ., —�� \s. \ \B,. ?np\]\\G\\\50' CAE 2(0 23/ 2= 2/ 22G' 254" \ ��� \295' A8\ 1 ... ._.. 215_I 200• _ ..__. _...._. i ,„ \aFi'&:::\ 260. 'T,.;2c An9u - - E0 I 275' -:�f U �flO Ef.. _`�.M UFF.f0 �_�2]0' Ea TING _ {.. - 1� _ E- OE�OC 260' . I ..�:� 1WG / ' .. FE, f0et ---.,..) N ..---------.255' l � -------------- \]R�gmm : N ,....,-.." 891.75' 245' 235 225' 215' ]� iy�n\�////////�������' ® ^I n e \ --- - 2/ 2]0' 2A0' 255' 255' 260' 20/ 2G0' 255' 250' 20' 230' 220' __ (`J-,V C„/// t`J I\F�� \ ZAS' ))) / DATE- 25 SEPTEMBER 2025 / P.O.BOX 2954 NAME- VANBUSKIRK SLVERDALE, A. TAX D- 1232033-00010 98383 \ / STREET- 1080 NE SAND HILL RD TEL.360-698-8488 SCALE:1"=80' I SITE PLAN INFO@ACMESEPTIC.COMi1 WATER LINE DISCLAIMER: EXISTING TANKS AND DRAINFIELDS TO BE ABANDONED TO CODE PROPERTY OWNER NOTE' NOTE: ° Carett a ALL aspects of Als septic PRESCRIPTIVE FLOW CONTROL MEASURES ISCMSELOCAMSMHEMONSIIeaa.ee aeslanft lgi neurtetl aue to chen0os to ARE TO BE DESIGNED BY LICENSED INDIVIDUALS cavv.vu,w.nvuxxacs:°xsiv.Im EllisCosign vole responsibility oCho open DepnNnenl \\ ( ary u,a solo rospensmlllty or the property owner. TAW WITH APPLICABLE STATE AND COUNTY CODES. N \ \ \ \ \\\\5'\ \ I / / 22� / -------------------___— _j 295' 290' 285' 280' 275' \265 260' 250' 245' 240' 2I0' 23/0' 220' 989.48' L— ..... 215' BU1LONU ENVELOPE N \ • \,� 110% \'� sl '' RES-•VE ♦Y© f \OR PDD+ DU l ,111 \,` • Y ROPOSED I -BR ADU 1 \ O'' - ' -4B d. Ar E is i G _ •.'`•. ` 3 SH EXISTLNG I EXISTINGBARN '- /�\ \ e �-+� ! _________J SHED I 1 3 BR HOUSE - u zt_• PROPOSE _ � \ ON,E- - \� Ile 31 BUp�Z-•. TATr FTg sD.-.- O Q - gR /.` :' DIIgIIN .-':'',13- .ECN� - ' \,-t--).------- NG ! E0 11-1-111:11.-tool VEG $0 S rn sal TowEL 11-71/-O-::: �E rQ tai /:. •''•':.:.-�• -- TO WELL ., EXISTING o BLQG. 3-BR410USE / TO Bg-REMOV _ ; /-7- ,. ' / /- -- IfRENCH CONSTRUCTION PROFIT Fl PERCENT SLOPE IN PRIMARY: 8-12% • _Th/J T/S NOTA SURVEY ALL PROPERTY LINES/BOUNDARIES HAVE MAXI sUMTTRENNHHDEPTH 21 Inches SOIL LOG#1: SOIL LOG#2: SOIL LOG#3: BEEN DEMONSTRATED BY THE OWNERS)AND/OR THEIR A GENT(S). -.s-a.-.TALLCO MUST VGRIP,THAT WATER'LINO LoOAT1ons AT Ti rut e OF INSTALL memre ALL coo0s/sFTOACIcs VERTICAL SEPARATION: 36 Inches SOIL TYPE:3 SOILTYPE:3 SOIL TYPE:3 -IT-IS-rI-IE 12ESPONSIBILIT'Y OF OWNER/REPRESENTING AGENT TO PROVIDE TO ACME IN WRITING TRENCH\MOTH: 36 Inches Cr.325:LIGHT BRO V001 SAND Er-36°:LIGHT BROWN SAND 0"-36":LIGHT BROWN SAND VA SOME PEBBLES 0NY ANC,ALL INFORMATION PERTINENT-re THE'DEVELOPMENT OF SEPTIC FEASIBILITY AND/OR ESIGN INCLUDING ALL'DRAT/LACK WATER STUB OUTS.UTILI'T'Y LOOATION5,PROPERTY DIMENSIONS ADDITIONAL COVER REQUIRED: D Inches 32"-62":GRAY MEDIUM SAND 36"•l2":GRAY MEDIUM SAND IN/SOME PEBBLES 36"-52"+:GRAY MEDIUM SAND 'DIMENSIONS.EASEMENTS,BUFFERS AND SETBACKS REQUIRED BY GOVERNING OR REGULATING ENTITIES LEGEND -OR, ..ARE) P R R WEATHER INSTALLATIONSITE PREEQUIE=. ' I,O�OTECT PRIMARY AND RESERVE 113A1NFIELD AREAS FROM ANl'VEHICLE TRAFFIC. NO FOLINIDATION SPOILS OR BURNING ON GRAINFIELD AREAS. ,p =SOIL LOO ACME DESIGN UE TO UNFORESEEN WATER TABLES,A CURTAIN=RAIN MAY B REQUIRE.. -....• a NO BUILD ZONE 'DEPENDING UPON FINAL ELEVATIONS,A PUMP MAY BE REQUIREO F CLEARING LIMITS -DIRECT ALL DOWNSPOUT/SURFACE WATER AWAY FROM GRAINFIELD AREAS. , m LOW AREAS M D A R X M AND DATE- 25 SEPTEMBER 2025 IF OF LATE ALS OR OULES ARE=EPICTED.THEY ARE PPOIATE MAY VARY. ` P.O. BOX 2954 PROVIDED LATERAL. HEV REMAIN IN THE DELINEATED CF AREA. `'/I` m TREES a 12.DIA NAME- VANBUSKIRK SILVERDALE, WA. -'ALL WELLS WITHIN'100 PEET OF PROP.BOUNDARIES HAVE BEEN SHOWN(200•FOR CLASS-B WAIVER). 'll` •EXCEPT FOR THE DISPERSAL COMPONENT,ALL SEPTIC COMPONENT.MUST BE VVATERTIGHT TO SURFACE. Q =CLEAN OUT 98383 -R LINE MUST BE A MINIMUM OF 1 O•FROM ANY SEPTIC COMPONENT. TAX ID- 12320-33-00010 -MAINTAIN A MINIM •SETACK= SLOPE OF I-PITS.M NM Mse-re,...,, L IIU OF 10• IJPSOF'e OF 1-01-re. 0 =1250-GAL SEPTIC TANK E =AN=M U H-SCLC MINIMUM B WN ,o',AIN FreL=oOVER IM one.IATELV UPON COMPLETION. 0 =D-BOX STREET- 1080 NE SAND HILL RD TEL. 360-698-8488 = D- EPENINO ON-r-I-1_ E-E TYPE-OF ATU USED.A. A USE . TRASH TRAP MAY BE B.O.-J.2.C, INF0@ACMESEPTIC.00M LATERALS MAY BE NO CLOSER THAN S.ON CENTER. =EXISTING SEPTIC TANK SCALE: 1"=50' SITE PLAN IF WATER ANO SEWER LINES CROSS,THEY MUST BE CONSTRUCTED IAW STATE F.COUNTY CODE. Na SITE DIAGRAM ?ice. I ii DYE PACKET RESULTS Background Series 1 Retrieval Social 2 Retrieval Series 3 Retrieval Silt Number Date Date Results Date ri.tr Results Dale Date Results Date Date Results Placed Retrieve Placed Retrieve PL+ced Rd.rieve Placod Retrieve } w b ' } I _________ i_______:17_1 i i BACD RIOIA)GICAL RESULTS Sate Date Results i Number I 1 r