14 109494 HE - 10901 Ball Hill Rd SE f �
Q�FTHFp�9� City of Yelm
� �
Community Development Department
105 Yelm Avenue West
Yelm, WA 98597
YELM
WASMINGTON
May 7, 2014
Sara Brallier
Thurston County Public Health
Environmental Health Division
2000 Lakeridge Dr SW
Olympia, WA 98502-6045
Re: Water System Priority of Service for 10901 Bald Hill Road SE, Yelm, WA 98597
Dear Ms. Brallier:
The City of Yelm has received your request for a Determination of Priority Service for a Group B
Public Water System located at the address above.
The property is located in the Future Water System service area for the City of Yelm. The City
cannot serve the property with water service at this time.
The Group B water system must be constructed to meet City of Yelm Standards as defined in
the Yelm Water System Plan and the Yelm Development Guidelines.
The City of Yelm requires, as a condition of approval of this satellite water system, an
agreement between the water purveyor and the City of Yelm that when City water connections
are available to the property, that the property connect to the City water system, the Group B
well be decommissioned per Washington State Department of Ecology standards and any water
rights associated with the system be dedicated to the City of Yelm.
If you have any questions, please do not hesitate to contact me.
Sincerely,
,____s
��'�: �'��_
Tami Merriman, Associate Planner
Community Development Department
Copy: Tom Peters, Water Engineering Solutions, LLC
Janis Stiebrs
(360)458-3835
(360)458-3144 FAX
www.ci.yelm.wa.us
Thurston County Environmental Health Division
��`�'` 2000 Lakeridge Dr. SW,Olympia, WA 98502
y�gf �`' ..' ,
(360)867-2673 /(360)867-2660(Fax)
�- . .:, TDD Line(360)867-2603
��-������;-���,; �������-� http://www.co.thurston.wa.us/health/ehadm
.i�3N:1�.i:'.w5>
WATER SYSTEM PRIORITY OF SERVICE
�Owner/Applicant �Applicant Only Date Received
Name Janis Stiebrs Phone# �360) 458-3333
Mailing Address PO BOX �J9H, Yelm, WA 98597
Property Address 10901 Bald Hill Rd, Yelm Parce�#22729310600
(attach location map)
Project Description (Plat, short plat, et�> : Construct Group B Water System
Primary source Area uti�ity City of Yelm - WITH CONDITIONS
Prioriry �-Area uti�ity City of Yelm- SEE ATTACHED LETTER AND AGREEMENT
Yes, the applicant will be provided with terms of service
Yes, via area utility satellite service
� No (Go to Priority Level II)
;...—
' �� � 05/07/14
Signature of Utility Representativ�-� - / ,( �� , id , Date
Priority II-Neighboring Utility
Yes, the applicant will be provided with terms of service
Yes, via neighboring utility satellite service
No (Go to Priority Level III)
Signature of Utility Representative Date
Priority III-Other Approved Satellite Service Company
Yes
No (Go to Priority Level IV)
Signature of Utility Representative Date
Priority IV-Water Supply Developed by Applicant
Date
Signature of Thurston County Environmental Health Representative
Approval of Service
Date
Signature of Thurston County Environmental Health Representative
To obtain a list of approved utilities, and the name of your primary area utility, contact the Thurston County Environmental
Health Representative.
UPDATED 12/29/09
WATER SERVICE AGREEMENT
THIS AGREEMENT is made and entered into the day of , 2014,
by and between the CITY OF YELM, a municipal corporation, and Janis Stiebrs.
Stiebrs Farms;
1. RECITALS:
1.1 Janis Stiebrs holds record title to the following described property located
within Thurston County, Washington:
That part of the NE1/4 of the SW1/4 in Section 29 Township 17 Range 2E &
NW '/4 & SE 1/4 SLY AND WLY OF BALD HILL RD & NW SW THE E 260F
LY S OF RD & E2 SW SW & W 320F OF SE SW LESS .92 C
1.2The property lies within the future water service boundary of the City of
Yelm.
1.3The City of Yelm water main does not currently extend to the Stiebrs
property and is not immediately available.
1.4Janis Stiebrs is in the process of providing water to said property using a
private well to form an interim Group B water system.
1.5The Coordinated Water System Plan (CWSP) permits the development of
interim water systems in locations where potable water service is not
immediately available.
1.6The City of Yelm has agreed to allow Stiebrs to construct the water system
on an interim basis to serve the immediate needs of the property.
1.7The City of Yelm Water System Plan identifies the water service area for the
City of Yelm, and this area incorporates the water system. The City of Yelm
is vested with certain rights and responsibilities as defined in the CWSP.
2. Agreement
2.1 Stiebrs shall maintain the existing connection(s) from the well to the
buildings as they exist at the time of this Agreement; no new structures
requiring additional connections to the well shall be permitted, unless
approved by the City of Yelm, and this Agreement is modified in writing.
Water Service Agreement Page 1 of 3
2.2 Stiebrs agrees to decommission the well and connect to City of Yelm water
service when it is immediately available to the site and pay appropriate fees,
including but not limited to appropriate connection fees, meter installation
charges and/or drop-in charges, within ninety (90) days of receiving written
notification from the City.
2.3Stiebrs shall make all improvements required to connect to the City water
system at such time as City water service is immediately available to the
site, at or across the parcel boundary.
2.5A11 provisions of this Agreement shall be construed to touch and concern the
land, shall run with the land, and bind the Stiebrs, its heirs, assigns and
successor(s) in interest, and such provisions are to be pursued in good faith
and diligently by Stiebrs, and any such successor(s).
Water Service Agreement Page 2 of 3
STATE OF WASHINGTON )
)ss
COUNTY OF THURSTON )
On this Day of , 2014 before me personally appeared Janis Stiebrs
to me known to be the ep rson who appeared before me, and said person acknowledged that she signed this
instrument, and acknowledged to be her free and voluntary act for the uses and purposes mentioned in the
instrument.
IN WITNESS WHEREOF I have hereunto set my hand and affixed my official seal and year first above
written:
Signature:
Print Name:
NOTARY PUBLIC in and for the State of Washington
Residing at:
Commission expires:
STATE OF WASHINGTON )
)ss
COUNTY OF THURSTON )
On this Day of , 2014 before me personally appeared Shellv Badger, to me known
to be the City Administrator of the corporation that executed the within and foregoing instrument, and
acknowledged said instrument to be the fee and voluntary act and deed of said corporation, for the use and
purposes therein mentioned, and on oath stated that she is authorized to execute said instrument.
IN WITNESS WHEREOF I have hereunto set my hand and affixed my official seal and year first above
written:
Signature:
Print Name:
NOTARY PUBLIC in and for the State of Washington
Residing at:
Commission expires:
Water Service Agreement Page 3 of 3
O��FTHFp�9� City of �'elm
0�. Rl
Community Deuelopment Department
I05 Yelm Avenue West
Yelm, WA 98597
YELM
WASHINGTON
May 7, 2014
Sara Brallier
Thurston County Public Health
Environmental Health Division
2000 Lakeridge Dr SW
Olympia, WA 98502-6045
Re: Water System Priority of Service for 10901 Bald Hill Road SE, Yelm, WA 98597
Dear Ms. Brallier:
The City of Yelm has received your request for a Determination of Priority Service for a Group B
Public Water System located at the address above.
The property is located in the Future Water System service area for the City of Yelm. The City
cannot serve the property with water service at this time.
The Group B water system must be constructed to meet City of Yelm Standards as defined in
the Yelm Water System Plan and the Yelm Development Guidelines.
The City of Yelm requires, as a condition of approval of this satellite water system, an
agreement between the water purveyor and the City of Yelm that when City water connections
are available to the property, that the property connect to the City water system, the Group B
well be decommissioned per Washington State Department of Ecology standards and any water
rights associated with the system be dedicated to the City of Yelm.
If you have any questions, please do not hesitate to contact me.
Sincerely,
_�__.�.
,�-�'- - ���
�. �
Tami Merriman, Associate Planner
Community Development Department
Copy: Tom Peters, Water Engineering Solutions, LLC
Janis Stiebrs
(360)458-3835
(360)458-3144 FAX
www.ci.yelm.wa.us
I
Thurston County Environmental He
alth Division �
:�.. 2000 Lakeridge Dr. SW,Olympia,WA 98502
(360) 867-2673 /(360)867-2660(Fax)
TDD Line(360)867-2603
THL)R�T{�� C,tJL.�NTY http�//www co thurston.wa.us/health/ehad�n
.�t�t i.in5:
WATER SYSTEM PRIORITY OF SERVICE
�Owner/Applicant ❑Applicant Only Date Received
NameJanis Stiebrs Phone# �360) 458-3333
Mailing Address PO BOX �J98, Yelm, WA 98597
Property Address 10901 Bald Hill Rd, Yelm Parce� #22729310600
(attach location map)
Project Description (Plat, short plat, et�> : Construct Group B Water System
Primary source Area uti�ity City of Yelm - WITH CONDITIONS
Priority �-Area uti�iry City of Yelm- SEE ATTACHED LETTER AND AGREEMENT
Yes, the applicant will be provided with terms of service
Yes, via area utility satellite service
� No (Go to Priority Level II)
./
'� ' ^ 05/07/14
Signature of Utility Representative� ��G � -t' - �-� G� , � �d � Date
Priority II-Neighboring Utility
Yes, the applicant will be provided with terms of service
Yes, via neighboring utility satellite service
No (Go to Priority Level III)
Signature of Utility Representative Date
Priority III-Other Approved Satellite Service Company
Yes
No (Go to Priority Level IV)
Signature of Utility Representative Date
Priority IV-Water Supply Developed by Applicant
Date
Signature of Thurston County Environmental Health Representative
Approval of Service
Date
Signature of Thurston County Environmental Health Representative
To obtain a list of approved utilities, and the name of your primary area utility, contact the Thurston County Environmental
Health Representative.
UPDATED 12/29/09
WATER SERVICE AGREEMENT
THIS AGREEMENT is made and entered into the day of , 2014,
by and between the CITY OF YELM, a municipal corporation, and Janis Stiebrs,
Stiebrs Farms;
1. RECITALS:
1.1 Janis Stiebrs holds record title to the following described property located
within Thurston County, Washington:
That part of the NE1/4 of the SW1/4 in Section 29 Township 17 Range 2E &
NW '/ & SE 1/4 SLY AND WLY OF BALD HILL RD & NW SW THE E 260F
LYSOFRD & E2SWSW & W320FOFSESWLESS .92C
1.2The property lies within the future water service boundary of the City of
Yelm.
1.3The City of Yelm water main does not currently extend to the Stiebrs
property and is not immediately available.
1.4Janis Stiebrs is in the process of providing water to said property using a
private well to form an interim Group B water system.
1.5The Coordinated Water System Plan (CWSP) permits the development of
interim water systems in locations where potable water service is not
immediately available.
1.6The City of Yelm has agreed to allow Stiebrs to construct the water system
on an interim basis to serve the immediate needs of the property.
1.7The City of Yelm Water System Plan identifies the water service area for the
City of Yelm, and this area incorporates the water system. The City of Yelm
is vested with certain rights and responsibilities as defined in the CWSP.
2. Agreement
2.1 Stiebrs shall maintain the existing connection(s) from the well to the
buildings as they exist at the time of this Agreement; no new structures
requiring additional connections to the well shall be permitted, unless
approved by the City of Yelm, and this Agreement is modified in writing.
Water Service Agreement Page 1 of 3
2.2 Stiebrs agrees to decommission the weil and connect to City of Yelm water
service when it is immediately available to the site and pay appropriate fees,
including but not limited to appropriate connection fees, meter installation
charges and/or drop-in charges, within ninety (90) days of receiving written
notification from the City.
2.3Stiebrs shall make all improvements required to connect to the City water
system at such time as City water service is immediately available to the
site, at or across the parcel boundary.
2.5A11 provisions of this Agreement shall be construed to touch and concern the
land, shall run with the land, and bind the Stiebrs, its heirs, assigns and
successor(s) in interest, and such provisions are to be pursued in good faith
and diligently by Stiebrs, and any such successor(s).
Water Service Agreement Page 2 of 3
STATE OF WASHINGTON )
)ss
COUNTY OF THURSTON )
On this Day of , 2014 before me personally appeared Janis Stiebrs
to me known to be the ep rson who appeared before me, and said person acknowledged that she signed this
instrument, and acknowledged to be her free and voluntary act for the uses and purposes mentioned in the
instrument.
IN WITNESS WHEREOF I have hereunto set my hand and affixed my official seal and year first above
written:
Signature:
Print Name:
NOTARY PUBLIC in and for the State of Washington
Residing at:
Commission expires:
STATE OF WASHINGTON )
)ss
COUNTY OF THURSTON )
On this Day of , 2014 before me personally appeared Shelly Badqer, to me known
to be the Citv Administrator of the corporation that executed the within and foregoing instrument, and
acknowledged said instrument to be the fee and voluntary act and deed of said corporation, for the use and
purposes therein mentioned, and on oath stated that she is authorized to execute said instrument.
IN WITNESS WHEREOF I have hereunto set my hand and affixed my official seal and year first above
written:
Signature:
Print Name:
NOTARY PUBLIC in and for the State of Washington
Residing at:
Commission expires:
Water Service Agreement Page 3 of 3
WATER SERVICE AGREEMENT
THIS AGREEMENT is �nd entered into the day of , 2014,
by and between th Y OF YE 11�, a municipal corporation, hereinafter referred
to as the "CITY", and Janis ie rs, hereinafter referred to as the "9�AFPd��";
1. RECITALS:
�, � The OWNER holds record title to the following described property located within
Thurston County, Washington:
That part of the NE1/4 of the SW1/4 in Section 29 Township 17
Range 2E & NW '/4 & SE 1/4 SLY AND WLY OF BALD HILL RD
& NWSWTHEE260FLYSOFRD & E2SWSW & W320FOF
SE SW LESS .92 C
1.�. The property lies within the future water service boundary of the City of
Yelm.
1.2�The CITY water main does not currently extend to the OWNER's property
and is not immediately available to the OWNER.
1.3. The OWNER is in the process of providing water to said property using a
private well to form an interim Group B water system (SYSTEM).
1.4. The Coordinated Water System Plan (CWSP) permits the development of
interim water systems in locations potable water service is not immediately
available.
1.5. The CITY has agreed to allow the OWNER to construct the SYSTEM on
an interim basis to serve the immediate needs of the OWNER.
1.6. The City of Yelm Water System Plan identifies the water service area for
the City of Yelm, and this area incorporates the SYSTEM. The CITY is
vested with certain rights and responsibilities as defined in the CWSP.
2. Agreement
F an ' consideration o e terms d conditions mutual pr ises
c ined rein, it i reed between t ereto as follows:
Water Service Agreement Page 1 of 3
2.1 T e O R acknowled s tha this Agreemen ' to s e the existing
a el and tructure , or purpose of do ic water us includin
irrigation an ' stock watering.
2.2 The OWNER shall maintain the existing connection(s) from the well to the
buildings as they exist at the time of this Agreement; no new structures
requiring additional connections to the well shall be permitted, unless
approved by the CITY and this Agreement is modified in writing.
2.3 The (JWNER agrees to decommission the well and connect to CITY water
when it is immediately available to the site and pay appropriate CITY fees,
including but not limited to appropriate connection fees, meter installation
charges and/or drop-in charges, within ninety (90) days of receiving
written notification from the CITY.
2.4 The OWNER shall make all improvements required to connect to the CITY
water system at such time as CITY water service is immediately available
to the site, at or across the parcel boundary.
2.5 All provisions of this Agreement shall be construed to touch and concern
the land, shall run with the land, and bind the OWNER, its heirs, assigns
and successor(s) in interest, and such provisions are to be pursued in
good faith and diligently by the OWNER and any such successor(s).
Water Service Agreement Page 2 of 3
STATE OF WASHINGTON )
)ss
COUNTY OFTHURSTON )
On this Day of , 2014 before me personally appeared Janis Stiebrs
to me known to be the ep rson who appeared before me, and said person acknowledged that she signed this
instrument, and acknowledged to be her free and voluntary act for the uses and purposes mentioned in the
instrument.
IN WITNESS WHEREOF I have hereunto set my hand and affixed my official seal and year first above
written:
Signature:
Print Name:
NOTARY PUBLIC in and for the State of Washington
Residing at:
Commission expires:
STATE OF WASHINGTON )
)ss
COUNTY OF THURSTON )
On this Day of , 2014 before me personally appeared Shelly Badqer, to me known
to be the City Administrator of the corporation that executed the within and foregoing instrument, and
acknowledged said instrument to be the fee and voluntary act and deed of said corporation, for the use and
purposes therein mentioned, and on oath stated that she is authorized to execute said instrument.
IN WITNESS WHEREOF I have hereunto set my hand and affixed my official seal and year first above
written:
Signature:
Print Name:
NOTARY PUBLIC in and for the State of Washington
Residing at:
Commission expires:
Water Service Agreement Page 3 of 3
�OF THEp�P,y�` City of Yelm
iO�,
4 �
Community Development Department
105 Yelm AUenue West
Yelm, WA 98597
YELM
WASHINGTON
April 30, 2014
Sara Brallier
Thurston County Public Health
Environmental Health Division
2000 Lakeridge Dr SW
Olympia, WA 98502-6045
Re: Water System Priority of Service for 10901 Bald Hill Road SE, Yelm, WA 98597
Dear Ms. Brallier:
The City of Yelm has received your request for a Determination of Priority Service for a Group B
Public Water System located at the address above.
The property is located in the Future Water System service area for the City of Yelm. The City
cannot serve the property with water service at this time.
The Group B water system must be constructed to meet City of Yelm Standards as defined in
the Yelm Water System Plan and the Yelm Development Guidelines.
The City of Yelm requires, as a condition of approval of this satellite water system, an
agreement between the water purveyor and the City of Yelm that when City water connections
are available to the property, that the property connect to the City water system, the Group B
well be decommissioned per Washington State Department of Ecology standards and any water
rights associated with the system be dedicated to the City of Yelm.
If you have any questions, please do not hesitate to contact me.
Sincerely,
,�"`��'ri.c ��� _
Tami Merriman, Associate Planner
Community Development Department
Copy: Tom Peters, Water Engineering Solutions, LLC
Janis Stiebrs
(360)458-3835
(360)458-3144 FAX
www.ci.yelm.wa.us
RETURN ADDRESS
Document T`itle(s)
WATER SERVICE AGREEMENT AND COVENANT RUNNING WITH THE
LAND
Reference Numbers(s} of related documents
Additionat Reference#=s on page
Grantor(s) ��St,First and Middle Initial)
CITY OF TUMWATER
MCCLAIN, KARI J
Additional grantors on page
Gralltee�S�(Last,First und Middle Initial)
CITY OF TUMWATER
MCCLAIN, KARI J
Additional grantees on page
LCgal DQSCI'lpt1011(abbreviated form:i.e.lot,block,plat or section,township,range,
quarter/quarter)
3z-18N-2W PT NW/SE NKA TRACT C BLA-i4i8 i4/35
Additional legal is on page
Assessor's Property Tax Parcel/Account Number
i2832420206
Additional parcel a=s on page
4351733 Payes: 5
08/�1/2013 11:07 AM MULTI
Thurston County Washington
KARI MCCLHIN
■iii �� w�����,r�{i �!��,c��,c��r�w�� ���� �� �i i
4351733 Page 2 of 5 08/01/2013 11:07 AM Thurston County WA
WATER SERVICE AGREEMENT AND
COVENANT RUNNING WITH THE LAND
TH S AGREEMENT is made and entered into this �� day of
, 2013, by and between the CITY OF TUMWATER, a
municipal c rporation, hereinafter referred to as the "CITY," and KARI J.
McCLAIN, hereinafter referred to as the "OWNER";
WITNESSETH:
WHEREAS, the OWNER holds record title to the following described
property located within Thurston County, Washington:
Section 32 Township 18 Range 2W PT NW SE NKA TR.ACT C BLA-1418
14135. More specifically, TPN: 1283242Q206.
WHEREAS, said property lies within the water service boundary of the City
of Tumwater; and
WHER,EAS, the CITY water main does not currently extend to the OWNER's
property and is not immediately available to the OWNER; and
WHEREAS, the 4WNER is in the process of providing water to said praperty '
using a private well to form an interim Group B water system (SYSTEM); and �
�
�
WHEREAS, the Caordinated Water System Plan (CWSP) permits the �
development of interim water systems in locations potable water service is not
immediately available; and
WI�EREAS, the CITY has agreed to allow the OWNER to construct the
SYSTEM on an interim basis to serve the immediate needs of the OWNER; and
WHEREAS, it ia the intent of the parties hereto to further the goals and
objectives of the CWSP for Thurston County; and
WHEREAS, the CWSP identifies the water service area for the City of
Tumwater and this area incorporates the SYSTEM, the CI'I`Y is vested with certain
rights and responsibilities as defined in the CVVSP.
Water Service Agreement and Covenant Running With The Land
City of Tumwater 1 Kari J. McClain
Page 1 of 3
4351733 Page 3 of 5 08/01/2013 11:07 AM Thurston County WA
NOW, THEREFORE, for and in consideration of the terms and conditions
and mutual promises contained herein, it is agreed between the parties hereto as
follows:
1. The OWNER acknowledges that this Agreement is to serve the existing
parcel and structures, as shown in Exhibit A, for purposes of domestic
water use, including irrigation of less than one-half acre of land, and stock
watering.
2. The OWNER shall maintain the existing connection(s} from the well to
the buildings as they exist at the time of this Agreement, as shown on
Exhibit A; no new structures requiring additional connections to the well
shall be permitted, unless approved by the CITY and this Agreement is
modified in writing.
3. The OWNER agrees to decommission the well and connect to CITY water
when it is immediately available to the site and pay appropriate CITY
fees, including but not limited to appropriate connection fees, meter
installation charges andlor drop-in charges, within ninety (90) days of
receiving written notification from the CITY's Public Works Director.
4. The OWNER shall make all improvements required to connect to the
CITY water system at such time as CITY water service is immediately
available to the site, at or across the parcel boundary.
5. All provisions of this Agreement shall be construed to touch and concern
the land, shall run with the land, and bind the OWNER, its heirs, assigns
and successor(s) in interest, and such provisions are to be pursued in good
faith and diligently by the 4WNER and any such successor(s).
* * * Signatures Appear on the Following Page * � *
Water Service Agreement and Covenant Running With The Land
City of Tumwater ! Kari J. McClain
Page2of3
4351733 Page 4 of 5 08/O1/2013 11:07 AM Thurston County WA
IN WITNESS WHEREOF, the parties hereto have executed this Agreement
on the day and year first above written.
Q� .�,R. STATE OF WASHINGTON )
� )ss.
COUNTY OF THURSTON )
lj�r�.v. �� /'��""- I certify that I know or have satisfactory evidence
Kari J. McClain that Kari J. McClain is the person who appeared
before rne, and said person acknowledge that she
signed this instrument and acknowledged it to be her
free and vo3untary act for the uses and purposes
mentioned in the instrument.
�
Given under my hand and official seal this c� day
of ,2013.
Nots.ry Public �.
8hte af W�shi��toa (notary signature)� �
SllSAN M.'fUG6LE �,
�y�,OMMIS510��� (typed/printed name of notary
0?/081���
Notary Public in and for the St1 e of as in on.
My commission expues: 7� � � �
CITY OF TUMWATER• STA'I'E OF WASHINGT(?N )
' )ss.
COUN'I'Y OF THURSTON )
� i
T�,,��-�c� On this day, personally appeared before me, the
Pete Kmet, 1VIayOr undersigned, a Notary Public in and for the State of
Washington, duly commissioned and swom, Pete
Kmet, to me known to be the Mayor of the City of
Tumwater, a Washington municipal corporation, the
corporntion that executed the foregoing instrument,
and acknowledged the said instrument to be the free
�,��«������/ and voluntary act and deed of said corporation, for
`�����`���Y�y',����i�� st t deth tdheuwase autheori ed eto�exe ute t he said
� j�' N o r�9�y�f instrument. �
� �°•� j i _ Given nder my hand and official seal this ( day
'� �: A ��� � ` of �U��-t ,2013.
' � �BL1G ' :
�'�►'•,. �
i R .... • 2 � �.� � , �d--�-w�C' _
�� p •.,,, .'�O �.
'�i,����wasH�NG����� (notary sign )
VYIeI od u R. �(A I i r�r�
(typed/printed e of notary)
Notary Pablic in and for the State of VJashin ton.
My commission expires: 0�Z3'o��I�
Water Service Agreement and Covenant Running With The Land
City of Tumwater / Kar{J. McClain
Page 3 of 3
4351733 Page 5 of 5 08/O1/2013 11:07 AM Thurston County WA
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Tami Merriman
From: Ryan Johnstone
Sent: Tuesday, April 29, 2014 11:26 AM
To: Tami Merriman
Cc: Grant Beck
Subject: Stiebrs Farms - Priority of Service
Tami,
I reviewed the Stiebrs Farms Group B Water System submittal. I don't see any big"gotcha's" from our perspective.
Ultimately it is the responsibility of their engineer to make sure they are in compliance with DOH regulations. I did note
that there have been some rule changes to DOH's Group B requirements as of January 1st 2014.This report is dated
April 4th 2014,so I assume that these rule changes have been incorporated. In light of this I have two comments (feel
free to edit these as appropriate):
1.The water system must be designed to current City of Yelm and Department of Health requirements. Please ensure
that the water system design accounts for Group B rule changes adopted January 1, 2014.
2.At such time as this location is able to be served by City water, the well is to be decommissioned and the Farm will be
required to connect to City water.
Thanks
Ryan
Ryan Johnstone, P.E.
Public Works Director
City of Yelm
901 Rhoton Rd. � Yelm, WA 98597
rvanj@ci.velm.wa.us �( /�
p:360-458-8406 � �.y
,`V-
1
__ Page 1 of 1
Sara Brallier - Priority of�ervice Request.
From: Sara Brallier
To: Tammy Merriman
Date: 4/9/2014 10:45 AM
Subject: Priority of Service Request '
Attachments:. PriorityServServiceApp.pdf; Tax Parcel 22729310600_priority of service request.pdf
Attached is a priority of service request form and copy of the water system design application to construct a
Group B public water system within the City of Yelm's Urban Growth Area, as defined by the Thurston County
Coordinated Water System Plan. Our office is requesting on behalf of the application a decision from the City of
Yelm as to whether they are authorized to proceed or any conditions they must meet before they can proceed.
This water system is operating as an existing unapproved Group B water system. Our office is requiring they
obtain approval as an existing non-expanding Group B public water system before we an authorize the release
of a building permit application the property owner has submitted to Thurston County Permit Assistance Center.
Any violations on a property must be corrected before Thurston County can review and approve any
development permits on the property. In this case, the violation is operating an unapproved public water
system.
Sara Brallier
Thurston County Public Health
Environmental Health Division
2000 Lakeridge Dr SW
Ofympia, WA 98502-6045
L360) 867-2629
7:30 - 5:00 M-Th
7:30 - 4:00 Every other Friday
file://C:\Users\brallis�AppData�Loca1\Temp�grpwise\534524D8ThurstonLakeridge-po21... 4/9/2014
� �
Thurston County Permit Assistance Center
2000 Lakeridge Dr.SW,Olympia,WA 98502
��.-�:� (360)786-5490 / (360)754-2939(Fax)
1:�,._ TDD Line(360)754-2933
_ Email:�rmit(u.�co thurston.u�a.u;
_ t
w�e�i'co thurston vr�a.us�permittin�
THURSI�C�� �C)L1NTY
Creatitrg Solutions for Our Future
�i�cr.��s�
MASTER APPLICATION .
CTAFF TTCF. nNT,Y DATE STAMP
14 109494 HE
Permit Type: Water Systems
Sub Type: Group B
site: 10901 BALD HILL RD SE YELM WA 98597
Assessor PropertylD: 22729310600
Applicant:JANIS A STIEBRS
Owner:JANIS A STIEBRS '
I�►take by:
The Master Application is required for all projects and shall accompany a project-spec�c supplemental
application(s).The Master Application may not be submitted alone.
Property Taz Parcel Number(s): 22729310600
Lot#:
Subdivision Name(if applic`ble):
Ci : Yelm State: WA Zip Code:98597
Property Address: 1099�1 Bald Hill RD SE tY
Directions to the Property:
Property Access Issues(locked gate,code required,dogs or other animals): QNo �X Yes
If yes,Deseribe: �'oPeTtY is organic farm,please check with office for access to wellsite.
OWNER IS RESPONSIBLE FOR SECURING A1vIMALS BEFORE SITE VISIT.
DESCRIPTION OF PROJECT PROPOSAL
Approval of an existing Group B public water system
Form No.MA001
Revised 8-13
lhurston C;ounry t'erm.tt Assistar�P c:enter
Master Application "
Page 2 of 2 f �
Type or Print: Additional property owner sheet can be abtained online at wmw.co.thurston.x•a.usinermtttina or copy obtained
from the Permit Assistant Center.
Property Owner(s): Janis A Stiebrs
Mailing Address: PO BOX 598
City: Yeim State: WA Zip Code: 98597
Phone#: 360-45&-3333 Ext. F�#: 360-458-3899
Cell#: E-mail:
Signature:* Date: ( _ �
Applicaut(if different than owner): Janis Sriebrs
Mailing Address: PO BOX 598
City: Yelm State: WA Zip Code: 98597
Phone#: 360-458-3333 Ext_ Fax#: 360-458-3899
Cell#: E-mail: jon(�a,stiebrsfarms.com
Signature:* Date: �
/ - z �1
Point of Contact: Tom Peters Water Engineering Solutions,LLC
Mailing Address: 2201 SVJ 152nd St.Suite i
City: Burien State: WA Zip Code: 98166
Phone#: 206-243-2818 Ext Fax#:
Cell#: 206-707-6480 E-mail: peters{a�waterengineeringsolutionsllc.com
Signature:* _ ��,,�,,,,,,,�_^ ..i:::J-.,�— Date: 3/28/2014
BILLING INVOICES
The base application fee charged at the time of application covers base hours listed on the fee schedule. When the base
hours by a Department are used,a monthly billing invoice will be generated for additional hours at the hourly rate listed
on the fee schedule. Should review of the project exceed the base hours allotted,billing invoices shall be mailed to:
❑Owner �X Applicant ❑Point of Contact
"AppIication is hereby made for a permit or permits to authorize the activities described herein. I certify that I am familiar
with the informarion contained in the application and that to the best of my lalowledge and belief, such information is true,
complete,and accurate. I further certify that I possess the authority to undertake the proposed activities. I hereby grant to the
agencies to which this application is made or forwarded,the right to enter the above-described location to inspect the proposed,
in-progress or completed work. I agree to start work only after all necessary permits/approvals have been received.
Revised 8-13 Form No.MAd01
R
,
' Thurston �'ounty Environmental Health
����.�� � 2000 Lakeridge Dr.5W�Olympia,WA 98502
'-=_�y. (360)867-2673/(360)867-2660(Fax)
,� -., TDD Line(360)754-2933
— _ _�.
THL'�RtiT�ti' COU:�TY www.co.thm•ston.wa.us/health/ehadm
.�•>�: _
Supplemental Application
GROUP B WATER SYSTEM DESIGN
STAFF USE ONLY DATE STAMP
PLEASE I�TOTE;
ALL APPLICATIONS Ai�D SITE PLAl'�T�
MUST BE COMPLETEI} IiieTT BLACI� OR
BLUE II�TK C�I�TL�i'
Intake b :
This application cannot be submitted alone.In addition to this form, a complete package includes:
Applicant S��Z'TAL CHECKLIST Staff Use
Use Onl
QX Master Application. ❑
QX Supplementai Checklist for a Group B Public Water System. ❑
� Applicable processing fees.Refer to current fee schedules.Depending on the adopted fee �
structure, additional ees ma occur i base hours/ees at intake are exhausted.
ENGINEER/DESIGNER OR PROJECT APPLICANT
Name: Tom Peters Company Name: water Engineering Solutions,LLC
Mailing Address: 2201 SW 152nd St.Suite 1 City: Burien State: WA Zip: 98166
Phone#: (20�243-2818 Ext. Cell Phone# (206)707-6480 Fax#:
E-mail Address: eters wateren ineerin solutionsllc.com
CITY JURISDICTION REV�W AND COMMENT:
Comments:
Signature: Title: Date:
PROJECTS ASSOCIATED WITH TAIS APPLICATION
FOLDER/SEQUENCE NUMBER PROJECT NUMBER DATE RECEIVED
Revised 1-IS-14 Form No. SA019
r
Thurston County Environmental Health
Supplemental Application for a Water System Design
Page 2 of 3
TYPE OF PROJECT:
❑Residential-Single Family ❑Residential-Multifamily #of Units: �Non-Residential
TYPE OF PERMIT:
OGroup B Public Water System
Water System Naxne: Stiebrs Farms ID#(if existing)
Subdivision Name(if applicable):
Thurston County Coordinated Water System Plan Service Area ❑Inside Service Area 0 Outside Service Area
WORK TYPE:
❑New Water System Proposed �Existing Water System,New Source Proposed
TAX PARCELS TO BE SERVED BY THI5 WATER SYSTEM
Well or Spring Property Tax Parcel Number: 22729310600
Well or Spring Property Address: 1090�Bald Hill Road SE,Yelm,WA 98597
Pro Tax Parcel Numbers To Receive Water Service list below :
22729310600
Water System Classifications:
• Group B Public Water System is classified as community system with 3 to 14 residences and less than 25
people per day(such as a workplacej or 25 or more people per day for fewer than 60 days per yeax.
For water system projects within a City jurisdiction or Thurston County Coordinated Water System Plan Urban
Service Area:Environmental Health Division will mail the application to the applicable jurisdictional authority and will
hold permit issuance until their review and comment is completed.
NOTE:Expansion of a One or Two Single-Family Residential Water Supply to provide water service to additional
connections will require the water system meet the Group B or Group A public water system requirements of Article III of
the Thurston County Sanitary Code. This includes a design of the proposed system expansion by a licensed professional
and subsequent approval by Thurston County Environmental Health Division or Washington State Department of Health,
if applicable.
APPEAL: Any person aggrieved by a decision,a.n inspection,or notice made by the Health Officer shall have the right
to appeal the matter as specified in Article 1 of the Thurston County Sanitary Code.
For additional guidance and fact sheets visit our web site at http:/i��u�w.co.thw-ston wa us/health/ehadm
Revised 1-15-14 Form SA019
Thurston County Environmental Health
Supplemental Application for a Water System Design
Page 3 of 3
GROUP B PUBLIC WATER SY5TEM DESIGN CHECKL�ST
All Group B Public Water Systems are regulated by the Thurston County Environmental Health.These systems must comply
with Article III of the Thurston Counry Sanitary Code and Chapter 246-291 WAC Group B Public Water Systems and
associated workbook for Group B Public Water System Approval. For projects located within a City jurisdiction or Thurston
County Coardinated Water System Plan urban service area,additional standards may apply.
Applicant GROUP B PUBLIC WATER SYSTEM DESIGN Staff Use
Use SUPPLEMENTAL CHECKLIST Only
� 1. Submit copy of an appraved well site inspection application. An approved well site �
application is required prior to drilling and before the water system design application can
be submitted (See Supplemental Well Site Application and Well
Construction/Decomm.issionin Ins ections form .
� 2. Submit a completed Group B Public Water System Design Application form. A �
Preliminary Engineering Report prepaxed by a Waslungton State licensed professional
engineer must be submitted with the application. The engineering report shall follow the
Group B Public Water System Approval workbook, including Satellite Management
Agency information,draft documents(covenants,easements,operations and maintenance
a eements ,and water uanti and uali re orts.
REVIEW PROCESS
1. Staffwill review the water system design and preliminary engineering report and send a letter granting preliminary water
system approval,if all the requirements are met.
2. After the water system design has received preliminary approval and construction is completed,the engineer shall inspect
the water system to assure compliance with the approved construction documents.
3. Within sixty(60)days of the inspection,the engineer shall submit a completed Certificate oflnspection and Installation of
Public Water System Projects form along with the Final Engineering Report.
4. Staff will review the documents and grant final water system approval and the required sampling freqnency, if the
requirements are satisfied.
5. Staff will recommend approval of the Certificate of Water Availability(COWA)after the water system has been granted
fmal approval.
CAUTIONARY NOTES
• It is important that ali itexns listed in the preliminary approval letter aze submitted with the final report to avoid delaying
the final review and approval of the project.
• Staged Construction: Projects having staged construction shall submit certification documents for each separate stage of
the construction prior to approval and use of any segment.
• Well Isolation Covenants: Public road right-of-ways shall not be located within a well's 100-foot protective radius.
Private roadways may fall within the well's protective radius if they are ditched and graded in a manner which conducts
run-off away from the well and outside the protective radius.
For additional guidance and fact sheets visit our web site at http://www.co.thurston.wa.usihealth/ehadm
x�ed r-ISaa Form SA019
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Stiebrs Farms Engineering Report
Existing Group B Approval
Introduction
Stiebrs Farms is a family-owned organic egg farm located approximately 1 mile southeast of
Yelm on Ball Hill Road SE.
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Parcel Map
The business recently celebrated its sixtieth year in operation. In addition to the egg-producing
portion of the business, Stiebrs Farms operates an egg processing plant and liquid egg (Easy
Wisk) facility at this site. The company distributes eggs and Easy Wisk throughout western
Washington and northwestern Oregon. The facilities are inspected by USDA, who maintains a
staffed office onsite.
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Egg Processing Facility
During the recent addition of a third storage facility, a document review revealed that the water
system serving the workers onsite had never been approved as a public water system. This
application for approvai of the existing Group B water system is submitted to satisfy a condition
of the building permit. The water system provides water only to Parcel Number 227293310600,
as shown below. The well is also located on this parcel, 100 feet north of the three poultry
houses fronting 110th Avenue SE.
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Aerial View of Site, Showing Parcel Numbers
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Stiebrs Farms is outside the City of Yelm's existing water service area and designated future
retail service areas. However, the company is located within the City's Urban Growth Area
(UGA) and future water service area. Appendix 1 provides a copy of the existing and future
water service area maps from the City's approved Water System Plan. According to the water
plan, the City cannot provide service outside the existing water service area until additional
water rights can be secured. Therefore, water service from the city of Yelm is not a viable
option at this time.
System Description
Three separate onsite water distribution systems use the same well, pumps, pressure tank, and
pump house. The systems serve the poultry houses/brooding shed, a fire sprinkler system in
one storage building, and the office/processing building (Group B system). The only water used
for domestic purposes is in the office/processing building.
Each distribution system begins in the pump house. All pipelines are 2-inch diameter
polyethylene pipe. The system that serves the poultry houses and brooding shed splits from the
main system using 1'/z- and 1'/4-inch pipe to supply individual buildings (see Appendix 2). The
poultry houses use an air-gap type watering system, and no nutrients or chemicals are added to
the water. Both the fire sprinkler system line and the line to the poultry houses have a double
check valve assembly (DCVA). A new, second pipe to the office/processing building was
installed in 2010.
The water source is a 10-inch well drilled in 1950 to a depth of 66 feet by L.B. Richardson.
According to the well log (see Appendix 3), the well had a static water level of 28 feet and was
test pumped at 500 gallons per minute (gpm) with 3 feet of drawdown when it was drilled. The
well log form provides no information on a sanitary seal, and the driller did not provide notes
regarding grouting or sealing. The well log did show various levels of clay mixed with either
sand or gravel and 20 feet of hardpan. A water right for the well was issued in 1953
(Appendix 4).
Source Water Protection
The well is located 100 feet north of the nearest poultry house and approximately 200 feet
southwest of the drain field serving the office/processing building. The pump house in which the
well is located is shown below, along with a portion of the sanitary control area. The foundation
to the left of the pump house has been constructed for a future storage tank to ensure
continuous water flow to the chickens in case of pump or power failure.
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Pump House
The aerial photograph below shows the area around the well in August 2012. The blue line on
the figure indicates the 100-foot distance to the poultry house closest to the well. The three
poultry houses are cleaned by dry scraping to collect manure, which is then hauled offsite and
composted.
The red lines on the figure depict the 600-foot radius from the well. The long building on the
western (left) side of the photograph is the brooding house. The office/processing building is
the large building on the northeast side. Three storage buildings are located east of the well on
the same parcel. Only the storage building closest to the road is equipped with a fire sprinkler
system. Other structures on the main parcel are also used for storage. The building across Bald
Hill Road on the northeast side is a shop constructed in 2012. Two single-family residences are
located south of 110th Ave SE.
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August 2012 Aerial Photograph of Facility
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Pumping and Pressure Tank
The well currently contains two pumps, each producing approximately 35 gpm. The pumps
operate within a range of 40 to 70 pounds per square inch (psi), with the pumps able to run
simultaneously. The water lines to the office/processing building and the fire sprinkler system
tee off before reaching the 1,000-gallon hydropneumatic tank, which contains an ASME
pressure relief valve.
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Recent water quality analysis results are included in Appendix 5 (Inorganic Chemical) and
Appendix 6 (Bacteriological).
Distribution Piping
The line to the poultry houses and the brooding barn leaves the pump house after the pressure
tank. Both the fire line and the poultry house lines are protected with DCVAs. The most recent
test report for the fire DCVA is attached in Appendix 7.
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Fire Line DCVA Newly Installed Poultry House DCVA
The water for the office/processing building is treated with an Aquafine ultraviolet light unit
(CSL-6R), which is rated at 60 gpm. Jon Stiebrs, owner, estimates that the processing
equipment uses approximately 3,000 gallons per day and the chickens use 4,000 gallons per
day. Employees and visitors use an estimated 300 gallons per day (see workbook for details).
Although it is difficult to calculate peak hour demand for the domestic and processing water,
about 6 psi pressure loss would occur through the approximately 200 feet of the 2-inch
polyethylene pipeline from the well to the office/processing building. Operating pressure at the
UV unit was field-verified at 58 psi. With the pump on pressure setting at 40 psi, the pressure at
the office/processing building would remain above the 30 psi minimum.
Operations
Wayne Johnson, the farm's full-time maintenance man, is responsible for water quality
monitoring and operation and maintenance of all equipment on the farm, including the water
system. Richardson Well Drilling (State Contractor Registration #RI-CH-AW-*32108) is the
farm's pump service company and provides 24-hour emergency service (253-537-7332).
The UV light is replaced annually, and replacement tubes are readily available in the area. As
required by the USDA, semiannual bacteriological sampling is conducted jointly by Wayne
Johnson and a USDA staff person and analyzed by Water Management Laboratories in Tacoma
(253-531-3121). The backflow assemblies are tested by a certified Backflow Assembly Tester.
In case of a water outage or a water quality problem, Stiebrs Farms will provide bottled water
and portable toilets for employees and outside contractors who would address the cause of the
problem.
The Water Facilities Inventory (WFI)form (Appendix 12) has been completed.
DOH GROUP B Design Report Workbook
1.0 Designer and Owner
1.1 Water System Designer
Workbook prepared by Tom Peters, P.E.
Mailing Address 2201 SW 152°d Street, Suite 1
Burien,WA 98166
Company Name Water Engineering Solutions,LLC
Day Phone 206-243-2818
If prepared by a Professional Engineer, apply seal here. /
i l
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1.2 Water System Owner ,�P,p��,29,�,r-
i
Owner's Name Jon Stiebrs ����,� �� -----
Owner's Mailing Address PO Box 598
Yelm WA 98597
Day Phone 360—458-3333
��
��� ���
Owner's Representative Signature ���'� �--Q���� Date 4/03/2014
2.0 Basic Water System Information
2.1 Water system name and location
System Name Stiebrs Farm
Water System Location Yelm, Thurston County, WA
(Town or City, County)
Public Water System ID#
2.2 Group B Planning and Design Submittal Checklist
CHECKLIST FOR A NEW OR EXPANDING
GROUP B WATER SYSTEM
Group B
Planning and Design Submittal Element Design �'eS� No, Not
Guidelines Included Applicable
Section
Completed submittal checklist for a new or expanding Yes
Group B system
Completed project approval application form Section 2.2 Yes
Property title notice Section 2.6 N/A
Service area map Section 2.3 Yes
Demonstrate compliance with SMA requirement Section 2.5 No
Applies to new systems only.
Demonstrate compliance with PWS Coordination Act Section 2.4 No
Completed Water Facilities Inventory(WFI)* Section 29 Yes
Water users' agreement(OPTIONAL) Section 2.8 No
Water right permit ar other needed Dept. of Ecology approval Section 3.0 Yes
Well log Section 4.1 Yes
Well pump test report Section 4.1 Yesl
Well water quality sampling results Section 4.2 Yes
Documentation of well site approval Section 43 No
Section 2.7
Well sanitary control area protective covenants and 4.3 �'es
Intertie agreement Section 4.4 N/A
Section 5.2
Well and pump house detailed drawings and specifications and 5.3 yes
Distribution system detailed drawing and specifications Section 610 Yes
Storage tank sizing, detailed drawings, and specifications Section 7.6 Yes
Booster pump sizing, detailed drawings, and specifications Section 81 N/A
Secondary contaminant treatment design Chapter 9 N/A
Completed Group B Design Report Workbook Yes
1. As reported on well log -Appendix 3
2.3 Connections and Population
Connections Service Population
Dwelling units Nonresidential Residential Nonresidential
1 15
There are normally a total of 12 workers and USDA inspectors in the office and processing building.
Only a few vendors, additional inspectors, contractors, and a few visitors visit the office. Because of the
organic nature of the farm, tours are not allowed, and visitors are usually limited to the office area.
3.0 Estimating Water Demands
3.1 Summary of Peak Hourly Demand (PHD) and Maximum Daily Demand (MDD) Summary
Worksheet 3-1.
Line Group B Design Description Value
Guidelines Section
A 3.1.1, and 3.3 Total residential MDD, gallons per day n/a
B 3.1.2, and 3.3 Total residential PHD, gallons per minute n/a
C 3.2.1, and 3.3 Total non-residential MDD, gallons per day 3001
D 3.2.2, and 3.3 Total non-residential PHD, gallons per minute 20 gpm2>3
F-1 3.4 Fire suppression flow required (if any), gpm n/a
F-2 3.4 Fire suppression flow duration, minutes n/a
1. 3 visitors/day @ 5 g/d = 15 gallons; 5 average of�ce workers/day @ 15 gallons=75 gallons; 7
processing/field workers at 30 g/d = 210 gallons
2. 6 toilets x 2.5 fixture unit weight= 15fixture units; 8 sinks x 1.5 fixture unit weight (assume all
kitchen type sinks)= 12 fixture units 12 + 15= 27 total fixture units, rounded up to 30 fixture
units
30 fixture units = 20 gpm PHD (DOH Group B Design Guidelines)
3. Assume 40 gpm processing equipment PHD
Total area intended for irrigation: N/A square feet or acres
Total system MDD (Lines A+C): 300 gallons per day
Total system PHD (Lines B+D+F 1): 60 gallons per minute
---------------------------------------------------------------------------------------------------------------------
Is a water right permit or other written Dept. of Ecology water resource approval required? See Section 3.0 of
the Group B Water System Design Giridelines. No
Although a water right is not required for the minimum public water system related us of the well, a
water right was issued for the well in 1953. A copy of the certificate is attached in Appendix 4.
4.0 Source of Supply
4.1 Well information
If a well will supply water to your system,you must attach the following to your design submittal:
Item Status
Well Log Attached(Appendix 3)
Pump Test A dedicated pump test was not performed for this
application. The well log indicated a yield of 500 gpm
with a 3 foot drawdawn and instantaneous recovery.
The water right certificate was issued for 175 gpm. The
water system currently serves the existing facilities
satisfactorily,and no expansion of water use is
anticipated as a result of this application
Water Quality Results A complete Inorganic Chemical and recent
bacteriological analyses are attached (5 & 6)
Well Site Inspection by Existing well with no obvious 100' encroachments
DOH/LHJ
Protective Covenants Attached (Appendix 8)
Low yield water supply n/a Well yield is more than satisfactory for existing uses
contingency plan based on well log and water right information.
- .
4.2 Wellhead Protection Inventory
Please indicate whether any of the following are present within 600 feet of your well.
Potential Water Quality Threat Yes No Unknown
Likely pesticide application X
Storm water injection wells X
Other injection wells X
Abandoned groundwater wells
Landfills, dumps, disposal areas X
Known hazardous materials site X
Another water system with known water quality problems X
Residential development greater than one house per acre X
Residential septic tanks X
Underground storage tanks X
Sewer lines X
Storm water disposal areas X
Surface water-If yes, specify distance from well site: feet X
Red lines in the picture below indicate 600' distance from the wellhouse.
The blue line i�idicatcs the 100' distance to the closest p��ullr� hc�lisc.
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4.3Interties N/A
5.0 Well Pump, Bladder Tanks, and Pump House
5.1 Piping Schematic
Siebrs Fa�m Pumphouse Schematic
To fire sprinkler system
ASME Pressz�re Relief Valve
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5.3 Summary of Well Pump Selection
Cycle Stop Valve (CSV) incorporated in design: No
Variable frequency drive well pump(s) incorporated in design: No
Pump Design Parameter At well pump "on": At well pump "off': Comment
Pressure switch settings 40 psi 70 psi Well pumps to
hydropneumatic tank
Discharge rate 35 gpm 31.5 gpm
Total Dynamic Head 151 feet 221 feet
Well pump setting (depth)below top of well casing:63 feet
� Pump curve (or table showing discharge head and corresponding discharge flow)
Appendix 9 (305425-17)
• Identify the pump "on" and pump "off' operating points on the pump curve
• Pump manufacturer and pump model number
Appendix 10
• Pump horse power : 3
5.4 Hydropneumatic Tank(DOH Water System Design Manual—Horizontal Conventional
Pressure Tank)
V= ((Pi+ 14.7)1 15 Qp(MF)
[Pi— Pz] X N�
V = Total tank volume required
P1 P� =Pump off and pump on pressures
Qp = Pump Delivery gallons=70 gpm(assume both
pumps pumping at 35 gpm)
N� = 6
MF= 4' diameter tank= 1.08
V= f( 70 + 14.7)] (15 (70) (1.08))
[70—40] X 6
V= 84.7 1134
30 X 6
V= 2.8 x 189
V= 529 gallons Existing 1000 gallon tank exceeds minimum size required
6.0 Piping and Distribution System
6.1 Summary of pipe design
Distribution system pipe size and material specified:
2" Polyethylene Pipe (specification is unknown) —installed in 2010
Minimum pipeline depth of bury specified: 2 feet across field
Pipeline hydrostatic pressure testing specification: unknown
Pipeline disinfection specification: unknown
Private property easements required? Not required
6.1 Service meters
Service meters: Not provided at each connection
6.3 Cross connection control
Are there any existing or proposed cross connections? Yes
A fire sprinkler system in one of the storage buildings is protected by a double check valve
assembly. Appendix 7 is a copy of the most recent test report
The distribution line to the poultry houses and breeding shed is also protected by a newly
installed double check valve assembly.
6.4 Distribution system detailed drawings and specifications
Attached (Appendix 2)
6.5 Disinfection
The water for the office/processing building is treated with an Aquafine Ultraviolet light
unit (CSL-6R) as it enters the building. The unit has a rated capacity of 60 gpm.
Additional information is presented in Appendix 11 The bulb is replaced annually.
7.0 Atmospheric Storage Tank n/a
8.0 Booster Pumps n/a
9.0 Secondary Contaminant Treatment Design n/a
10.0 Financial Viability
10.1 Financial Viability
Water reliability and quality are vital to the day to day operation of the entire farm. In
addition to the workers, the water is essential to the health of the poultry and for the
processing of their eggs. ,
The organization maintains a budget operational reserve for equipment replacement, and
to address unforeseen events (various types of emergencies). USDA requires a
maintenance and operations fund for the entire water system. Because the well, pump, and
pressure thanks are common to the drinking water system and the poultry houses and
brooding shed, it is not possible to separate the reserve for only the drinking water system.
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� � - . p1A/NER'S COPY Hppenaix :�: vveii �og
..-�`'
� � _ ' : '
�:,, cCORD::BY WELL pRILLER OR OTHER CON ' �
�` FOR WITHQRAWAL:OF GROUND WAT�R : °
.. .�,! , _ ,..., �
_ _ -
•: ' Under Permit No. G.W .�..� ,.:�..-� . , `
- ("The well driller or other constructor of worlis for the withdrawal of pubHc ground waters shall be obli�ated to fur-
rish the permittee.a certified record:of the factual inYorma�on necessary :to show compliance"witn the provisions of,this -
section." Sec.8,Chap.263 Laws of 1945.)
i ..,.�------: .._._:..: --.�y�,.�=-'� ...._..----�1..:..:.(��.-�.' E.'r-,�$.::�!��..'�.�"n' �Q%t-�c�..-��--�
-.� , � � (Name and�address�of oWner qi well or other�works for with,dIr/awal of waterp� . . . . ..
2. Type; name or.nusnber of works where water Ls taken ..��Y.�� ...:.... .::...:.. ... . ........
. � . � ' � . � � ' . . . � : .(SVeli,.tunaelorinfiltratlontrench) ��
..:. . . � .� . . - ... .� :. . . : ..
3: Date on which work on well or other stru9�u'�was started ...:: _'�.::.
._..,�.,� ..:...�,�....lp,'p .:......
4. Date on which work was completed.:......... .. :....._ ..--: ......�:` /:,,.... p.:,3 .....:..r 9'b.:�.. ... :.',
. . , .
; .. : .
, ,._. ` .. �w
; r :. _ . ..
�: 5, If work on_well or other structure was abandoned, give date::._ .,.:.. .....;., ::;.. ._.:_., ,� ..�,:. '
� . : .:. ` c ',, ;:. . < _
. ,
and reason'for abandoiiment...:::::. _.........._.........:.:.... .:...... ......... .. ... �.:.•- -.-.,., .., ._.._
F). .DESCRIPTION OF WORKS: 1
. . ` � . .. , :
(a) WE�,L: Depth __�G. L.�.....:::ft.�Diemeter :..� 4 .:.:in. or ft:Dug or drilled----.. �.:.��..� ........
i
Flowing or pump well .:.�..�x�,�,�,-i.�i� - _ �
Ir PU!vrn WELL: Type and size of pump is. ....:.:.�� ��^'`'`"*`':*�J.�' �...- ..:.., --- .
Type and size of motor or engine is ::........._.. ..:... �.�f..- `'?"� ..._ . ._.,..;.:. ....!..... .
�..:..:
. _ , �
Depth from ground surface to water level befQre pumpuig...: : ,g' '�.._.'... .::..:....... �eet
. _ ...� ,
�
After continuous `operation...� �.. _£� hours; the measured discharge of the pump is
. - . - . � � . (Atlea .Sour)` . � - ' � �
---_.._..__.......... `_��.v.--fl ......:.g.p.m., and the drawdo.wn of water�level is---- .....:...� ._.:...: �...feet
Recovery data (taken after pump has been shut off) ,(time taken as zero when pump t,urned
off) �(water level measured from well top to water level) ' ' '�
_ - �.
Ty�ne W¢te�� LeveT ` Ti�ne , Water Levei j -
: ....: ......... . ..:...... . ....: : . ...... . • -
; ::.. .::. ._._. .
��
, ..��,�-�.:`-�.``` ��`-�' ,.� :- ---� l�' - :: � ......:_
,, ,., � _ � �
: ..:�:...:::..:.. _
Date of test......... �,,,;:..�.._.� .... . � ..�..J:. _
' ` IF FLO�vrxc WELL; Measured discharge..... ....... ___ .. :. g p.m,, on ..::.--�'r.,. _
�-'°
..�.... .. .............
� r. .. . . . . . . ...: � - �. . .-�. .�.. . ' . . �. .... �- ����`(Date)�-�..
Shut-in pressure at grQUnd sur-face .: . .. • :.lbs, per:sq in: o2i
� '- - j➢ate)
I
Water is controlled by:. _
....... ...: .... . . . .. . .. .... .......
. : . . - _,(Cap valve.etc 1 _ . - .
_ ...1..� .
C9s?rrc: (Give diametc,r, commercial specifications and depth below grottnd surface of e�ch_�as- _
= • - --_- _.....-- - -,_- - - -.._---- --- — - - _
---- _.. —'.uigsize;) -
..... .... :, .in. diameter.:....:......: . ._...,.from.:. _....::.: to:..:..... ... .... .ft. . .
_ -
...:.........:...:....in. diameter...:.:.. . .......,....:: ..: ....... • ----.. .: --- . „_...from,.. : .....,. ..to.. ..... :. ::...:ft.
.. . ....... ..in. diameter......: ....:.:.. .:...... . ...:. . ........... ...... ......from. .:...,... :to.,::�.. _.;:.:;ft,.
: :......::...........in. diameter....... .: ...,. . :..:.. . . ,......., . :....... ... .....from- ---_:, to......_ .._.....ft,
Describe:and show depth of shoe, plug, adapter,liner or other details: _ _ _
/`' (� " /��,f'-�%.-••..e. ��" � � .�i �� _
�/ . - -
_ � .,-,
_. . . . � .I
�
Perforated casing or screens: �""'""� � w
..%.l�;.�'�...�......Zo.-'��?.....:...--'���--�-f..,�kl.....�.... ._..... ;---. .. _.. - --`-�`..�-.ft.
..from_ .�-� .:.:.to.. _
(Number per toot size ot erforatlons,or describe screea �
. p ) .
.�.,.� �� � " �'
....... . .... ... . ' . .... ......_.. .... ----_.........----................---......_ om_........._..._...........to._.._...................�....�.
�'. �._ �_.
................................._... ..:............._.....-.._...----�---.......-�--�-�--.................._._.........___............_...-�---..._.....from......_..__......._:....to....._........ ..:...:...:.ft.
- ..............................-......_..--..... ....._._.--�--.......--� -..............----._............_......---.............----_.....-----------from-----......-------.....to.__..._.._._........_.._...ft.
�-----.._...................:. :. :---......from...---.,.............._._to_......:...,... --.........ft.
_.__...................... ........._..._..................-•--....._..........._....-- -�--. .....
`LoG oF WELL ox TvrlrrEL: (Describe each stratum or formation clearly,ir�dicate if water bearing,
and give thickness and depth as indicated.)
MA'1'F'Riar. - � � Thickness� Depth to 6ottom-
. . (Feet)- �(Feet) - �.
- ��/� �' �`�`'�'J•�
� ° T—.' .. ' . . --— - - •,-_.
!
f�e�..���-�.-�.- - � .
� _
� - .� o �' �� _
�'z-�-
c� ".� S`
� - - . +' � . - . Y�� ._ . ... �
� . �' . . .�� .. . . l -�� .
� — " D � D Y
�.�= �"� �a '��'L°{�T�ti� . .
r `
� --- --�� � �`- - - -- - -- -- -- -----..
;
� " i . . . . . . � . . . .
: . �L1L , . . ... �✓(l� ` , .1�! '�,_� .`� '
�I7� INFII,TRATION TRENCH OR TUNN�L: �p2........_... ` ..��3-- '
---��,�,�,,� -�.�-, � �.:_�--
. : - � :..; _
Dimensions: .. ..........._..._................--........-----.... -------........_.....__................_._....._:..--::;-_--..._...............---:_.�...::_.:---=-`---............----.._...._..........!,...
(Tunnel�length,course,and cross-sectlnnal size) � . (T7ench-minimum aad maximum depths)
Bottomwidth_..._._........_........_ft. Discharge-------........__.....------._..._.....g.p.m: Date of.test..._------.............--............._......--..�._
Position of water bearing stratum with reference to portal "of tunnel_...I..........:..._.._._.................._._....._.............�_.
I
' I
.. ......-- ..._...._........ ...............---.._...... ----°------...—-- ......._._.___...., ._ --.. .._----......----..._._...-_.------...._.......----
�-/ ` i..
� y��
............. ...... .. _�.."'"�''.4..3=C�c'�c��'.�'�,--,,,�°........---�-_
(Signatute of well drSller or other constructor) �
� (
I
• . _ '........ ..... ......... ....�." '..._............................ .....
, ,��
. . . - .. • . - . . '� (Address) � � . . . Fu,_,.
STATE OP WASHINGTON. r
�SS. ,.:,.
�
Count� o f .................�.'�'tC.,e...........).........._......_.............._..................
j, ..__......._�.�____�,.c���....... ......................., beiny first dul� sworn, do he�•eby certify that I
am the driller or constructor of the aforesaid well or tunnel or trench who fu�•nished the foregoin
statement of jacts; thnt I have reacl saic� statement and each and all of the items therein containecl a e
true to the best of my knowledge and belief. j� �
`"1.t` �.... '����..._
:
............_..---. :,�::.......................�..�... .. ......._......::_.................................�...
(Signature) �
1 / � ,�}
Sicbsc-�ibed ancl sworn to before me this.......lo�.._.�.._da� of...._...... ..�.��,�ci�,,.�,`��..�..�..........., 195....U...
, , i
e�=�Y.�.1�.'.�-..'.�U_.
........_....... r����:--........
........._....._..._... ....-�-- .��. ��
Not¢ry Pubiic
. �_ --------� ).
_ i .
� , , - , �� ------ Appendix 4: Roehr Water Right � -
, ,- �
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- T j , , - ,, i:a:<:,:.
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__a� . • = - _ -
,
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'_ _"''�_, ti _—'----- �� � � ---- � ---- �-- -- -- ------- -- -- ------/---� —
� '.. -:- --------- ------Cr.�r�ce�zRr�oa��PTo,�3"�.._..�FdcsRo.�....'�
'"'".�„i - �— — —- = . , ..
_ : . �� ,-- Ssa�c�eorR�'�:cxox,Covi��op ��— - - ° '
. r ,: .
�i=��_ � ..,! .,,-_. � _ � . _
. � : -� �r�cat�-of Gronnd Water Right � r
. ;.
� L�uerl in aeeoiQance with the nravis2ans a2 CLsD�ZQJ.Ls�rr oi Wasflington fos 10A3,ana ammsiment�thsrctv.naH thc � . �
= `ivtes wnd sesulatioas of the SLte 5ugervisor e!Weter fteso�cq tIIercun3cr. �
, f:
s�815 L9�GERTIE�3t ThRE�......_-._...�.�.,.�l..�:�r..m....._....,.... . �. , . ..
. f
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- ;��;, Supertsisa�of WaBer Resaurces mtd tF:at said�ight to ti:e��se o�snid J��rnd�aters ha�Seea perfecter� . _
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Please Print Plainly ��g
1515so�st. E. Appendix 5: Inorganic Test
USr,HEAV'Y PEN � MANAGEMENT Tacoma,WA 984 Resu Its
DO NOT WRITE IN SHADED AREAS � I.ASO�TOIUES��. (253)531-3121
�
INORGANIC CHEMICALS (IOCS) REPORT
System ID No: /�J� Systenn Name:S ` �
Lab/Sample No: �g j�1 y 3�- Date Collected:43 -� _ � DOH Source No:�A
Multiple Source Nos: � Sample Type: (� Sample Purpose: �j
Date Received: �3 _� 7_ Date Reported: 03•i3��`� Supervisor: �
County:�u Date Digested: /1/A Group: A B Othe ���'
Sample Location: " � � ��
Send Results&Bill To:��' ��. Remarks:
� D ' � q
��
DOH# ANALYTES RESULTS UNITS SRL TRIGGER MCL EXCEEDS Method%Analyst
EPA RBGULATED Trigger? MCL?
4 Arseriic <D.001 m /L 0.001 0.01 0.01 /,1 t� �'� 200.8 �*3
5 Barium <�.e � m 0.01 2 2 200.8
6 Cadmium <O.��c�1 m /L 0.0001 0.005 0.005 200.8
7 Chromium <o•ab� m /L 0.007 0.1 0.1 200.8
11 Mercu C o•DW Z m /L 0.0002 0.002 0.002 200.8
12 Selenium �a.OO�. m /L 0.002 0.05 0.05 200.8
110 Be llium <c�.0003 m /L 0.0003 0.004 0.004 200.8 �''�
111 Nickel < a.c�o 5 m /L 0.005 0.1 0.1 200.8
112 Antimon �o•o o� m /L 0.003 0.006 0.006 200.8
113 Thallium <o. oo� m /L 0.001 0.002 0.002 200.8 �
116 ' C anide �, o,C I m /L 0.01 0.2 0.2 4500-CNF t<i
19 Fluoride { D.� m /L 0.5 2 4 300.0 �h'L
114 Nitrite-N < �• I m�/L 0.1 0.5 1 300.0 Glf�
20 Nitrate-N �•� m /L 0.2 5 10 300.0 ��Z
161 Total Nitrate/Nitrite 3•(.z m�/L 0.5 5 10 300.0 LltL
EPA REGULAT'ED(Secondary)
8 Iron .�p.( mg/L 0.1 0.3 0.3 �� N o 3111B �
10 Manganese < D•�t mg/L 0.01 0.05 200.8
13 Silver <o.01 mglL 0.1 0.1 200.8
21 Chloride S mg/L 20 250 300.0 L,r.�c
22 Sulfate (� mg/L 50 250 300.0 LN�.
24 Zinc �'o,,'?, mg/L 0.2 5 5 nJ0 200.8
STATE REGULATED
14 Sodium mg/L 5 200.8
15 Hardness S S mg/L 10 2340C L./fL
16 Conductivity ��(D umhos/cm 70 700 /VD 2510B LN�.
17 Tiirbidity Q,� NTIJ 0.1 2130B L y c.
18 Color S,� color uruts 15 15 No 2120B L/,<L
26 Total Dissolvecl Solids �/ mg/L 100 500 �i✓� 2540C �p/L
STATE UNREGULATED
9 Lead �� pn� mg/L 0.001 200.8 �}�✓
23 Copper p. ��y mg/L 0.02 200.8
COMMENTS: -�u l 1 �P� �� �--��C�
2010`PROPERTY OF WATER MANAGEMENT LABORATORIES,INC.
' 1515 80TH Si'REET E Hppenaix e:
TACOMA,WA 98404
(253)531-3121 Bacteriological Test
WATER �ACTERIOLOGICAL A Results
SAMPLE COLLECTION:READ INSTRUCTIONS ON BACK OF GOL
If instructions are not followed,sample wili be rejected.
DATE COL�ECTED TIME�.OLLFr.TFD COUNTY NAME
MONTH DAY ' YEAR (J O
� _—�:
� /� �,� ❑ PM ��ct`�n
TYPE OF SYSTEM IF PUBLIC SYSTEM,COMPLETE:
�PuBUC !�.D.No: CiRCLE GROUP
� �INDIVIDUAL �
(s rves only 1 residence)
NAME OF SYSTEM
����l$ ��,/J1,� �C,
SPECIFIC LOCATION WHERE SAMPLE COLLECTED TELEPHONE NO.
(ie,kitchen tap�school,fire station,fountain) DAY c36�, �S��3��-3
1�U�S,1�1���/' 1v'r']1� J�� EVENING(��C7) z�6 � ,5���
SAMP E COLLECTED BY: Name) SYSTEM OWNER/MGR.:( ame)
L�a�'ll ��llZi?J'or1 �o r7 S./"P
SOURCE TYPE� GROUND WATER UNDER SURFACE INFLUENCE
❑ SURFACE�,�U-or � SPRING �PURCHASED or �GOMBINATION
WELL FIELD INTERTIE or OTHER
SEND REPORT TO:(Print Full Name,Address and Zip Code)
• ����s,s .�ar.�r.s ��i-�
�, � cS`�'�
WASHINGTON
' � ',TYPE OF SAMPLE(check only one in this column)
: � <
^i�''ROUTINE � Ghbrinated(ResiduaL• Totai_Free)`
X'�"DRINKING WATER —
check treatment � ❑ Fittered
� Untreated or Other
. :
� REPEAT SAMPLE
Previous col�form presence Lab� '
%' PreVious coliform presence. ..Date ' r � '
Source#� m
� RAW SOURGE WqTER Total Coliform
� NEW CONSTRUCTION or REPAIRS. 8 Fecal Coliform
❑ OTHER(Specify)
� REMARKS
` ' 'LABORATORY RESULTS(FOR LABUse oNLY)
METHOD USED
' MF MPN PA MO� CPRG
_2410 2600 _ 2610_ 272Q=' 2730 . _.
TOTAL COLIFORM 7100 mi E.GOLI /100 ml
FECAL COLIFORM /100 ml HETEROTROPHIC - /per ml
1340
ANOTHER SAMPLE REQUIRED
SAMPLE NOT TESTED BECAUSE TES7 UNSUITABLE BECAUSE:
❑Sample too old ❑Oonfluent,growth
' `�Wrong container ❑TNTC
❑incomplete form ❑Turbid culture
❑ ' ❑Excese debris
DRINKiNG WATER SAMPLE RESULTS .
UNSATISFACTORY,Coliforms present SATISFACTORY,
. Coliforms absent
REPEAT �E.Coli present ❑E.Coli absent
SAMPLES
� REQUIRED ❑Fecal present ❑Fecal absent
SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS
• LAB NO. DATE,71lv1E REGENED. REGEIV�D BY
� � ��9 75 f�`b _ ��� �
. 'DAT EPORTED- ROUTE AGCT.�
;,r �'
i
_..�.�,.a _
� ' --: ,,��., .�� . .:f-_� Appendix 7: Check Vaive Test Results
�, KNIGHT FIRE PROTEC'TION,
9702 LATHROP INDUSTRIAL DRIVE SW ACKFLOW REVENTION
� ' OLYMI'IA,WA 98512 . -
(360) �g6-s6o6 � ASSEMBLY-TEST REPORT.
FAX 786-8722
WATER PURVEYOR:. ��Z'�C_;'"�
LICENSE NO. I�NIGHFP044LK : TESTED GOOD: �R..%j NO
"ON GUARD
24 HOURS A DAY"
Name of Premises: �°�r��,��` t'��2,.�.-, ��'°' _ �
Contact Name: ...."�'�,,,� Phone Number: °��°',� ti ���' -�:f=,.�� �
Service Address: s"r��� -`�-�' ' �.�.� �`,�� �%� ....,��'r�' .�
Location of Assembly: ,����� ,_�:,/ �,���-,,��,���" _
AssemblY� ��,�� �'.#w��^� �l/��. �.�'�' ��,�1�`��%
� Manufactur'er. Model . Size Serial No.
Type of.Assembly: . DC � DCDA RPBA RPDA PVBA �SVBA AIR GAP :
__._
� _ _ _ . .._ __. _ _.._.._ .
Type of.Tnstallation. :orizontal � .. Vertical Line Pressure at Time of Test: psi
Reduced Pressure Assemblies
Double Check Valve Assemblies Relief Pressure Vacuum Breakers
ls`Check 2nd Check Valve Air Inlet Check Valve
DC - -��.,� psid . DC - ..� `� psid Open at psid psid
. Initial Test �- Sld RP- Closed tight Open at . Did not Open
p Leaked psid .
Repairs &
Materials
DC - psid DC - psid
Test After.... Open at. . ....psid. _ ... psid:�. .
RP-_Closed.tight - Open at .
Repair RP..-: psid Leaked psid
Air Ga .Ins ection: Required mininlu�air gap se aration provided? . Yes No .
Water Service Restored:�Y�es,�No Proper Installation: �esr;� No
Remarks: �r`T�� ����r`�
�-�'��L. -�'�-s'�� . �r''��:� . . . ._� .
_.:::. _.� _.._,. F,.�-.'S�l ., . .Y: . ., '... .. .�, .. ...... .. 1`.Y•. . . ,. ..... .. .....
.,. .,..�n' ....;... . �-. ... . . R
� Type of Equipment Use�: -�r-o-�s�er Diff Eress. Gaug.e-Model A-S�P-4- Senal# Cal. Date. ��'�•� �'�
Type of Hazard: � ����� '��'�l�r,t'/����2
7Che above report is certiified�e true:.
Initial Test By: �,��„�,..f ��i�.�.�--� Cert. No.: ,���'� DatelTime: .�jr� �°:���°�'
F.epaired by: Cert. No__ Date/Time: �
Final Test By: . ,�, Cezt. No.: Date/Time:
Customer NamelSignature: �•;���� �{� Date: �,�''f����'��
� • .
Confined Space: Yes� Oxygen Q H2S CO Flammable Vapo r
/o m m /o LEL
White-Knight Fire e yellow- Water Purveyor o.Pink-Customer • Gold-Knight Fire
�
"QUALITY IS REMEIVIBERED...LONG AFT'ER PRICE IS FORGOTTEN!"
Appendix 8: Declaration of Covenant
Note: Must be on legal sized paper
JANIS STTEBRS
PO BOX 598
YELM,WA 98597
DECLARATION OF COVENANT
Public Water Source
KNOW all men by these presents that I(we),the undersigned,ow�ner(s)in fee simple of the land described herein,hereby
declare this covenant and place same on record.
I(we),the grantor(s)herein,am(aze)the owner(s)in fee simple of(an interest in)the following described real estate
situated in Thurston County,State of Washington,to wit:
Tax Parcel Number and Legal Description:
Parcel Number: 22729310600
S29-T17N-R2E-NE S�V&NW SE SLY AND WLY OF BALD HILL RD&NW SW THE E 260F LY S OF RD&
E2 SW SW&W 320F OF SE SW LESS.92 C
on wliich the grantor(s)owns and operates a well and watenvorks supplyin�water for public use,located on said rea(
estate,to wit:
See Attachmen[A
and grantor(s)is(are)requued 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 a ants and covenants to prevent certain practices hereinafter enumerated in the use of said
grantor(s)land which might contaminate said water supply.
NOW,THEREFORE,the grantor(s)a�ee(s)and covenant(s)that said grantor(s),his(her)(their)heirs,successors and
assigns will not constntct,maintain,or suffer to be constructed or maintained upon said land of the grantor(s)and within
100�One Hundred) feet of the well herein described,so long as the same is operated to fiunish water for public
consumption, any potential source of contamination, such as septic tanks, drainfields and reserve areas, privies,
sewerlines, underground storage tanks, railroad tracks, veliicles, structures, bams, feed stations, grazing aniinals,
enclosures for inaintaining fowl or animal manure,liquids or dry chemical stora�e,pesticides,herbicides,insecticides,
hazardous waste,or garbage of any kind or description.
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.
VYITNESS TM�_hand M this �J��dayof I�lil'(.l�v ,2pp�.
_(Seal) � `�`,
c;�
� f
n ., .
`� (Seal)-_ H ������, . '', r
Grantor(s) •�_-� �
State of Washington } u` " �•,•V:y L r,�:�;� _
�_}.,y y-f.
}55. '' �> ^�
COUD1)'Of�ur"J�vn } . "...1. f�Gf�' _
I,the undersigned,a Notary Public in and for the above named County and State,do hereby certify that,on this '31 S�
day of MG.+'L�- ,200�� ,personally appeared before me
.�C�V�.I S ��1�(OV h
to me known to be the individual described in and who executed the within instniment,and acknowledge that he(they)
signed and sealed the same as free and voluntary act and deed,for the uses and purposed wherein mentioned.
GIVEN under my hand and official seal the day and year last above written. ^
Y/ir[/L G'i,����i//�/.3!_Y�'
D�'OTARY PUBLIC m and for the state of�Vashington
residing at V� W�} _
My commission expires: ������
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4" and 6" SandHandler
o - Submersible Pumps
E-1467 ti �. 2�4� Owner's Manual
:�.
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Appendix 10: Pump Specifications
INSPECT THE EQUIPMENT
Examine the pump;�,nen�t is received to be sure there has
been no damage in sh,pping. �;�hould any be evident, report it
immediately to the Jacuzzi dealer from whom the pump was pur-
chased. Please-eheckt�a-g�p package to see that it includes - --
pump,motor,and motor leads(if your pump purchase includes a I
motor). These units will include either a built-in or external � � �
mounted check valve with the discharge head. Three-wire,single- i� ; ��_;
phase pumps should include a control box which has to be pur- I ! '` _
chased separately and matched to the pump motor. Example: ' I
Franklin Control Box for Franklin motors. Make certain that �
your available voltage conesponds to that of your motor. ; -
. I � ! -
�� ```.
•� , � -
��� ��I11111111 M � �: I - "
INSTALLATION RECORD : ����������� - - ; �
�_:�u������u .��.� _
: uuu�u�� -
It is a good idea to keep an accurate record of your installa- .,,°w�;• _ ;
tion. Be sure to record the data below: ~ � � � =�`�
Purchased from �'t�`.�1�� �-f�,���.` ' _
—�
Date of Installation �_j� — �� - � .`;�
PuZ�Moc1e1 No:� � �'jt'Z-�� �� ��C. ,,� ��-�
Pump Date Code*�L��� ����7��� � �� _
rr - _
Well Inside Dia. (in/mm)�� _ _ �
A :; ;
Depth of Well (ft/m) �0�� � � _
Depth of Water (ft/m) `,�,"7 �`'L
I / -
Pump Setting (ft/m) �'���;-� �` -_
1 '� `
Drop Pipe Size ��i _
Wire Size (From pump to control box) � ��` � � � � �
Wire Size (Control box to power source) _. -
Horizontal Offset(Between well and house) - -
*Make of Motor - Amps HP�volts���Dph _ C�� ,N -
Make of Control Box - HP Vo ts
Power Supply - Volts.�Ph , HZ� . . �
Pressure Switch (PSn Cutin Cutout
x`This information is on your pump or motor tag. It will help us identify - _
your pump in case of later inquiries. - - -
Appendix 11 : UV Specification
--- ___.__ _
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UV St�rilizerAquafine CSL-6R, 60GPM
ElectriCaL• 120V/60Hz-Single Phase T
Hands Off/Auto Option: r No Hands Off/Auto Option �
UV Type: Disinfection(254nm) � I
Connection Type: Flanged VO � I
Gaskets/0-rings: l EPDM(Disinfection)/Silicone(Ozone) � I
Optional Monitoring System: No Monitoring System �
Lamp Out Alert: No Lamp Out Alert T )
Interior Surface Finish: Standard Ra32 Dectropolished Finish . I
Compression Nuts: Standard CP�/C ' � I
Operating Pressure: � Standard 120PSI(8 bar) �
_I
Product Description
• Weight(Ibs): 120
• Total Amps.: 3.2
• Total Watts: 396Standard Features:
• 99% Plus Bacterial Reduction
• Operating Pressure- 120 psig
• Chamber- 316 Stainless Steel
• Chamber- Passivated and Electropolished
• Integral Ballast Enclosure: 304 Stainless Steel
• LED UV Lamp Operating Display Panel
• Running Time Meter: 99,999 Hours. -Non resettable
• Socket LokT"'
Mating flanges are NOT supplied with units.
Standard water temperature range 35 degrees F to 100 degrees F(2 degrees C to 38 degrees C)
Socket LokT"' is a registerd trademark of Aquafine Corporation.
�` t�'�i!'i�LfcYt Stu?c 17C^G'1i2t32r+c�
(�����t� WATER FACILITIES INVENTORY (WFI) FORM
&r,iro::n:zrcl:l?Hccilit n•r.7rsrr,>
Uiris�vtii�fi?-ir`�f!r.Y k:'if7er
RETURN T0: Eastern Re ionai Office, 16201 E Indiana Suite 1500 Spokane,WA 99216
1. SYSTEM ID N0. 2. SYSTEM NAME 3. COUNTY 4. GROUP 5.TYPE
Stiebrs Farms Water System Thurston B
6. PRIMARY CONTACT NAME�MAILING ADDRESS 7. OWNER NAME&MAILING ADDRESS 8. Owner Number.
Jon Stiebrs Jojo TR�e: Manager Jon Stiebrs
Stiebrs Farms Trr�: Owner
PO Box 598 Stiebrs Farms
Yelm,WA 98597 PO Box 598
Yelm,WA 95597
STREET ADDRESS IF DIFFERENT FROA1 ABOVE 5TREET ADDRESS IF DIFFERENT FROM ABOVE
arrN Jon Stiebrs arrN Jon Stiebrs
ADDRESS 10909 Bald Hill Rd. SE 10909 Bald Hill Rd. SE
crnr Yelm STATE WA ziP 98597 crrr Yelm STATE WA z�P 98597
9. 24 HOUR PRIMARY CONTACT INFORMATION 10. OWNER CONTACT INFORMATION
Primary Contact Daytime Phone: 360-458-3333 Owner Daytime Phone: 360-458-3333
Primary Contact Mobile/Cell Phone Owner MobilelCell Phone
Primary ContactEvening Phone 3Cd-4$$-3333 OwnerEvening Phone 360-458•3333
Fax: 360-458-5899 E-►„a�i jon@stiebrsfarms.com F� 360-458•5899 E-Mail: jon@stiebrsfarms.com
�� � i •� � , �• � � . � . �•
��.SATELLtTE MANAGEMENT AGENCY—5MA(check only one)
\�Not applicab{e(Skip to#12)
❑Ovmed and Managed SMA NAME: Sh1A Number.
❑Managed Only
❑Owned On
12. WATER SYSTEM CHARACTERISTICS(mark ALL that apply)
❑ Agricuftural ❑ Hospital/Clinic ❑ Residential
XX Commercial/Business ❑ Industrial ❑ School
❑ Day Care ❑ Licensed Residen6al Facility ❑ Temporary Farm Worker
❑ Food Service/Food Permit ❑ Lodging ❑ Other(church,fire station,etc.):
❑ 1,000 or more person event for 2 or more days per year Recreational/RV Park
13. WATER SYSTEM OWNERSHIP(mark only one) 14. STORAGE CAPACtTY(gallon
❑ Association 0 County ❑ Investor ❑ 5pecial District
C� City 1 Town ❑ Federal XX Private p State
15. 16 17. 18. 19. 2D 21. 22. 23. 24.
SOURCE NAAIE INTERTIE SOURCE CATEGORY USE TREATAlENT DEPTH SOURCE LOCATION
UST UTILITY'S NAME FOR SOURCE o W W W� �
W AND WELL TA61D NUMBER. LL � � W o W ? _ �
m � z W a � z z ? yLL �� o m
� Exam e: WELLftt XYZ456 INTERTIE W o n�. a � � � �' � � z � �w v �
P4 � w � z r- {y J a w �
Z SYSTEM � �' 'L �' w 3 ? w z � a o a � p< a�y v� z a
W w a � ? � w — z w w ? r o ~ �-� az z z
� IF SOURCE IS PURCHASED OR INTERiIED, �� J J J ? z z 3 a "' � � � � W o ga o � w �� "o � o Z �
� USTSELLER'SNAME NUMBER J J J LL Z W � W � Z -� t- � a s az � v 3 �
� Example: SEATTLE w w w a o�. n�. w � a � a w v�i z c=i LL LL � o o � \ y o
3 3 3 �n fn v� �n �n � o
Well X I X X X 30 70 NE,SW 29 17 02
(
� � �
' M� v
DOH USE ONLYI ppH USE ONLY!
ACTNE SERVICE CALCULATED pppROYED
', CONNECTfOHS ACTNE CONNECTIONS
CONNECTIONS
25. SINGLE FAMILY RESIDENCES(How many of the following do you havel)
A. Fuli Time Singie Family Residences(Occupied 180 days ormore per year)
B. Part Time Singie Family Residences (Occupied less than 180 days per year)
26. MULTI-FAMILY RESIDENTIAL BUILDINGS(How many of the following do you have7)
A. Apartrnent Buiidings,condos,duplexes,barradcs,dorms
B. Full Time Residential Units in the Apartrnents,Condos,Dupiexes,Dorms that are occupied more than 180
da ear
C. Part Time Residen6al Units in the Apartrnents,Condos,Dup{exes,Dorms that are occupied less than 180 �
da s!ear
27. NON-RESIDENTiAL CONNECTIONS(How many of the following do you have?)
A. Recreational Services andlor Transient Acxommoda6ons(Campsites,RV Sites,hotel/motellovemight units)
B. Instihrtionai,CommeraalBusiness,School;Day Care, Industrial Services,etc. 1
28. TOTAL SERVICE CONNECTIONS 1
29. FULL-TIME RESIDENTIAL POPULATION
A. How many residents are served by this system 180 ormore days per yeah
30. PART-TIME RESIDENTIAL POPULATION �nt� FEB Mna �tt t�uY �uM �u� pus seP ocT eov oec
A. How man part-time residents are present each monm?
B. How many days per month are they present? I
31.TEMPORARY 8�TRANSIENT USERS JAN FEB MAR APR MAY JUN JUl AUG SEP OCT NOV DEC
A. How many total visitors,attendees,travelers,campers,
atients or customers have access to the water system each
onth?
B. How many days per month is water accessible by the
public?
3Y. REGULAR NON-RESIDENTIAL USERS JAN FEB MAR APR MAY JUN JUL I AUG SEP OCT NOV DEC
A. if you have schools,daycares,or businesses connected to 65 20 65 50 65 350 50 65 50 65 50 65
our water system,how many students,daycare children
ndlor em b ees are resent each month?
1 8 �31 30 1 30 1 1 0 31 0 31
B. How many days per month are they present? I
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
33.ROUTINE COLIFORM SCHEDULE
34.NITRATE SCHEDULE QUARTERLY ANNUALLY ONCE EVERY 3 YEARS
l
35. Reason for Sabmitting VYFI:
i Update-Change i Update-No Change i Inactivate �Re-Activate �Name change XX�New System �Other
36. I certify that the infortnation ated un this W�1 form is correct to the best ofi my knowledge.
SIGNATURE: DATE: 3 '� S/ �' �Z D Z '�'`'
PRINT NAME: i S C � ✓--S TiTLE: ��j a(f'`'�