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Home My WebLink AboutWEL2020-00004 - WEL Application, Design, Letter - 2/4/2026 MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584 SHELTON:360-427-9670,EXT 400 BELFAIR:360-275-4467,EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 02/04/2026 BENOIT ALYSSAH 111 NE BEDROCK RD BELFAIR, WA 98528 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2020-00004 111 NE Bedrock Rd 223097600140 The 2-party water system, Two-Party Well (SFR + SFR): Bedrock (223097600140/223097690151), 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, D vid Anderson Environmental Health Specialist Mason County Environmental Health „0„, n(, r(�se Date Received: ,,\, MASON COUNTY 1 - a )..... �Si : , COMMUNITY SERVICES Amount iv Receivecik 'tf , i Building,Planning,Environmental Health,Community Health 415 N.6th Street,(Bldg 8)—Shelton,WA 98584 WE L )1C.) ZG .1 (0O6 Shelton: 360-427-9670 x400 Belfair:360-275 1167 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION v APPLICANT PHO HOr -, \z- ��e`1 (i-tZ., ) "75r) Ss -3 i MAILING ADDRESS-STREET,CITY,STATE,ZIP p t/� SITE ADDRESS-STREET,CITY,STATE,ZIP ` t �`� , `W b O I i) q o Co PRIMARY PARCEL NUMBER IV AR � � LL SITE) ' SECOND 2_ 30 MBE PPL�O)C5l LA b 22RY (I ct 7 c, 90 \ 51 WATER SOURCE SOURCE TYPE PARCEL 1 LOT SIZE PARCEL 2 LOT SIZE 0 New KExisting [Well 0 Spring 6-c—v---r Z, a cX eS , PROPOSED WATER STEM NAME(REQUIRED)( // PROJECT DESCRIPTION -A-11 ,\r) <--- G.CA-?A kNIf---(1- -4-01- -- / c .c---c_c;( 1 OW NZ.{6 t/ i p DIRECTIONS, TO CONDITIONS -a \G Ut),Lk_S N\‘,-' -k...)‘,\ so\-\ `v & ) L C tom c . VveAk S\ O V\ Le-f-± Site Plan: (may also bQttached (property boundaries,structures,well site w/100'radius,driveways,roads,septic/sewer components and lines,easements,etc...) (C\''''-6.- ' ,\0_, 4.. ) ---Th . rt`k" rcsis1 ('( > ,1AN 2 2 2020 ........... ICY. Submittals Checklist: (these additional items will be required for approval) q Satisfactory Bacteriological s • a be ' of yet drilled) Dr1Well Log with pump test o 4-hour capacity test performed by driller this may be deferred if well is not yet drilled) Cr Notice to Future Property Owners recor Ing(reccewith Mason o. Auditor, supply copy of recorded document) clz Septic Records (additional locating requirements may apply if there is a lack of septic records on file) This form may be scanned and available for public view on the Mason County Web site. Revised: 1/17/2019 Page 1 of - ------------------ Staff Use Only - Review Step 1: Well Site Inspection: ICU -,So YES NO N/O ❑ ❑ Evidence of existing sources of contamination within a 100-foot radius of the water source?(drainfields, tanks,buildings;indicate distance on plot plan) 0 El ❑ Are there roa within a 100-foot radius of the water source? " ' VCIs the road te, County,or State?(circle one) Distance to the road(s) O O Does the ground slope away from the water source site? ig O O Satisfactory well cap? ❑ qi30 Well cap screened and vented? , . O The well casing extends 70 above level: ou•• /concrete slab?(circle one) V I ❑ Well tag attached to well casing? . Lat: ��-�tt�� ft ►� ❑ Evidence of an adequate surface seal? (pfir&•�.1 2f /2026 Lon: Il2.730Pe' rt' ❑ Variance necessary, for well site approval? Tag: Comments: 1(/v¢ t let{ ` o ci I oval ci lei I rev I-tiple cam!/ ilf t It 0a of Le l( ( We lay • 'de IT 100?tea bl *O*e, .S74 I(fY w d: Cke ca( re'vovw(. Zl3/tot kit cullca( k sfct1 !c v - Ik(Pass Fail pector7........___-- Date /2/ZY/2e'z r 47...,Review Step 2: Two-Party Review: YES NO NA r6 O O Water well report(well log):Date Completed /7 f I 1 y tO Driller Pa 0#1111 . O O Satisfactory capacity test showing a minimum of 800 GPD with full recovery to static level/ithin 24 hours? Capacity test information:Date olleo(told Driller/Pump Installer am it ii GPM 135- Duration(minutes) Z(10 Total Gal 3 Z te Recovery Time(minutes)to Static 15 [12(❑ ❑ Satisfactory bacteriological analysis? Date I nil/2g Testing Lab TIWY5 Vn_67(/n W ip O O Signed,notarized,and recorded notice to future property owners? AFN \ 72 3 q ?33 ly ❑ O The system appears adequate to serve two connections based on the information provi Comments: R® I fM2ot6= Pecei r 34 / -'r 11.1 120 /*FB 1/ q�� c Pee& yi Approved ❑ Denied Reviewer Date l� �N 1/1RON Od4 41F4/z4474 FNr9t Findings in this review reflect observed conditions as they existed on the day of the site inspection. No claim is made, expresIgL/% 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 1O, 2018 per ESSB 6091. Revised:07/23/2025 This foam may be scanned and made available for public viewing on the Mason County website. Page 2 of 2 Fels Onymat end Feet Copy with WATER WELL REPORT Start Card No 064489 _ Department of Ecorogy Second Copy—Owner's Copy STATE OF WASHINGTON Third Copy—Dniler'a Copy Water Night Permit No Im (1) OWNER: Name Todd Apling Address 111 Bedrock Rd Thuya WA 98588 0. a (2) LOCATION OF WELL: County Mason— • NE r SE I. sec 9 T 23 N.,p 2W W fit (2a) STREET ADODRESS Of WELL (or(mania address) • (3) PROPOSED USE: Li DomesticIndustrial C Municipal( I (1O) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION O Irrigation 1 1 Dewater Test Well :-! Other U Formation: Describe by color, character, size of material and structure, and show (I) thickness of aquifers and the kid and nature of the malarial in each striatum penetrated, (4) TYPE OF WORK: O*m.r'e number of wit wall al feast on.wltry for Fisch change of information. (M more than one)4.4 WTERUL FANS TO C Abandoned L Newweil .7d Method: Dug G Bored El _.---" — ' - . -- -- '-- O Deepened Cabe g) Driven [1 Reconditioned l' D Rotary Jetted = Brown conglornorate O (5) DIMENSIONS: Diameter of well _ 6 _ inches. am- tD Dolled____131._ _tees. Depth of completed well 1337 ti. _Hardpan 4 . 83 G (6) CONSTRUCTION DETAILS: crt,nt,torl catlri & Qravi 1 wi th crater $3 i 110 4 Casing Installed: ...El__' Diem.from ]nn Lft.to 132 H. Liner u 1-0 ' Diem.from ft.to ft. cand & gravel with water -130 ! 137 Liner installed(1 �7a fL Threaded ❑ ''1 Diem from—_ II.to ft. 4-0 LJ Perforations: Yes NZ J ♦ -- - — - -- -- L Type of perforatorused O SIZE of pertoradana _ in.by_ In. 13 C __ perforagns from h.10 h. R perforations from ft.to_ _ It. CO perforations from ft.to n. - CICI Screens: YesiJ5i NOD -. Manufacturer'aName— HOUSton - t _ Type statnless Model No. _ Diem. V' slot siz. 50 from 1 32 n.to 1 37 n. *. = i ^— 4.. Diem Slot sirs Iron', _ft.to._- n. ,_.._--s- 1 (D Gravel packed: YeaE1 NOUL sizsol0 a•1 • - - L Gravel placed from ft.to ft. - nn -- r h.. - Surface weal: Yea.]CI Mop To what depth? la ft Im" Material used m seal__BP t can i tall OClod any strata Contain unuaabN wsler? Yma1_ ) No Lill I_ -T- Z Type of water?_ _ _ Depth of strata_ — s' --_- - -- ------ U) Method of sealing strata off - — Q (7) PUMP: Manufacturers Name Myers Typo. sub. Hp..3/4 C1) (8) WATER LEVELS: cans)rnnac.ea l erio( n/yn� abov.mean au Nwl_. ---. _ ft. � O Static level_100 ._—ft below top of well Date — O Artesian pressure _Iba.per equate inch Delft — _ -- _ ___ - -. - -.---- ---.-Ciii)U Anse'sn water is conlrolNd by u (Cop.waive.etc.)) - ' Work started ,19. Completed Dec. .1290 O (9) WELL 'TESTS: DrawdOwn a emlOun1 water level is towered below static Must a.+ Wes is pump test made?Vivo ID No(Xi if yes,by whom? WELL CONSTRUCTOR CERTIFICATION: C Yield. gal?men.with_._ ft.drewdown after hrs. fy __ 1 constructed and/or accept responsibility for construction of this well, E - •• and its compliance with all Washington well construction standards. Materials used end the information reported above are true to my best L Recovery date(time taken a zero when pump turned oft)(water level measured knowledge end belief. CO from well top to ureter level) CL T,me Water Lw.i Ton. W.i..Levet Time Wetter Level CD NAME_ Davis Drilling 0 (PERSON.FIRM,OR CORPORATION) (TYPE OP PRINT) (I) Address Bed 8528 I- Data or teat _ L (Signed _ License No. --1 ABC Bailer test 16 gel.?min.with 7 ft drewdown after_I__ hrs. (WELL DRIUER) Contractor's Airiest—. gal./min.with stem set at ft for__ ___hrs. N SU. 1 (X1A Dais Dec._ . 19_90 Artesian flow g.p.m. Date_ ___ _. — T.mp.ralur.Olwaist Was a chemical enelysismode? Yea t^l No® (USE ADDITIONAL SHEETS It NECESSARY) ECY G50 140 11O,en '329• sill..3 Davis Drilling, Inc. 340 NE Davis Farm Rd Belfair, WA 98528 275-5367 Test pump for: Erik Haney 111 NE Bedrock Rd January 20, 2020 Pump: 1 hp Depth: Static Level: 105' Pump set: Draw Down Time Water Flow GPM Level 0 min 105' 0 5 min 107.5' 13.5 10 min 107.4' 13.5 15 min 107.5' 13.5 30 min 107.5' 13.5 1 hr 107.4' 13.5 2 hr 107.5' 13.5 3 hr 107.5' 13.5 4 hr 107.5' 13.5 Recovery Time Water Level 0 min 107.5' 1 min 105.5' 2 min 105.3' 3 min 105.3' 4 min 105.2' 5 min 105.2' 10 min 105.1' 15 min 105' 1 hurslun County f nvlrt)nmcntal II 'tIth 412 I Illy Rli NI Olympia,WA Ofi;r)f, 116861 )611 1111 n•1\1N1111tN11' twirerterreeellnen COLIFORM BACTERIA ANALYSIS Dale Sample Collected 1 Mtn:;nmpin County Collo(Ind R0=0 1 I I 12 4 V� � fy".,3 r� JAN month Dal \en, --__._----_. .- ZOLQ U Type of Water System(chock only ono box) Prlvale Household 0 Group A 0 Group B 0 Other_ RECEIVE/1 Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# System Name: Contact Person: ( (` S S1k toe-s o I Day Phone:( ) J Cell Phone:(3(of0 ) 2C 1()I G E•mail{n`�)p)y(SIT-F? 6.)1 yr p,I,CO;v Eve.Phone:( ) S d results to:(Print full name,address and zip code or email address) [1'tySS�J.I� fr�el�lbt �_ lit V1/ 0otROGU( io41 ca3s2s, SAMPLE INFORMATION Sample collected by(name): I)—t 1 J 1 6-e y-ko t Specific location or address where sample collected: Special instructions or comments: -dot 1 ss Type of Sample(must check only one box of#1 through#4 listed below) 1.p Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes No 0 Distribution System Chlorine Residual:Total Free Chlorinated:Yes No 3.Raw Water Source Sample Chlorine Residual:Total Free_ ❑E.coil—GWR(NP) ❑Fecal—Surface,Gwl,springs(numeration) Unsatisfactory routine lab number: Filtered.Yes No ❑Assessment Monitoring(NP) Unsatisfactory routine collect date: ❑Other 1 1 S 4.0 Sample Collected for Information Only Investigative Construction/Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAQ USE ONLY 0 Unsatisfactory Total Coliform Present and Satisfactory ❑E colt present ❑E.coli absent No Coliform detected Replacement Sample Required: ❑Sample too old(>30 hours) 0 TNTC ❑ Bacterial Density Results:Total Coliform /100ml. E.coli /100m1. Fecal Coliform 1100m1 Enterococci /100 ml. Method Code:0 SM 92238 ❑SM 9222D Date and Tree Received.b"1O0 ❑SM 9215B O Enterolert0 l- `Ck, 2..t, te S Date and Time Analyzed. l. I 1•2tD Date Reported:('L5+ 'ys(.�� Sample Number(DOH nunbe,plus fire d s e) Lab Use Only: 0 8 DOH km*315.3% 11 --_ Cast•. 1786 SE Mile Iiffi Drive — It 3PECTRA Laboratories-Kitsap Port Orchard.WA 98366 A - . .r.�,n,,,,.m,u„ H'ww.spectra-Iab.com w4'4414---s'`�' !tom, `' ' ' : �'opf,.. 1 (360)443-7845 L. x j.vi COLiFOR BACTERIA ANALYSIS FORM �' '' ,4.. 1`.,.%,,a—Z-,,,,%71‘` r, oaa sernp�a Collected. sr "` `_�' Tine Sample Courtly , e! _ ; � ,„`‘. Z.r�2� Card ae �; c� � +' MmR AP Ws .--N . II �V t, • r• �'r .- k ve 6 w Tpa Water System(dregs gllyDne box) i ' to M�'-.�• Group R and s Systems—Provide from wetsrF ., ' " / '` `� , lOff �� rte. ♦ ` hSul �� 4...,,—,), Contact Pere= 0 t 5 �.rr-..vl;t;VI E. at.Phone: '�rn'ti.e+�` Send mael�b;(Pad - ,. �w �,;;� _ 3 l l 4 s l pit i 1j,,, r . '' 'r ` 4 wiN.'F`,.,;,r , • a ^�srs y � ,.q - any N x a ter`*t ,i` Semple ceded by(name): a. Tt} R.. re basket whereeamplecoilectet Special instructions or ,,, Colif+tir m Distribution System �5ovrC Sampling Procedure woe ofSemRler(chedcC1. y 1.O RouBne Distnbutian � a Step One Ste Tour CModouti Yes 0 Q Z Repeat Sample(alter unset routine} Avoid poor sample sites such as _The a maybe some litinidor CMaine Residual:Total Free D utwn System srvivelfauoets,i hot and eoldmiaing r in the sample bottle to faucets(with a singlelever),dealtyor remove chlorine.Do not rinse it Unsatisfactory routhe lab number. — s0s raring faucets,drinking 3.Source Ground Water Rule Sample c, untains;janitorial sinks,frost.fine s 1 ! I Unsatisfactory routine collect date: hose biibs,and faucets below ornear 'tell rive / / ground level To avoid contamination while Triggered Chlorinated:Yes U U Step Two taking the sample,hold the bottle aearthe bottom with one hand and 1:30 Aases'srnent . Chlorine Reslduet T Free Remove anyattaehinentsfromthe hold the top of the cap with the 4. mum ,Souse a wrters.�ie faucet,including aerators,screens, other.Now unscrew thecap. DEW pFecat- I S I I I washers,hosesand water filters,If sampfecoleead epM Rlr a�+,.❑ �� you chooseto disinfactthesample DONOTs�eeapdo�touch _ site prior to samp le plc collection,be anppartofthe tip thattonches the fx�-tA -S€�l--,- ' DR1AtKi � `,e " `..- ,.- sure taflnshthoroughly ,� WATEg_LTS all disinfectant. wremave oft ebotorltleorin ides etttherim .• unsatisfactory Totes Coilorm Present and ebottleorinSidethecap.J •--�Ecofaresent CEcoi absent . S S 'Reelaicementr?amPl Recostvd: ► • Hoidthabottleunderthe stream of ,` $ nplat000{dZ>30fwprs) �1MC i�3. water,be careful not tolettbeboftle touch thesamgletnp.Filthebottlt Se to to the indicated Milne,donotallew • :/tom col _rf0Ornt• it to overflow.Remove_the bottle Ggi�rm _ . n:,�: - from thewaterfowandsecurethe = t a6teane �U St 0p Three cap. o ` . G 3 �rr1 201_Q- • \\ T�rraaatliecold ��d Step Seven ;ai�rodaide.: . • wfthastea Compietethelab slip>Sltfi+922� ,. Wutd:.. atflleastfiveminutes.Before. unusualaboatthe Note gs taaaa �,, collecting the sample,turn the P 4.1s);:2- �OZQ • 2 2 . �t Tel e r streamand Step:E t onemmute. Secursthe lab td•ubr<nn If sliFterthes ttIeseto 3, they is �, � rabbal•band.�Del�rthesampieto : 5•- .% 0 3 measure thefreecblonaeandnote Centric Analytical Labs as soon as �".wiAIN, ...°°,b*At S"M �■o Rom++r.rn,} themeasnrementonthelabslip. possrble. .`WATER AI MANAGEMENT 1515 sock St. E. Tacoma, WA 98404 LABORATORIES INC. (253) 531-3121 MEW May 19, 2025 Nicholson Drilling oFC 442 PO Box 123 "Z/ Port Orchard, WA 98366 Attn: Alex James fi �F Z01S O Dear Ms. James: Results of analysis of one drinking water sample taken on 05-08-2025 at 12:30 p.m. and received on 05-09-2025 at 11:20 a.m. are as follows: Sample Identification: Alyssah Benoit - 111 NE Bedrock Rd Test Results Microscopic Exam 1. Iron Bacteria (64,000/L) Gallionella ferruginea 2. Sulfur Bacteria (< 2*/L) * < is less than Lab Number: 08915467 Sample was analyzed according to Standard Methods for the Examination of Water and Wastewater, 22nd Edition. Chain of custody record is enclosed. Sincerely, Diane DuMond Microbiologist DD:mmj Enclosure R:\DRILL\NICHOLSONDRILLWNG5-9 COOLWATER DRILLING, INC. 10921 HOLLY RD NW BREMERTON, WA 98312 L t, 360-830-9005 COOLWDI941QM DEC 2 2 2025 RECEIVED 1. A well inspection was conducted at 111 NE Bedrock RD, Belfair on 1 October 2024. The following was found. a. The pressure tank has the proper air pressure of 30 PSI. Recommend airing it up to the required 38 PSI. b. The pressure switch is in good condition. c. The control box had no corrosion on the start capacitor. Condition good. d. Motor windings had the following OHM readings BLK/YL— 2.9 Range should be between 3.0-4.0 RD/YL — 11.9 Range should be between 11-13.5 Pump and motor seem ok. e. The pressure gauge is not reading at all. Recommend replacing. f. The plumbing is in good condition with no leaks. g. The well head well cap is secure and in good condition however the conduit going into the well head is free from it and allowing spiders and dirt in the well. Recommend reinstalling conduit to secure to the well head. h. The boiler drain on the tank is leaking. Need to tighten packing nut 2. No pump test was performed. A bacterial sample was taken and will be forwarded when received. //s// Brian Trotter Pump Installer 2234933 MASON CO WA 12/22/2025 03.35 PM NOTCE MASON COUNTY ENV *217407 Rec Fee $304 50 Pages 2 1 KIM III fII 11I!!II 111111 II �►►►1 l!VIII 1111111!1'11111 VIII I Im Return To U Str1 C DLtn} b nv f Cyr, c\,1 n--\u.1 �c�0� \i' LA4O/\ L.KDA c\Y-3'34 [9) LiCIPTIPPre DEC 2 2 202 f 5 ,/ Grantor(s): (I) i9-1S5@k1 Venal 1 ,(2) {-( '1kene n S1.). •e- Grantee(s): (1)PUBLIC Legal Description(1) \ ( (D(' Sus- (Abbreviated form:i.e. lot,hlocI plat or section, tots nsltip,range) Assessor's Tax Parcel: (1) a-4 3 D Ct - 1 - DC) 14O GO —7—a3— ,R ")- NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM I(We)the undersigned grantor(s), certify that the water source located on the above-described real estate under Legal Description(1) and Assessors Tax Parcel(1)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) a 3oci — -11O_ 00 ►,{-0 Tax Parcel: (Connection 2) 3 C - ti -L1 Q 1 ej l The system owner is responsible for keeping this system in compliance. The name of the water system is: C' V 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 day of .20 Signature of Grantor(s): (1) . t 2) \`u • Page I 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 2 day of bece_wyto.e r ,205, 41 SG' il Ae'i c,ft i(j'G,I fi.e Swd)personally appeared before me,who is knom,n to he 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 written. Notary u lic in and for the State of Washington, residing at 6e,t .�,vt I kAm- My commission expires: 0147---1 el j Z 0 z4 2 K 1thle ie O L.,L)ofe ,L)--V(?-- y { P'- � � p r D eL c + ,fit ..��\g5l0N�E}A 4, .�' ��;�c,�< <2c1 a •'c° NO TA R Y ��Fo t, ms's V C s �- z w A C'V 6t4 e 171724 N� , PUBLIC '. . ,��'•�4/i812016 '/A?�.: Page 2 of 2124650 MASON CO WA 01/22/2020 01 41 PM AGREE DAVIS DRILLING #134794 Rec Fee $105 50 Pages 3 III II II III III II IIIIIII VIII IIII I II VIII III II III II III I II I III II Return To: Davis Drilling 340 NE Davis Farm Rd Belfair,Wa 98528 Declaration of Water Use Agreement Bedrock Water System Private 2 Party ABBREVIATED LEGAL DESCRIPTIONS AND PARCEL NUMBERS OF TRACTS BEING SERVED: The well and water system being situated on Parcel#22309-76-00140 Section 9 Township 23N Range 2W NE% SW%-'h 111 NE Bedrock Rd Belfair,Wa 98528 Grantor:Erik Haney Grantee: Erik Haney has been designated to serve a source of water to the following parcels situated in Mason County,State of Washington;herein described: Parcel#22309-76-00140,TR 14 OF SURVEY 12/34 111 NE Bedrock Rd Belfair,Wa 98528 Parcel#22309-76-90151,TR 15-B OF SURVEY 12/34 TR B OF SP#1695 151 NE Bedrock Rd Belfair,Wa 98528 OWNERSHIP OF 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 and 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. COST OF MAINTENANCE OF WATER SYSTEM Each party hereto covenants and agrees that they shall equally share the maintenance and operational costs of the well and water system herein described. An annual utility fee shall be paid by the owner(s)of Parcel# 22309-76-90151,TR 15-B OF SURVEY 12/34 TR B OF SP#1695 151 NE Bedrock Rd Belfair,Wa 98528 to the owner(s)of Parcel#22309-76-00140,TR 14 OF SURVEY 12/34111 NE Bedrock Rd Belfair,Wa 98528 of $100 to cover electrical utility costs. This fee shall be determined annually to be revisited and agreed upon by both parties at the beginning of each year. The expense of water quality sampling as required by the State of Washington and Mason County shall be shared equally by both parties. The parties shall establish and maintain a reserve account at at mutually agreed upon banking institution. Each party shall be entitled to receive an annual statement from said banking institution regarding the status of the reserve account. The monetary funds in the reserve account shall be utilized for the sole purpose of submitting water samples for quality analysis and maintaining,repairing or replacing the well and components to complete and maintain a properly functioning water system and appurtenance thereto. NOTICE TO FUTURE PROPERTY OWNERS The water system is designed to provide for two services. Additional planning and design approvals must be obtained from the local health jurisdiction prior to expanding beyond this number of services. Design flow standards account for domestic use and watering of a typical lawn and/or 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 WELL SITE AND PUMPHOUSE There shall be an easement for the purpose of installing,maintaining and repairing the well,distribution and water system components to complete and maintain a properly functioning water system and appurtenance thereto,within 100 feet of the well site in any direction. Said easement shall allow the installation of well/pump house,pumps, water storage reservoirs,pressure tanks,waterline and 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 be no leakage of seepage,or other defects which may cause contamination of the water,or injury,or damage to persons or property. Cost of repairing or maintaining common distribution pipelines shall be borne equally by both parties. Each party in this agreement shall be responsible for the installation,maintenance,repair,and replacement of pipe supplying water from the common water distribution piping to their own particular dwelling and property. Water pipelines shall not be installed within 10 feet of a septic tank or within 10 feet of sewage disposal drainfield lines. PROHIBITED 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,railroad tracks,vehicles,structures,barns,feeding stations,grazing animals, enclosures for maintaining fowl or animal manure,liquid or dry chemical storage,herbicides,insecticides, hazardous waste or garbage of any kind. The parties herein,their heirs,successors and/or assigns are required to keep the water supplied from said well free from impurities which might be injurious to the public health. It is the purpose of these grants and covenants to prevent certain practices hereinafter enumerated in the use of said grantor(s)land which might contaminate said water supply. Exhibit A NOW,THEREFORE,the grantor(s)agree(s)and covenant(s)that said grantor(s),his(her)(their)heirs, successors and assigns will not construct,maintain,or suffer to be constructed or maintained upon the said land of the grantor(s)and within fifty(50)feet of the well herein described,so long as the same is operated to furnish water for public consumption,ANY POTENTIAL SOURCE OF CONTAMINATION INCLUDING BUT NOT LIMITED TO:cesspools,sewers,privies,septic tanks,drainfields,manure piles,fenced pasture,garbage of any kind or description,any enclosure or structures for the keeping or storage of non biodegradable fertilizers,liquid or dry chemicals,herbicides or insecticides as well as any enclosures or structures for the keeping or maintenance of fowl or animals such as barns,chicken houses,rabbit hutches,pigpens,livestock sheds,and further agree(s)not to use, apply,dispose or suffer to be used,applied or disposed,non biodegradable fertilizers,any liquid or dry chemicals, herbicides or insecticides within the above described protective radius.These covenants shall run with the land and shall be binding on all parties having or acquiring any right,title,or interest in the land described herein or any part thereof,and shall inure to the benefit of each owner thereof. WATER SYSTEM MANAGER The owner of Parcel#22309-76-00140,TR 14 OF SURVEY 12/34,111 NE Bedrock Rd Belfair,Wa 98528 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. HEIRS.SUCCESSORS AND ASSIGNS These covenants and agreements shall run with the land and shall be binding on all parties having or acquiring any right,title,or interest in this land described herein or any part hereof,and it shall pass to and be for the benefit of each owner thereof. ENFORCEMENT OF AGREEMENT ON NON-CONFORMING PARTIES AND PROPERTIES The parties herein agree to establish the right to make reasonable regulations for the operation of the system,such as termination of services if bills are not paid within 45 days of the due date,additional charges for disconnection, reconnection,etc. Parties not conforming with the provisions of this agreement shall be subject to interest charges of 18%per annum together with all collection fees. i/77/ 00?v Signature Bedrock W ystem User/Owner Date /7(772020 Signature Bedrock Water System User/Owner Date State of Washington, County of V`1v,S1ni4Cn I,the undersigned, a Notary Public in and for the named above County and State, do hereby certify that on this (7 day ofianuarki, 202Q, personally appeared before me En PLC. /(C.le,y to me known to be the individual described on and who executed the within instrument, and acknowledge that he(she) (they) signed and sealed the same as free and voluntary act and deed, for the users and purposes herein mentioned. GIVEN under my hand and official seal the day and year last above written. /i ELIANA ALLYN N to Public in and for the State of Washington, I Notary Public residing at srtr,ho#-rn Sh ' State of Washington My Appointment Expires Aug 1, 2020 My commission expires:c/o/ /20 2O , E } sa a -" #^a $ t L- i, . w�-.t^ 6�s No, pCt"R#Y' *J'C!7`TtT ';k ,"-....k. + `. ' ` yV1 MASON COUNTY DEPARTMENT OF GENERAL SERVICES - FOR )EPAR7 ENT it ST-. Or4 .si ENVIRONMENTAL HEALTH *., " 5 ' .._, t _ '., ". 303 NORTH 4TH/P.O.BOX 186/SHELTON,WA 98584 ` PHONE(208)427-9670 ¢ -.� ' _ a r 7 . APPLICANT SIGNATURE A ,,,, JJ - Ale-rive q-- -- ��,�/ y �f ADORES Ali_L:. Ale—ri a ._. (1 E p7_.t...i-._ /G O A .4 v aE 4 t f 4PF#st7.4GIA ?flit PROPERTY OWNER ADDRESS PHONE SEWAGE SEWAGE ��•/ CONTRACTOR .. r76./ 0 DESIGNER ...----- LEGAL DESCRIPTION .�.r 1'/I*er l'i't Ai—oil/47 v 7%214?-7 . e G `j—{a..4,:t 3 0.^ R Zw,v.x TYPE OF NO.OF LOT 4eBUILDING h/�0lt� BEDROOMS _SIZE 'I SINGLE RESIDENCE ✓ PUBLIC WATER NAME WATER SYSTEM SYSTEM €.'.;,'s. . -- 'tca a COMMERCIAL ONLY LIQUID WASTE G.P.D. cx DIRECTIONS TO SITE: , f t; ft 44 t'',. 7j-4_4.4.4.,...4"...uf4L t i„ 1't ',,it‘...... C O i4 3`T 5R 4 44.7°A/ 441'6 7a nizitic4.41 OQA 47,y - Tiled) LE f7- To GaT II' t.--!"IN r i Tt.N ARE'A .?T Yxl.. „;:::•1,414p _ Ct " PL t es • /IA P_. •4INital INSPECTION REQUIRED EEc0RE i i L Qt ... ! tr i vSf 1 t>'. f one► S PTf SPFA d ofZY 'Roil- tov i? §.� o.a - Viz*�,c: :' I__Ii_7.,s 9 / 01--)V . ,,, .....,...,,,...,„„....„....,•-• - • , TE PLAN AND SPECIAL STIPULATIONS `, '. 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APLii14 ADDRESS//40 4 '(,4t/AA"C THIS RECORD IS NOT A GUARANTEE OF PERFORMANCE. CITY //7� ZIP A SEPTIC SYSTEM IS NOT A MUNICIPAL SEWER. HOWEVER ORCAICATO/./ f jVA /I„_. WITH PROPER MAINTENANCE AND CAREFUL USE OF LEGAL DESCRIPTION WATER IT CAN GIVE MANY YEARS OF TROUBLE FREE SER- 'TWIT 1.ff '1t1(1N5 0�/ Tk. J 41-]''te.fo qv t tE' VICE. MANY PROBLEMS WITH SEPTIC TANKS ARE CAUSED SOIL BY FLUSHING EXCESSIVE AMOUNTS OF PAPER, CLOTH COMMENTS [y(h� 4-U AND PLASTIC MATERIALS DOWN THE DRAIN, OR BY SITE FIELD X LARGE AMOUNTS OF WATER FROM LEAKY FAUCETS OR NO. SIZE FAULTY FIXTURES. DEPTH TO MONTH • THE SEPTIC TANK ITSELF SHOULD BE CLEANED EVERY WATER TABLE OF YEAR 1 J L /�/ TWO OR THREE YEARS DEPENDING ON THE HABITS OF THE INSTALLER n J j FAMILY, THE NUMBER OF FIXTURES IN THE HOUSE, AND ! •4 k' L) THE AMOUNT THAT A GARBAGE DISPOSAL IS USED.CLEAN- SIZE r �_ LNG AT THE RIGHT TIME WILL AVOID THE RISK OF INJUR- SEPTIC TANK (S) /2..60 �� /1 < INC OR DESTROYING THE DRAINFIELD DUE TO SOLIDS DRAINFIELD . FEET CARRYING OVER INTO THE DRAINFIELD. CALL THELENGTH a ��'� MASON COUNTY HEALTH DEPARTMENT FOR A LIST OF TRENCH AREA SQ. FT. LICENSED SEPTIC TANK CLEANERS IN YOUR AREA. THE CLEANER CAN SERVE YOU BEST IF YOU SHOW HIM THIS TILE ❑ CORRUGATED Q'R GID ❑ CEMENT RECORD WHEN HE COMES. DEPTH /2 - DEPTH ROCK TOTAL HEAVY TRUCKS OR EQUIPMENT SHOULD NEVER BE j MOW Cu. YDS. DRIVEN OVER THE TANK OR DRAINFIELD. CONSULT THIS PIPE / DEPTH RECORD IN CASE OF ANY BUILDINGS, DRIVEWAYS, SPACE RESERVED FOR REPLACEMENT DISTRIBUTION FIELD: SQ. FT. SWIMMING POOLS, OR EXTENSIVE GRADING OR FILLING ARE LATER CONTEMPLATED. + NORTH SHRUBS OR TREES SHOULD NOT BE PLANTED CLOSE TO THE SEPTIC TANK AS THEY WOULD INTERFERE WITH CLEANING OF THE TANK. THEY CAN BE PLANTED IN THE DRAINFIELD AREA PROVIDING WILLOWS ARE NOT USED. <<v„ THE YARD GRADE IN THE DISPOSAL AREA SHOULD BE SUCH THAT SURFACE WATER IS NOT POCKETED ON THE DRAINFIELD. ANY SETTLING OF THE GROUND OVER THE o TRENCHES SHOULD BE FILLED IN WITH SOIL. DO NOT EX- A CESSIVELY WATER THE LAWN IN THE DRAINFIELD AREA. o WATER EVAPORATION FROM THE DRAINFIELD IS ABOUT EQUAL TO ONE HALF INCH OF RAIN PER DAY. 15 l FOOTING DRAINAGE, DOWNSPOUTS AND WATER SOFTENER RECHARGE WATER SHOULD NOT BE CON- NECTED TO THE SEPTIC SYSTEM OR DISCHARGED INTO THE DRAINFIELD AREA. THE TYPES OF BACTERIA NEEDED IN A SEPTIC TANK ARE ~b I ALWAYS FOUND IN SEWAGE. THERE IS NO NEED TO ADD YEAST OR OTHER STARTERS TO A SYSTEM. THE USE OF RE- JUVENATORS OR CHEMICALS TO CLEAN A SEPTIC TANK HAVE NOT BEEN PROVEN TO BE BENEFICIAL AND MAY BE HARMFUL BY FLUSHING SOLIDS OUT OF THE TANK OR BY CHANGING THE CHARACTERISTICS OF THE SOIL. THE NORMAL USE OF BOWL CLEANERS OR CLEANING COM- POUNDS WILL NOT KILL THE BACTERIAL ACTION OR SLOW _ SOUTH >Ir DOWN THE OPERATION OF THE SEPTIC TANK. a 5 f �S .�1 IM c, Te N t ¢ SIGNATURE OF INSTALLER P" �(NI t Et OTf ER-1 �)k ZS-1 9 t +4�► P — ' t.' E,�SEN AL Pr4PER$c..+Urrny' L}:� DATE SGN RE OF INSPECTOR