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HomeMy WebLinkAboutWEL2026-00011 - WEL Application, Design, Letter - 5/19/2026 MASON COUNTY 415 N 6TH STREET,SHELTON,WA E 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 05/19/2026 MORRISON WILLIAM JAMES & MARCIA G 51 E PIRATES DRIVE GRAPEVIEW, WA 98546 RE: WA TER SYSTEM PERMIT: TWO-PARTY WEL2026-00011 260 E Lombard Rd S 121074401020 The 2-party water system, Two-Party Well (SFR+ SFR):Voight Estate (121074401020/ 121074401010), 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 / r MASON COUNTY Date Received COMMUNITY SERVICES Amount Received: Received ( Building,Planning,Environmental Health,Community Health ']I(�l 415 N.6°i Street,(Bldg 8)—Shelton,WA 98584 WE L o 52i (p '- c L Shelton:360-427-9670 x400 Belfair:360-275-4467 x400 Elma:360-482-5269 x400 TWO-PARTY PRIVATE WATER SYSTEM APPLICATION APPLICANT •PHONE \ ®,��V� -/V is 4' A 6- g . 2 'q q MAILING AD RESS-STREET,CITY,STATE,ZIP _7ppy� 'A/ _ R♦ / ' - S TE ADDRESS-STREET,CITY,STATE,ZIP S AI4AfrMIW C® ;? [s/ WA. e PRIMARY PARCEL NUMBER(WELL SITE) — i c .� SECONDA Y PA EL NU ER(SA AS PRIMARY IF LOCATED ON SAME PARCEL) WATER SOURCE SOURCE TYPE PARCEL I LOT SIZE(no minimum) PARCEL 2 LOT SIZE(no minimum) ❑ New xisting ellfl Spring - cJ2 ≤-. PROPOSED WATER SYSTEM NAME(REQUIRED). �q Vo f PROJECT DESCRIPTIO e.g.,detached ADU,new single-family residence,existing connection,etc.) DIRECTIONS TO SITE/CONDITIONS/ApGATE CODE/KEY LOCATION/JJETC.© CJ Aoôp t e h r /Zii' OF ' i°3 O a 2— Required Submittals/Requirements Checklist: ❑ Original water well report(well log)or DoE water well report for an existing well. ❑ Well tag secured to the well casing. APR 0 / LLLJ ❑ Capacity test showing 800 GPD with drawdown and recovery to static level information. ❑ Bacteriological test(Bac-t)results: current(within 12 months)and satisfactory. ❑ Septic Records(additional locating requirements may apply if no septic records are on file). ❑ Applicable utility easement documents. ❑Notice to Future Property Owners of a Private Two-Party Water System,Water Use Agreement, and Access Easement(s)recorded with the Mason County Auditor's Office. *Note:May be recorded after the permit has been preapproved. I own the proposed two-party water well and have the right to grant access for a second connection.I attest that the well currently has no more than one connection. Print:W/ &i f,tNV A-/M lf:4 I'd19�7/S.�I s ate: ' /` 02 ` W26 This form may be scanned and made available for(/ublic viewing on the Mason County website Pg 2 Last Updated: 1/7/2026 Tiease include the following site features for each parcel served by the proposed two-party well: ❑ Parcel numbers(s) ❑ Property lines/boundaries ❑ Applicable easements with the Auditor's File Number(AFN) ❑ Roads and driveways ❑ Well location with a 100 ft radius around it ❑ Structures*Water wells shall not be located in garages,barns,storage buildings,or dwellings(WAC 173-160-171) ❑ Water lines for existing and proposed connections ❑ Septic and sewer components(tanks,primary and reserve drainfields,transport lines) ❑ Barns,chicken coops,barns,manure piles,dog kennels,commercial gardens,compost piles ❑ Chemical Storage within 100 ft ❑ Landfills(existing or former)within 1000 ft Site Drawing K O Are AR - E / L ,ei 'IV kIAY ® e ItR 1ira ZpoØ 1 J This form may be scanned and made available for public viewing on the Mason County we site Pg 3 Last Updated: 1/7/2026 ---------------------------_____------_-- ______—__-- Staff Use Only ----- ------_----_--------------------- f Review Step 1: Well Site Inspection: YES NO N/O ❑ Z ❑ Sources of contamination within 100 ft of the well?(septic components,chemicals,livestock,etc.) ❑ ❑ Roads located within 100 ft of the water source?Private/C y un /State Distance to road(s) / t7 ❑ ❑ Ground slopes away from the well? ❑ ❑ Well located outside of garages,barns,storage buildings,and dwellings,with at least 5 ft of separation? ❑ ❑ Satisfactory metal or plastic well cap that is mechanically secured or welded to the casing? ❑ ❑ Access ports and openings sealed/screened to prevent contamination;pressure gauge installed for artesian wells? ❑ ❑ Adequate surface seal,filled to land surface level?*Leaving voids for future installation of equipment is prohibited. ❑ ❑ The well casing extends above level gr u /concrete slab. Lat: 4 .�!f 3 ❑ ❑ DoE well tag attached to the well casing? Y Lon: � l2L•g1tS3r Tag: A of c 8Z ❑ ❑ Variance necessary for well site approval? Comments: Pass ❑ Fail Inspector Date , /?z Review Step 2: Two-Party Review: YES NO NA❑ ❑ Water well report(well log): Date Completed 6(Z (`/t r y 5 Driller & (4 Dil l!1', ❑ ® Satisfactory capacity test showing a minimum of 800 GPD with full recovery to static level wi l in 24 hours? Capacity test information:Date 3 112(71C Driller/Pump Installer�Ccq' 44'QOt'I(ti�, GPM Ii Duration(minutes) O Total Gal 880 Recovery Time(minutes)to Static 6 © ❑ ❑ Water system capable of supplying at least 30 PSI to each connection?PSI ® ❑ ❑ Satisfactory bacteriological analysis? Date 11 t 6(11?6 Testing Lab iI n(M5 v COV)I$I F 14 ® ❑ O Signed,notarized,and recorded notice to future property owners?AFN a Z3? 3 I 1W ❑ ❑ Signed,notarized,and recorded water use agreement?AFN Z Z l 0)1 ❑ ❑ Signed,notarized,and recorded access easement(s)?AFN 2_Z U tI ❑ ❑ The system appears adequate to serve two connections based on the information provided? f ec e1`y'erk w-qW Vt ag ra#W1/- 5 ( cd( 7o 76 f 1 74.9 3((( Comments: Approved ❑ Denied Reviewer Date 5(( 7( 7 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«',2018 per ESSB 6091. This form may be scanned and made available for public viewing on the Mason County website Pg 4 Last Updated: 1/7/2026 Start Cord No. W 0 61313 ptimntofE ologyopywns► WATER WELL REPORT UNIOUEWELLLD.I A 7 artment of Ecology and Copy—owner's Copy STATE OF WASHINGTON Wad Right permit No. d copy—Dreller's copy OWNER: Nam Bill Voight MleS PO Box 289 Grapeview, WA 98546 LOCATION OF WELL: col rdy Mason _SE y1 SE 1m Sec 7 T. 21N N.,R 1W W.M. STREET ADDRESS OFWELL(ornearestaddleas) E Lambard Rd Gra eview WA 98546 PROPOSED USE: 10 Domestic industrial ❑ Municipal ❑ (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION ❑ Irrigation o Dewater Test Well O Other ❑ rm Foation:Describe by color,character,sae of material and structure,and show thickness of aquifers and the kind and nature of the material in each stratum penetrated,with at least one entry for each change of inlortrhatton. { TYPE OF WORK: Owner's man�of well MATERIAL FROM To -- Abandoned 0 New wall M Method:Dug 0 Bored 0 Deepened 0 Cabl�p Driven❑ Brown_conglomerate -_(L _1 Reconditioned❑ Rotary O Jetted❑ DIMENSIONS: Diameter of wet 6 Inches. Brown sand 18 3 Drilled 17 2 feet. Depth of completed well 172 it. CONSTRUCTION DETAILS: Casing Installed: _______ Dial from__ft.to 16 7 n. Welded [[33(� hem m n.to n• Liner installed❑ Diam.from n.to n Threaded ❑ Perforations: Yes❑ No®' Type of perforator used SIZE of perforations in.by In. perforations from f.to •, n _.. perforations from it.to n• { perforations from ft.to n' Screens: Yes Name No ❑ xxxscx u^��etnn Manufacturer's Name rt Type Stainless wire wrap ModelNo• tt 167 n.co_ 1 tt Diam.�slot sae 35 •hom_ - t- Dim. -Slot size iron _ft to n. Gravel packed: Yes ❑ No[ Size of gravel Gravel placed from tL to n. Surface seal: Yes[S No❑ To what depth? fL Material used in seal R en t on i t s Did any strata contain unusable water? Yes❑ No Type of water? Depth of strata Method of sealing strata off 7) PUMP: Manufaaure?aName' GruedfoS Type: a ub H.P. Tana sunaoe efevuwn Work Started 6J2.2/95 ,i .9. completed 6 2 9 to p) WATER LEVELS: q �mean sea level n. Static level 1-S U ft.below top of well Date WELL CONSTRUCTOR CERTIFICATION: Artesian pressure lbs.per square inch Date I constructed anchor accept responsibility for construction of this well, and its Artesian water is controlled by (Cep, ,etc. with all Washington well construction standards.Materials used and compliance p) WELL TESTS: Drawdown is amount water level Is lowered below static level Was a pump test made?Yes❑ No[$ It yes,by whom? NAME D a V i S D r i l l T r►¢ ft.drawdown after hrs. (PERSON,FIRMI,OR 4Y7RPOFtll7more I�iris . Yield: pal./min.with •• Address(Sig �t2 F„ r A 9 R 5 2$ ' ned) n`/�r� - License No. 1 R R4__ Recovery data(time taken as zero when pump turned of)(water level measured from well (wFu ORIIJ EFhJ top to water level) Water T Water Level one • Level Time Water Level Time Contractor's N ' 1_SD Ill OOA Date Thrl v 1995 .19__ (USE ADDITIONAL SHEETS IF NECESSARY) Date of test Bailer Banertest• 12. /min.with 10 n drawdown aver hra rtun and Affirmative Action employer.For spa- Ecology is an Equal Oppo ity DJ ° e ET ryei•Imin.wig stem °tom—�'ti t°r clam accommodation needs,contact the Water Resources Program at(206) �A � n o ( ( I) dT, a U n.ia.er��Q�Cf11 1�� ll )�(� r m ,' 407.6600.The TDD number is(206)407-6006. Temperature of we&i•niPri Yl >i; �,.sn ,My bl il°�'❑ No O J Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: James Morrison Well Tag#: ABG082 Site Address: 260 E Lombard Rd S,Grapeview Depth: 172' Date of Test: 3/31/26 Static: 130' Pump Set: Unknown TIME GPM LEVEL RECOVERY 1 Min 11 126.5 TIME LEVEL 2 Min 11 126.5 1 Min 122 3 Min 11 126.6 2 Min 121.2 4 Min 11 126.6 3 Min 120.8 5 Min 11 126.6 4 Min 120.7 6 Min 11 126.6 5 Min 120.6 7 Min 11 126.6 6 Min 120.5 8 Min 11 126.6 9 Min 11 126.6 10 Min 11 126.6 15 Min 11 126.6 20 Min 11 126.6 25 Min 11 126.6 30 Min 11 126.6 35 Min 11 126.6 40 Min 11 126.6 45 Min 11 126.6 50 Min 11 126.6 55 Min 11 126.6 1 Hr 11 126.6 1 Hr 10 Min 11 126.6 1 Hr 20 Min 11 126.6 Total Gallons Pumped: 880 gallons Thurston County Environmental Health 412 Lilly Rd NE Olympia,WA 98506 zHviiMNCOLNW 360 867-2631 COLIFORM BACTERIA ANALYSIS jDatemple Collected Time Sample County Collected >r e nr� p'n s QtDay Year � G a []PPd / ( 6 6 G;<4! Type of Water System(check only one box) (] rivate Household Group A ❑Group B 0 Other Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: Contact Person:IAaJ4,1 E All , } Day Phone:( t✓) ee r Cell Phone; E-mail• � � �_ .� Send results to:(Print full name,address and zip code oremail address) SAMPLE INFORMATION Sample collected by(name): , VrA A41 t ..5 /Vie'/';f? ,J C/ii r Specific location or address where sample collected: Special instructions or comments: Type of Sample(must check only one box of#1 through#4 listed below) 1.0 Routine Distribution Sample 2.Repeat,Simple(after unsat routine) j Chlorinated:Yes No Drstribufron System 1 Chlorine Residual:Total Free Chlorinated:Yes / No 3.Raw Water Source Sample Chlorine Residual:Total Free_ ❑E.coli—GWR(A1P) Q Fecal—surge.Gwti springs(numeration) Unsatisfactory routine lab number. Filtered:Yes_No o Assessment Monitoring(A/P) — i Unsatisfactory routine collect date: QOther S 4.0 Sample Collected for Information Only {� Investigative Construction I Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY Q Unsatisfactory Total Coliform Present and D�Satisfactory 0 E.col!present O Ecoli absent No Coliform detected Replacement Sample Required: -0 Sample too old(>30 hours) [I TNTC [] Bacterial Density Results:Total Coliform 1100ml. E.coll I100m1. Fecal Coliform /100mI Enterococcl 1100 ml. J� Method Code:'Q SM 9223B ❑SM 9222D Date and Time Received:f„!'f Q SM 92158 Q Enterolert® I l z &. v Date and Time Analyzed: l . ? ( 7 , Date Reported:- l .h Q Samps Number(DOH number plus rive digits) Lab Use Only: LL±1JLLcL I ] DOH Form#331-319(versed 1123) — 1 ' Return To 1�9I1ic asm 2239831 MASON CO WA 04/28/2026 09:03 RI NOTCE MORRISON #221395 Rec Fee: $304.50 Pages:111111111111 III III III III 10111 III!III III!X1111 lilI I III I III.1111 III 2 �l '�rCZ� 9 `\ - �` APR 1,9 2026 By , Grantor(s): (1) i,Lli4 4TiF/srli�S/ Grantee(s):(1)PUBLIC � O l N 'IL. SERE Legal Description(1)XJ� f l�l� / d� f& 7� Q b Q(3 (Abbreviated form:i.e. lot, block,plat or section, township,range) Assessor's Tax Parcel: (1) /2 /07— f 7 ` D 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 l)T Q 7 — /h1 - c9 1O'O' 0 2.(L0 6 bOrci.S Tax Parcel: (Connection 2) I a. I O7 r 4/ '-/ 0 / c / 0 4O C; t Ufydoalr k J The system owner is responsible for keeping this system in compliance. The name of the water system is: V/i (5/ ' f /e /j4 t 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 thisday of Signature of Grantor(s): ( i (2) 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 494f i day of ' 4 O 2 , 20L4 , WI AA,M 3' v^e,5 WV 0('N-S O V\ personally 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. FState NH NGUYEN Notary Public in and fo the State of Washington, ry Public Washington residing at T"UpoJ7. on#76001419 My commission expires: FL6 /2� 2°3 0 pires Feb 12, 7.030 Page 2 of 2 2240314 MASON CO WA 05/08/2026 12:19 PM AGREE Name and Return Address: WILLIAM MORRISON #221796 Rec Fee: $307.50 Pages: 5 uyi�c; Avi f 4A4 IIIIIII IIIIII III IIII IIIIIII IIIIIIIIIIIIII IIIIIIIII IIIIII Ii III IIII I III II M 01Z 1K IsoA( 57 fj9≤ f P'2 'p, �h9f4-�� V1�w� �r/ffi �j S5'7r�v COVERPAGE THE RECORDER WILL RELY SOLELY ON THE INFORMATION PROVIDED ON THIS COVERPAGE FOR INDEXING PURPOSES. THE STAFF WILL NOT READ THE DOCUMENT OR VERIFY THE ACCURACY OR COMPLETENESS OF THE INFORMATION PROVIDED HEREIN. Document Title(s) 1. x/4 /9-J/ F 2. Reference Numbers(s)of Documents Assigned or Released ADDITIONAL REFERENCE#'S ON PAGE Grantor(s) 1. /A-AA A4 / / i / 2. / Y 1 /. y/O ( $ /`/ ADDITIONAL GRANTORS ON PAGE Grantee(s) 1. //� /1ir� 2. ,/14/4/?_ - 1q6_,/1,1 d AA /_?e/\/ ADDITIONAL GRANTEES ON PAGE Legal Description (abbreviated form:i.e.lot,block,plat or section,township,range,quarter/quarter) / - / ADDITIONAL LEGAL IS ON PAGE Assessor's Property Tax Parcel/Account Number(s) /2 / Y ? bey- / /O / '_/ ô7_-_4"/ / o / 7 _ D I _o y ADDITIONAL PARCEL#'S ON PAGE TWO PARTY SHARED WELL WATER USERS AGREEMENT Well ID Number: /4L31 O 2. Serves Parcel Number: ( /07 O/2_2 Lot Number: of - Subdivision Physical Address: 2 ro tO i . 110 M-/�f) Ra £ - I AND Parcel Number: i Lot Number: of Subdivision Physical Address'A 4/0 • ,f A D nJ ≤; 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 and water system to be constructed. Each party shallbe 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 Water System Construction Both parties herein agree to share equally in the cost incurred in well site approval, well construction, and construction and/or installation of the waterworks equipment,the pump house and water distribution pipes,and initial well water quality tests. 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. 2 Party Shared Well Users Agreement Page 1 of 4 Water Line Easements 'rl/ .T,41t'( R(c OA 64M/? /,4 /'101�2 fS9iV /2/ '7-4 4'.d%0 ® (owner name and parcel It,name of subdivision,and lot number containing the well) GRANTS - J'Ma2�,l�d/NI &A6C-(A-1401 '/V /2//�7— , /V- O/ O/ ' (owner name) parcel#, name of subdivision,and lot number adjacentto well) An easement for the use and purpose of conveying water from the well to the property of / Rc./i G• /I/r�l ≤ 'v ,/z a 4/ la I O (owner name, parcel#,name of subdivision,and lot number adjacent to well). Said easement shall be five(5)feet in width and shall extend on, over, across, and underneath said strip of land from designated well site to shared property line. No new permanent type of building shall be allowed to be constructed upon the water line easement except as needed for the operation of the well and water system. Maintenance and Repair of Pipelines All pipelines in the water system shall be maintained so that there will be no leakage or 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 born equally by both parties. Each party in this agreement shall be responsible for the 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 sewage disposal drain field lines. Prohibited Practices The parties herein,their heirs,successors and/or assigns, will not construct any potential source of contamination,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 two-party domestic use.Any potential source of contamination may include but is not limited to:septic drainfields, sewer lines, underground storage tanks;feed stations and/or grazing animal pens where manure can accumulate, enclosures for maintaining fowl or animal manure, liquid or dry chemical storage, herbicides, insecticides, hazardous waste or garbage of any kind.New structures and/or barns shall meet required setbacks and not harbor any potential source of contamination.The parties will not cross connect any portion or segment of the water system with any other water source or waste water disposal outlet without prior written approval of the(Mason County Public Health Department and/or other appropriate governmental agency. Provisions for Continuation of Water Service The parties agree to maintain a continuous flow of water from the well and water system, herein described in accordance with water supply requirements of the State of Washington and Mason County. In the event that the quality or quantity of water from the well becomes unsatisfactory the parties shall develop a new source of water. 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. Restriction on Furnishing Water to Additional Parties 2 Party Shared Well Users Agreement Page 2 of 4 • J. It is further agreed by the parties hereto that they shall not furnish water from 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 (Mason County Public Health Department. Restriction on Water Use Use restrictions are set at the time of water budget neutral determination and associated with the parcel. The amount of water allowed is recorded on the deed of the parcel and may be monitored and recorded depending on the source of the water rights. Water use for the lots referenced within this .agreement are acre feet/year for parcel 4 and acre feet/year for parcel# .(Include indoor and outdoor use restrictions). Termination of this Agreement This agreement may be revoked at any time; 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 to provide; 1) proof of a notarized revocation of this agreement and 2) proof of the potable water source for each property to the Mason - County Health Department for review and approval.After, review and approval by the health department the property owners 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 Mason 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 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, BOJA- i s 'ein aa���� �b ��1a► - uIL( to t Ld5� qhcl tes�oes;h;l-4y oc .lpz('o c3..t- j �n we-« wa+ero 2 Party Shared Well Users Agreement Page 3 of 4 Signed: rr Owner(s1�erty with the Well Print Name: 4L/AM State of Washington County of _ ) I,the undersigned,a Notary Public in and for the above named County and State,do hereby certify that on this, day of ,20 personally appeared before me to me known to be the individual(s) described in and who exe�uted the within instrument, and acknowledge that he(she) (they)signed and sealed the same as free and voluntary act and deed, for the uses and purposes therein mentioned. GIVE�uN YjW,J nd and official seal the day and year)astAove written. Notary Public In and for the, t'ate o 'Washington, siding in: /Y OLLft 4 4 iv,y Commission Expires: c � Signed: Ow er(s)of Seco Pro y Served by t 5h d Well Print Name: W/h/- rf Al tS M&iq& io'iv I, the under_sjgned,a Notary Public in and for the above named County and State, do hereby certify that on this Jay of 4 ,20 D, personally appeared before me to me known to be the individual(s) described in and who executed the vdithin instrument, and acknowledge that he(she) (they)signed and sealed the same as free and voluntary act and deed, for the uses and purposes therein GIVEN under my hand and official seal the day and year last ab ve yritten. .���\'�� •.`Ss�on Fko• . �'� c° ^NpTARY Notary Public in and fe Ste a i gton, _ ;� PUBLXC o:Z Residing in: emu' ��s ho��'/Q My Common Expires:Ia ) , -�� 2 Party Shared Well Users Agreement Page 4 of 4 Mason Coulpty OSS Installation Report pg. 1 MASON COUNTY PUBLIC.HEALTH Permit Nur ber SWG 24 0ZtiiI Parcel#_'I OJ OI Applicant Marne ,.JR n '1 Subdivision (Name/Div/Block/Lot) Applicant 41dress £7 E P/ +Ljk':g Cis state,izip G P,.,r es-' l.J,r 'i9 Installer Name Site Addre s XA LW1i1a4E 4 Designer Name I STAt A"i'It?> C» CKl ST w Y" Orainf ld Only Repair Other Full yatem installation ❑-Tank(s,,)��jjniy ❑ ❑ P ❑ S+stem Type . 'x'.;10 4 L 3Aretreatment Type ilO DYES ❑ NO ��1 1 >50ft ttmwells? ------------ - --- - �► ❑ ❑ r Cleanml t between building and tank? -- _�---�-' -- ❑ Tankb fflaspresent? --- ----- ---a -� -1 --- ---- ❑ m rt ---- 61 • 24 access racers over each co pa rpent?- - - ❑ Effiuen filter installed?----- ---- -- -- - --- - - - - ❑ ❑ Septic Manic rapacity(working) ZC.:T Manufacturer 5p5 - r�t 13-box meter level and speed levelers.used? ----- -- --- --- - NIA YES NO rpi ❑ ❑ Maraifo1d/D-box accessible from surface?- -- --- -- -- --- -- - ❑ Check valves installed? ------- ------- - - - - ---- -- -- -- - -------- ❑ • � Transp�rt Line Size L Schedule/Class Bedrooms installed(check one) ❑2 ❑4 ❑ 5 ❑6 . []Commercial/Other >1tDt romfoundation?- ----- -7- - - - - -- ❑ NIA ❑ YES ❑ NO rr. >99 fromwells?- --- --- ------- -------- ---- ❑>lDD fr+orra surface water ❑ -- ------ ----- ----- --- - -- - ❑ ❑ ❑ a: >litftroln potable an►aterlines?- --------- - - -- ---- --- - ❑ 0 >5 fit rr�property lines and easements?- - - ---- - - - ------ 0 1f >3 ft.;from downgradient curtain/foundation drains?- - - --- -- - - 0 ❑ Dreirrfi'1d level and observation port$present -- - -- - - - - -- -- - ❑ O ❑ Gi veless chambers or a Clean gravel used? (check one) proper!cover installed over drainfieldn- -- -- - - - - - - - --- ---- ❑ af ❑ pump tank setbacks consistent with septic tank? - - ---------- - ❑ NIA 'YES ❑ NO j � gat Manufacturer_ P5 _ Pumpnk capacity(flood) /• ❑ Zs' 24"access riser(s)and accessible from surface?- -- -- - -- - ---. ❑ Alarm r Control Panel Installed? - - ❑ Contr Panel equipped with Timer/ETM/Counter-- -- - --- -- - - O Pump'i stalled in ❑ Bucket or IOn Block or ❑ Other 4 loats or ❑ Transducer Tank dfaw down in/mi�n Pump capacity 5 ) apm Squirt Height fi •%la: Pump n time w Pump off time Daily flow set at_ opd Uptlatt4 E21n0t9 llnnte FromMon y � S; Prnnfi doom Mason Owinty M-.P.S Mason County OSS lnstEUUat n Report pg. 2 Parcel r sn ABANDOf !v1 T RECORD y ra eY ik:9 Septic c r per»nts s va.-. of ;:i p+oe: ^ ----_ - - --..-- --- O YES �I� NO tf Yes se cleScn: em aii be nen s purpm.c cut a.. pi 3'.,:'r°+fined;e;WC 24 -272A- ?-2?'A-v� �? -- ----. YES �0 RECORD DRAWNG n i5 ara e-,uv.to aasarCi zaz ra:' to In xcs^Y�.:sn8 and fø CeveCaya:nt. 'yr:sel Rem ^a J uada. n 1-r ,ciP 3;1e w-a ti t=s,es r,G ara pr•^,saea b l gs. czi+a.1 zf we .%awzri"r.�s. 'f �r.:-35r1o' S � ..,. ,.93^0.� . _..� :•G:-xti.6 ..._.. ..,,. .6:a ,zC.'•'9 3Lnw•gs rt e ¢s at°if' 3 ire'^.w:.:3r:?.a-3+:••x8!ama..reL's,:;k.^,v:3. lcP,� AU Record Drawing A tack d C RTC ICAT O OF INSTALLATION -- aa_t�¢�R.sva.R-T�W'�'c zriy;ii3a:i insm#&a tr;e sy zemi it :" °; e system has been.installed in accor- ia a sep'iic aes,' n s p& APPROVE' 'by Maso 7 rpt::-design siamped bAPPROVED"by County'.Lblic s� earth?fr.-3 fl a:'c?7! I M23u. i:i s�.6. Heattb anal that any deviations bare°3a3 en de iapp!,^ ' c :; vG:.. ;'c Pc . .,.? e&r c a7re /applJv d by botr7— ,� t LL Cr ' .:c :.? .. .. a�''c. :J i•'. [�^ :c:y!PiibH'c Health and dn-eer al .a any.A,14a : d a�dlr :Y ^de. R.. .. .� and€ff -ar.•Cou. r' :c s. ..d sJr, (" :,)r'y Codes 1%."7'sC•inLsr.f.r <n :r v^ " ^. _ t. - ^.a.'8:1' ,r-s� .c7Von contalr.anrf on this fDITas? &wC:1a.C " 1""a..'r a.�.a: :a':: .`` .'T _ /tJ e:�.ieG' �v�J c��378S IS accuraie. Pe rfed 6'an a of Si9r as MASON COUNP :=':S:, 's:E--- ii�St %5 '1,, a f LICENSER 1f ^ w� .a•:b.rsi •' .•APP Imo` Jr o.- . 12 E%PIRFS:0Si1� _ `J F�scO:��F�:meR,.rj ....�P:�r,t' �• r r•�:y,�..l, r7 , _ / / zas b _____ Si na S P9? ':^:lC.^.f en a1 $BcFY".`.i3 Ciri)SC c:T 'q' � (a.wr.p,Stgna& re and:late) TIPS 61__ 1i1�� s3 cOJMY WEB Si i E �teb From Mason CouF , �y Print c from M&71 COUniy D ;aS 1. Residence 2. 1200 gallonseptic tank Ld, �„z�l '? - 3. 1200 gallon pump tank 4. Audio/visual alarm 5. Clean out `'� 6. Transport line ID � , 7. Water line ' 8. Valve box 9. Primary drainfield i tid( 1 . Reserve drainfield 13.5 . y' ' 1O0' . / rLf A @9.�d' ey QUA � �J r - ,, 'It 1\ $ T.fPeCl O Pte • s�ooa�e o8�s. _ ��soNc0 S�P Q 9 CINDY E.WgITE LICENSF�OI:SIGt+tE�{' ti l�1 (/ lQ�7� LICENSED DESIGNER �, QL�R0�'RfF ExWHts ossw Exwaes osna+ irate o ' son son un , DMS Prnte i from Masan comimty©fAs a / f�/ /; L c�GfLt/- ••1 j'O ' c / •' Va Ive c Lz C1� 0 441O1 is X WA1TE_ •, LICENSED DESIGNER �: EXPIRES 051101 ` ae,ns O I�iJd s'�c� 'e z 'i p ' ' etd SEP1p2 MASoNcQUNrYF;<j-'�� 025 1 M.a 1nted F am M . on County y. DJ } Printed from MMEso Cow, tt D AS } = IS �M� ���.•�liQ.� thY t t ' .x tt I , I , L a p,�p ✓Vlw� i SEP 1 '0 2025 �( MASON COUNTYENVIRONMENTq�y DJA EAiTy -ranted Fro 'n Mson c u l DMS e lint d urom MFtson County DMS