HomeMy WebLinkAboutWEL2026-00018 - WEL Application - 8/24/2026 415 N 6TH STREET,SHELTON,WA 98584
MASON COUNTY SHELTON.360-427-9670.EXT 400
BELFAIR:360-275-466O.EXT 400
Public Health & Human Services ELMA:360-x82-5269.EXT 400
FAX:360-427-7787
08/26/2026
MONTEJO MATEO
500 NE MISSION CREEK RD
BELFAIR, WA 98528
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2026-00018
500 NE Mission Creek Rd
223364200030
The above mentioned permit has been reviewed by Environmental Health and found additional
information is required.
The signature in the well ownership attestation section of the Two-Party Water System Application
form does not belong to the well owner. Permit WEL2026-00018 has been canceled.
If you have any questions, please contact me at 360-427-9670 Ext.353 or email at
danderson@masoncountywa.gov
Sincere
David Anderson
Environmental Health Specialist
Mason County Environmental Health
415 N 6TH STREET,SHELTON.WA 98584
MASON COUNTY SHELTO":360-427-9670,EXT 400
BELFAIR:360-DS-44fi7,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
08/26/2026
SEBASTIAN GASPAR-MARCOS
703 NE Mission Creek Rd
BELFAIR, WA 98528
RE: WATER SYSTEM PERMIT: TWO-PARTY
WEL2026-00018
500 NE Mission Creek Rd
223364200030
The above mentioned permit has been reviewed by Environmental Health and found additional
information is required.
The signature in the well ownership attestation section of the Two-Party Water System Application
form does not belong to the well owner. Permit WEL2026-0001 8 has been canceled.
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 Fw
° O ��l �
COMMUNITY SERVICES
1 � . /10 20 [-
ShermR 360-I 7-9670 0 70 x40BI fair:r3360175467400 h98a:360452-57 69 100
TWO-PARTY PRIVATE WATER SYSTEM APPLICATION
APPLICANT PIIONE
.� �sfl� 6ti
( 7 (v l / cos 3 ' G F (Fcp
NAILING• L7AnnmF.CT—STREET,CITY,STATE,zip
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,(�� sITEAoo9e5S SREEI',CIIv,STil'Rz@ {
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zIAR.333 ( 4L2Lond 3
SECONDARY PARCEL 1�R(SA AS PRIJIAPARCEL)YIF L C\TE..N SAME PA
2Z33 &t
NATER SOURCE SOURCE TYPE PARCEL]101512NIno minimum) PARCELI LOTSIZEIna minimum)
❑ New fisting WeII Spring a rI C . e 2
PROPOSED WATF.0.SYSTEM\-AFIF 0IFIj IIRED).
j5I C4 � Y E W Cr
raOJrcT DFSCRIPrIC}N(,a aDrnm Anu x ( £tingccnnccnon,.a .I S JL:,jljIJ [:7C f125
DIRECTIONS In SITFJCONDITIONS,GATECODFJ KEY LOCATION/FTC
JC V\
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.
❑ Capacity test showing 800 GPD with drawdown and recovery to static level information, as described on page one of this packet.
❑ Hacteriologieal test(Bac-t)results:current(within 12 months)and satisfactory.
❑ Septic Records(additional locating requirements may apply ifno septic records arc on file).
o Applicable utility easement documents.
❑Filing requirements, as described on page I of this packet*Note Maybe 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 T eU Sign: fltj C Date:
This form may be scanned and made available for public viewing on the Mason County website
Pg 2 Last Updated: 5/7/2026
Please 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, hams, storage buildings,or dwellings(V/AC 173-160-171)
❑ Water lines for existing and proposed connections
0 Septic and sewer components(tanks,primary and reserve drainficlds,transport lines)
❑ Barns,chicken coops,barns, manure piles, dog kennels, commercial gardens, compost piles
❑ Chemical Storage within 100 ft
❑ Landfills(existing or tnrmcr)within 1000 ft
Site Drawing
O Cc ) 21 ( 2 ' co v
c c� u C
J 1`t ; 2 S', r
l
- : L BSc � C)f
This form maybe scanned and made available for public viewing on the Mason County website
Pg 3 Last Updated: 5/7/2026
Staff I'seonly
Review Step 1: Well Site Inspection:
YES NO N/O
❑ t� ❑ Sources of contamination within 100 ft ofthe well?(septic components,chemicals,livestock,etc.)
❑ or ❑ Roads located within 100 ft of the water source? Private/County/State Distance to road(s)
❑ ❑ Ground slopes away from the well?
❑ ❑ Well located outside of garages,barns,storage buildings,and dwellings,with at least 5 ft of separation?
U ❑ 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 furore installation ofequipment is prohibited.
(� I
❑ ❑ The well casing extends If. level rood/concreteslah. Lot: Yf•43g08
❑ ❑ Doe well tag attached to the well casing? Lan: -Its f?469
❑ ❑ Variance necessa for wel site approval? Tag. BUM 81Z
- Ix _ t rot 05 M ThOvg7 1 v wet/ cap corm"
Commends. (pjv f c e` bl _ --
❑ Pass X Fail Lmpetor Date
z` WZ
Review Step 2: Two-Party Review:
YES NO NA
❑ ❑ ❑ Water well report(well log) Date Completed _Driller __ _
❑ ❑ ❑ Satisfactory capacity test showing a minimum of 800 GPD with full recovery to static level within 24 hours?
Capacity test information:Date Driller/Pump Installer _
GPM Duration(minutes)_Total Gal Recovery Time(minutes)to Static
❑ ❑ ❑ Water system capable of supplying at least 30 PSI to each connection?PSI _
❑ ❑ ❑ Satisfactory bacteriological analysis? Dam_ Testing I.ab __ _
❑ ❑ ❑ Signed,notarized,and recorded notice to future property owners? AFN
❑ ❑ ❑ Signed,notarized,and recorded water use agreement?AFN_ _
❑ ❑ ❑ Signed, nomnzed,and recorded access casement(s)?AFN
❑ ❑ ❑ The system appears adequate to serve two connections based on the information provided?
Well Carne t r� tf lton ho+ S 6 keel 1014( er.
Comments: �� _
❑ Approved %Denied Reviewer Date _/7,&/707(_.__
Findings in this review reflect observed conditions as they existed on the day of the site inspection. No ctairn is rnade,express or implied of the future
snccees or failure of this system_ Well site approval does not constitute seater system approval
Ai/proposed connections to new wells are subject to water adequacy requirements at time ofbui/ding permitper MCC 668_ Water usage restrictions
and additioruljzs mayapple to all new wells drilled after January 19"", 2018 per ESSB 6091.
This form may be scarred and made available for public viewing on the Mason County website
Pg 4 Last Updated: 5/7/2026
WATER WELL REPORT .-.ia °EPdh MhN' ° Ndree of intent Nn. WE55693
Time of Work: ECOLOGY Unique Ecology Well ID Tag No. BNM872
bate F s ng.1,r
cousin'°'ion Site Well Name(if more than one well):
1 Decommiavon O Ongiaal inmlplion NOt No. Water Right PerniUCenificate No, _
Priapmea en ®Dmrestic 0llglmtrbl JMunicipl ptopeny pwmer Name MICHAEL DDNAHUE
fl bide '.l lnigtnn ❑Test Well C Od r_ _.
Well Street Addmss 5 MISSION CREEK RD _
CnnhncHn Type: Mbbd:
M New web G°°station ❑Driven ❑Jetted [:cable Tom City BELFAIE C.ounry MASON
❑Deepening ❑Other U Dog ®Air- '_l Mud-Rmary Tax Parcel No. 223364200030
Di w oaom: Domeln ofbonng 6 1 n., u 93 a. —_._
Depth orcotrykul sell 93 a_ Was a rarianee approved fortis wool? LI Yes Nn
Co-M.mdtn Details: Wm; If yes.what was the 3ancc ear,
Casing Liner Diamu¢ From To Thickreas Steel PVC Welled TNead —
.=
0 ❑ 6 BS 29_ in- —'
- ! L t lr ainamsi npnge 2l; WWMeTpEWM
❑ _ _ _ 1 r F NW efthe SE ;;Section 36 Township 23N Range 2
❑ C rn _ _ _ i G D ! L and (Example:47,12345) 47,43908 __
Perrnrniom: J Yes ANo Tvpcofpeffombraxd Longitude(Example:-120.12345)
No.oroerfonlien, Se olperfontma: in by Ddller's Leg/Construction or Deeomniubn Procedure
PMbrared from_R.In_ft below ground,tjrqace Formation:Deacrte by color.character eve orvutenal and wuenre,and the kind and
nature of,M1e material ine li layer penemted with Imxl one enrty ror each change or
Screens: p1'n L]No K-Packer r Depth n. ofnrnaiioi Use additional sheets ilneceamry,
Manubnwer'a Narc - Mat
From To
Type STAFILESS Model N. erial
Demeter 6 n. Slb size 12 in.from 6a q.lo 93 n CLAY&GRAVEL BROWN p 30
De_ in slw.izc in.dean tin n. CLAY&GRAVEL BLUE 30 i 55
Sand/F:ber pmk:Gvb- FNn s otpukmaceta;_:n CLAY&GRAVEL BROWN 55 86
Makncls 11"ream_A m_R tAVEL H2O BROWN 86 93 _
Surface teal: pe Yes ❑Nn To what dcplk' 20 it
Mmerwiteedinaml BENTONITE
Did and sinla conlam unasshir _Yes d No _ _
Traof pep':orrlrns
Mmhptl f f g Imts R ______
Pump: M f Name GOULOS Type SUB 3 PHASE—
' HP 1 Pump i ldph' B6 fl. Uzgdiox me 10 gp {
tact,:
Wtl lands ace lv na m buvenoe I -I N
Sheets ae ufxell casing 1 fi-ahuvc groom,xurfncc
5'inacwamr let l 34 R below top ofxdl easing Dale 7-15-24 _
Aneaian pro um_lb,.per square inch {Jae
\rile°wamr is wnwlled 61 op,'abe.eIe.
"a Teeb: _
pumping wn perfumed? U Nu i Yt .—) by wham"
Yield 12 gpm with 2% p_dnxdown afler4 hat. __
Yield _gp with ft.ds nerhrs.
Yield_gp N_ILdo do after his. _________-
Recovery data(rimc em whet,peep is titmecinrt-viler le.el maaumi from well
pew W q
Tate µamr local Timv Wan bevel T . Watts level
-
Ova nl'pump,ngua
Bailer test with It drewdown after hrs. I
Airtcstypmwitbzmmcam n for_ M. F Ihm —
°rain°mw_eve, - —
Tempnammorwater_•f Wsachemleaianalysis made? CYes ANo [Sun Dam 6-26-24 Completed Ogre 7-1-24
W'El.l.CONSTRUCTION CERTIFICATION: 1 consm,ded md'or accept responsibility iM conmrvaion of 15rs well,and its compliance with ell Washington well
oomeme ion standanis.Metenals used and the information repelled above are me m my beat knowledge and belief
L Dinnerf TraineeCFE—Prim Name MADI TROTTER Drilling(ompany COOLWATER DRILLING.INC.
Signature Address 10921 NW HOLLY RD
License No, 3967 City,State,Zip BREMERTON WA 98312
_ DTRAINEE:Sponsor's)icons No. Cmvactors
Spoasm's SiP.mturc _ Re¢ist ahon No.CDOLWO1941OM pate
C1 0511 'f kri l.Ixl /it idthir Jr Hann -I.Ploosccu//I/ti 3'mor Runni. .-f gmm cc
15,�1)7- S 72. J•i. (yo..v/I/i/Uaflnirl--.,cz:col( /(/ -OiaWu ee N ,m1no l D ii cpnc-h f In nee,,
a. _v3J-6J4I.
COOLWATER DRILLING, INC.
10921 HOLLY RD NW
BREMERTON, WA 98312
360-830-9005
COOLWDI941 QM
CUSTOMER NAME DATE 2-9-26
SABASTIAN MARCOS
CUSTOMER ADDRESS
500 MISSION CREEK RD
TIME STATIC GPM TIME STATIC GPM
32 15
05 64 15 120
10 72 15 135
15 72 15 150
20 72 15 165
25 72 15 180
30 72 15 205
45 72 15 220
60 72 15 235
75 72 15
90 72 IS
105 72 15
RECOVERY STATIC RECOVERY STATIC
TIME 72 TIME
05 50 30
10 38 45
15 32 60
20 75
25 90
26276 Twelve
Too .LoNW I
sta.c SPECPRA Laboratories Kitsap
Poulebo WA _It —
98370
(360)779-5141! COUFORM BACTERIA ANALYSIS FORM
Gale Sample Colkcletl NC Sample Canry
Calkcatl
Amen so, ver IZ ,Bw :^r/ffor
Type of Wakr System lcbe@mdy are[ox)
❑Gr ,,A ❑GroupB Ia0Mer_ — _
Group A and Group B Sstems-Pro t fiorn Walr FadfUes lrN ory Cfl
IN
Spt.Name: St A '
r4r' GASPe'2
conteuperso¢ c oew MT< __.
GzY Pl;pre 3Cq. bap ',p Cj-__ Cep Pnnne:
•Elraa:e,.urwKf2.J Frrctr<far`�'r7AN hT l .er-..
Send rewla ro.Prn Mr .ra.m...e r:,mml
uaiw�i>C 'i
/d 52/ /'g7 d�
StkC
SAMPLE INFORMATION
$amga muscled by(name):
Cactr.erNTK
SpecCa location where sample maeaeb ScecallnsbuCbOns prcommenB: '.
Sca rd,3ier,
TYw of SaenPM(NeG WYorwbx)
1.❑Routlna plalribution Sunpk(AN) 1.❑ Repeal$ample NP)
Cbbnn ted'.Yes 0 No❑ Ida"deMWbn ertlom flth al,roanncl
Unsatkkctry routine lao number.
CtYaine Residual total Fin
3.Ground WaterRule Sourn$mpIe — __— --- —
Un,flstaotow routine colect date'.
SF I
Chlorinated:Yes No
❑Triggered(ARI Cbbnne Resid el:Total_Free_
❑Assessment rpm)
4 Surface or GWl Raw Source Water Sample{Enumela ,) S
❑r�eE coil ❑Fecal csc yn _
5.L➢ o NNNCaarud M NXeamaapn aop RAYMNrw L.fiMr6W RapaNa
LAS USE.ONLY DRINKING WATER RESULTS LAB USE ONLY
❑pnaadsfactery TOW Coiform Presets and Satiafaotdry
❑E.mepresent ❑E.mbabsent
Bactarlal Density Resups.Total CW,fiml nlpnl10pnt.Eco mpn/10oml.
Fecal Collform_._. ..__-rduf100m1. HFCCW1ml.
Replacement Sample Required: 0 TNTG ❑Sample tm oB
❑ Sample VOWme ❑Dzrnag d Conner ❑
0 R.ca& Lab ReWerxa MvfM
131�,__25�1_�7a1
Recap(Tamp C' Motoc Cade:
�M9p33 OTWW?Sts 2210
__.1_a_ _ — ah —..
rote( DateOu Mw.
�a(zo ��o/ C A. `
J - 6+Mmunrwr. ies.eeu. �tl
DON La4Sfl #
I ..• F '�s arvr.rer eisum
srelIflm,a (- ift 2110
26276 Twelve Trees Ln NW Ste.C
Poulsbo,WA 98370
SPECTRA Laboratories - Kitsap (360)779-5141
...Where experience matters
IOC TEST PANEL
Complete or Selected Inorganics
System ID No: System Group Type: Private - _-
Sample Number: 0/047802 System Name: Sebastian Gasper
Sample Location: 500 NE Mission Creek Rd County: Mason
Sampler: Coolwacer
Source Number(s): Sampler Phone No:
Sample Purpose: Permitting Daze Collected: 07/09/2026 12:30
Sample Composition Single Source Date Received 02J09/202613:26
Sample Type'. Untreated:DW Date Reposed: 2/13/2026
Send Report to: Bill to:
Coolwater Drilling Qtolwater Drilling
10921 Holly Rd NW 10921 Holly Rd NW
Rremeson.WA 9X312 Bremerton.WA 98312
DOH# Analyle Results Qual. Units SDRL PQL Trigger MCL Exceed Method Analyst Analysis
0020 burst" MCL Date
ND — n9L 0.5 0.1476 5 10 SM4500 NO3F MS 02/09/2617.33
NOTEg, -- -
tonNmelion Include the camel lab number,sample number,and vagectim pate of orgmal sample in eitherbb Orsartglarmmmen6 ee( n.
SDRL: (State Deter on Repor ng Umjtl)The minimum repmlabe detecton of an anatyte as esladished by the detainment..
9ger Level: DOH dnnkingwaterraspona level.
k"I'switmmpoundsdeaDOHdnnncenp,-::oasis exmscout level may bereyuired mpke
addmmal samples°rmonimr more fiequently.Please contact your DON tlnnking.,: rregalaltice for(uMer infolmaAon.
MCL: (Maximum ConMlNranl Level)dme contaminant amount exceeds the MCL,please vented your regional DOH office to delennine foow-up actions.
(Not Ana�yn.M)m the results caWmn indkates this wmpound was not mtluded in Na elrrenlanalysis.
ND:
(Not Detecied In the resuts cok,m, indiIes this compound was analyzed and not deledad at a kvd greater Nan orequal b me SORL.
(0p0a1: The wmpp01I was rotdakcrad in the sample atorabove The concenlretion'no'ted(usually the hb method reporting dmit).
mfh: muligamsper heron parts per mitlion.
Mm: nepbelaneNC handily uni6(a measure of water darftyt.
pmN0Mun: MjapepmspHcenbmar&cri measure of me aNlRy of the waterm wnp'uct
sienen per ammeter(US/an)
One mrcm oMn percerldmeterk equivalent to one mkro
No evsgrg Mager or MCL value.
f' Sewndary MCL(Estffilahed for aesthetic puryoses,not health based).
Page I of 2
2213O365 MASON CO WA
lrR Iz10MEF 'Z"PHERSON01 NE99i%/ Fey cqc
IlNlinliil�llllliill:�lill V:Iniillll!�I�II�IhIIIUgU���� C R,9a,
llU " I ^ I urn
Return To ..LL e //1 1
C r, f0 v h
/1/ 3j9 jygS , t
Grantor(s): (1) 1f,9A/LT,* ' (2) l,-S/4 B, 4
Grantee(s): (1) PUBLIC ,1 1.
Legal Description (1) 63// �Y Ie6 3 5L
(Abbreviated tomr: i.e. lot block, plat or section, township, range)
Assessors Tax Parcel: (1) 3 L3 fe- Z - DO f2
NOTICE TO FUTURE PROPERfl 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 Wa&hington,lhas 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) 3 IL-1�- 0 O�rfGt O)
Tax Parcel: (Cbrinection 2) oZa,z a 6 - �-QSLSGL,L
The system owneris responsible for keeping this system in co plliian/ce`/
The name of the water system is: * /& czee, LU/f%r
,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. (Z
Dated on this ./ day of , 20
�T C
Sign r of Grantor(s):
(1) , (2)
Page 1 of 2
2222300 Mason County WA
03/04/202501:38:27 PM SWD
eRecorded #207041 RecFee: $305.50 Pages: 3
LAND TITLE CO
When recorded return to:
Lucia Esteban-Martin and Sebastian Gaspar
480 NE Minion Creek Road AFFIDAVIT
Beffair,WA 98328 No 64388
WARE EXCISE TAX
Mar 04 2025
PAID`. $2.400.00
USA FRAZIER
Treasurer Mason County
Filed for Record at Request of _
Mausetb Legal,PLLC
Escrow Number:002518-LR —
(-2O2$— -MW5 (i% C.i
Statutory Warranty Deed
THE GRANTOR CB McPberson Properties LLC, a Washington Limited Liability Company for and in
consideration of TEN DOLLARS AND OTHER GOOD AND VALUABLE CONSIDERATION in bud
paid,conveys and warrants to Lid*Esteban-Martin and Sebastian Gaspar,a married couple the following
described real ware,situated in the County of Mason,State of Washington.
Abbreviated Legal:
NW/SE 36-23N-2W
Tax Parcel Number(*=3¢42-00041
THE SOUTH HALF OF THE SOUTH HALF OF THE NORTH HALF OF THE NORTH HALF OF THE
NORTHWEST QUARTER OF THE SOUTHEAST QUARTER OF SECTION 36,TOWNSHIP 23 NORTH,
RANGE 2 WEST,W.M.,IN MASON COUNTY,WASHINGTON;
EXCEPT MISSION CREEK ROAD.
Subject to: Covenants, conditions and restrictions of record,as attached hereto and made a
part hereof by Exhibit"A"
12810.05(1-I)
PapI Pane I of3
EDIT"A"
RIGHTS,RESERVATIONS,RESTRICTIONS,AGREEMENT,CONVENANTS
ANDJOR EASEMENTS -Any defect, lien,encumbrance,adverse clam,or other manor thatappears for the frost time in the Public
Records ors seated,attaches,or is disclosed between the Commimsmt Date and the date on which all of the
Schedule B,Part I-Requirements are met.
Any question that may wise due to shifting or change in the coupe ofMmsion Creek or due to the creek having
shifted or changed its come,and rights of the State of W4lshmgton to arc!to that portion of said premises,if any,
lying m the bed or former bed ofthecreek,if h isnav able.
Any prohibition or limitation on the use,occupancy or improvements of the land resulting from the rights of the
public or riparian owners to use any waters which maywvFrthe land one use any portion of the land which is
now or may formerly have been coveted by water,and the right of use,control or regulation by the United States
of America in exercise of power ova navigation.
Exceptions and reservations contained ii1 Deed wkereby the granwr excepts and reserves all oils,gases,coal,
ores,minemis,fossils,etc.,and the right of entry for opening, developing and waking mines,etc.,provided that
no rights shall be exercised until provirion-hasbem made for full payment of all damages sustained by reason of
such entry:
From:The State of Washingeort.
Auditor's File No.: 51274(Volume 65 of Deeds,page 421)
Records of Mason Couhty,'Wash ngt n
NOTE:The present ownership of said interests and matters affecting said interests are not shown herein.
Mann disclosed by Survey recorded June 19,2000 in Volume 25 of Surveys,page 176 under Audfofs File
No. 1713129.
Terms and conditions as fully set forth in Notice to Future Property Owners of Private Two-Party Water System
recorded My 17,2024 under Auditors File No.2213365.
[.Pa re-0504)
Pge3 oft
2222300 Page 3 of 3 03/04/2025 01:38:27 PM Mason County, WA