HomeMy WebLinkAboutWAT2023-00150 - WAT Application - 6/27/2023 WA'I'aiDa - o o{
MASON COUNTY
COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Health
415 N 6th Street, Bldg 8, Shelton WA 98584, RECEIVED
Shelton: (360)427-9670 ext 400 4• Belfair: (360)275-4467 ext 400 4• Elma: (360)482-5269 ext 400
FAX(360)427-7787 SUN 27 2023
Application for Determination of Water Adequacy
615 W. Alder Street
Instructions
1. Complete Part 1. No determination can be made until Part 1 is fully completed.+Ii Tq
2. Complete only the portion of Part 2 applying to the type of water connection u W RON M EN 1 3. Submit completed application, with any required attachments for review. �'1L
4. An approved building site plan must accompany this application. H C A LT
Part 1: Applicant/ Parcel, Identification
Name on Applicant:.Z/1A;i-tr 1.-f"t QS101.1 1 rtS-kr. Date: ---Srii Q tRR7, c2 3
Mailing Address: 30 t o„ Sin k'Q ,iQ,c) Phone: CEO 6) e, Q - O l o? t
Parcel Number: as 10 3 - 50 - 0 0 03a
�/ Type of Water System Reason for Application
y� Public/Community Water System (2 or more Building permit /��U �L -d��� Q (0 Type
` connections) ❑ Division of land: 15 L 9 i-b- 00 V7(✓
o$- ---4(-"Individual water source (one connection), #of Parcels? SPL
OI '$1Nell ❑ Boundary line adjustment
❑ Spring/surface water 0 Other(explain)
❑ Other(explain)
❑ Replacement or Remodel (please indicate name
If you have more than one residence connected of water system below if applicable-no
ED
to this well, check the Public/Community Water signature required)
System box. �1
Part 2: Water Connection Information JUN 2 81013
Complete the section appropriate for the type of water connection being evaluated:
Public Water System /,,,, /,.,�
Name of Water System: 70 E k1So i C4k - z Pevl}� �q/e $y$7L"'l
Water Facility Inventory (WFI) Number: Port-� I I /
(write"none"for two-party)
X'I am the manager of this water system. The water system has been approved for Zs services.
There are presently l connection(s) in use. This will be the Z, connection.
❑ I am the manager of this system. This connection will be to upgrade or change the use of an existing
connection on this system (i.e.: recreational to full time). Please indicate on the following line the nature
of this change:
This water system is able and willing to provide water to this (these) connection(s)without exceeding
the limits of the water system or any limits set by state d ocal regulation. -7�
Signature of Water System Manager Date V� ��U/ G�
This form may be scanned and available for public view at www.co.mason.wa.us.
1\Ell Forms\Drinking Water Revised I/25/2018
b
r .—,
Individual Water Well
XWater well report(attached to application). Depth f" ft.
AWell capacity Test (attached to application) ( gpm > goo gpd.
The well driller often performs well capacity tests at the time the well is constructed. Results from
these tests are noted on the water well report. Results from these tests will be accepted. If the water
well report cannot be located by the applicant or if the water well report does not have a capacity test,
a well capacity test, which provides stabilization of draw-down and recovery data, must be performed
by a licensed contractor.
Satisfactory bacteriological test(attach to application). Z/Z3(20 20 2-3
Water Resource Inventory Area (WRIA)
Development within which WRIA http://qis.co.mason.wa.us/planninq 14[ ] 15U 160 220
Water use or limitation recorded N/A, Yes X 4VV:z1Q?S7Z
Well Drilled Date V/, l' "/
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ I have reason to believe that this water source can provide at least 800 gallons per day; and/or
provides water at a rate of 2 gallons per minute based on the following observations.
Author of Statement Date
Relationship to Applicant
• •
21e
Part son County Community Services Evaluation (staff use only)
Satisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the future,or guarantee compliance with all applicable WDOE water resource regulations.
71
Recommended approval indicates requirements of Sanitary Code,Title 6, Chapter 6.68.04 a••n o
Adequacy for Building Permits are satisfied. Additional Growth Management requirement a 'T: 0VED
36.70A RCW.
❑ Unsatisfactory Determination: Q 2023
Applicant's water supply does not appear adequate to meet the needs of its intended use for the fo
1 reason(s).
MASON COUNTY ENVIRONMENTAL HEALTH
Reviewer's Signatures: // / OJA
Environ. Health: Date V( ldrn i 3
2ofz
CSD Director: Date
,ilus() 1,15 04 F)776
;- —_ _-
'ile Original and First Copy with
)epartment of Ecology WATER WELL REPORT Application Nu'
,econd Copy-Owner's Copy i
hind Copy-DnI1eCs Copy 1 STATE OF WABLQNGTON
(1) OWNER: Name..-.S..GS.L.ixa.._..._-_..--.._...___--.___--._ Address S_t._-_..Rti.._--1_._B.DX_..5..5_...Bel f.aii._..._.-.-______._..
e 2) LOCATION OF WELL: County C7a.S.O..n.._.-_6 � _.._...._.
enn__Lake.. __ _/V�_ 3;.. . ua.. se ...3_.-.. T.?1..-lv.,a ,.._..w.aa.
G :eating and distance from section or subdiviskon corner
Y3) PROPOSED USE: Domestic lsl Industrial ❑ Municipal 0 (10) WELL LOG:
Irrigation 0 Test Well 0 Other ❑ Formation:Describe by color,character sise of material and structure,and
MT __-.-_._ stratumwchicpenetrkness ated,
old the kind and nature of the material in each
4) TYPE OF WORK• Jemeoc number of well Leith at least one entry for each change of formation.
(if more than onel.... FROIt 1 To
New well 70 Method: Dug 0 gored Q
H Deepened ❑ Cable cs Driven 0 t O p S O t�._•_-. -_—_ • •_.--_-_ 0 3 Reconditioned❑ Rotary D Jetted Q r a n gi wn ar a t e ., 3 40
C - DIMENSIONS: .._ . fine sand A clay- 40 4_5
Diameter of well ...___Ig-_..__.inches h ar ri {'l a c k a ti n r a ttgi 4 5 65. .
Drilled...........___-_..._ft. Depth of completed well_.. .u.._ _ __.ft.
C 0 - _ sand 66 _69-_
6) CONSTRUCTION DETAILS: I gra%Pl &- water • 69 7_0
ER Casing installed:---5--" Dram.fro,n_:._..0.. ft.to 2�__fi.. :, _
Threaded 0 "Diem. from .._...._--- ft.to n. �- --
O Welded ...._.._...... Diem.from ........ ft- to ..__-__ ft. - ---
so
▪ Perforations; xea❑ No® JUL_ 2 6 1021 • -
L Type of perforator cued______ .i. -
r SILL of perforations ..__.-._-..-..4-.. in. by _._....__.._.....__ in. -1 G w -
_.__.___perfor:lions from __! '_it.to _._._..... . . l A d e r S t rc c t - .
I
1 ____�— perforations from .__._:_. ft.to ..._._._.... ft. -
_____ perforations from __.j.....__.._. ft.to•-_._.-_..:-- ft.
SereellS: Yes a No • 'ENVIRONMENTAL
a Manufacturer's Name__..._. _. _.�:._ HEA •
LTH
Type—. xodel No.--�
Diem. _ Slot size..-......_:._4 - ft. to.._..-._ft. • .._ -
0 Diem... _.Slot size _.--.._from -.__._ ft. to--._-.-..- ft. -
• Gravel packed: yea❑ No rig size of gravel:._...___._____. .• __ _. __ -
.. Gravel placed from_..._.-_. __. tt.to._......_._-_--_._tt. - • - -
a •Surface seal: yes® No❑ ToLWhat depth? L8._.... ft.. -- -
0 Material used in seal.kl.e.n.tQ.Rl.:teL.........___._.._ ___.._.._ -
Did any strata contain unusable water? Yes 0 No IM
Type of water?..._.__._.._____.......... Depth of strata.._::_.____._
) Method of sealing strata off.....::..•_.:_. _ "- '
- 7) PUMP: Manufacturer's Name.___ _._ ...»......_.._._.__ ._ . . ,- }
q J ram,
8 WATER LEVELS Land•surfJce elevation —
3 ) Kb: meat tea level.... ...---..-._.-__It.
11 tatic level .._._....,4.4......___..___..ft.below top of well Data..-�3.- 7.-4- • -
J) rtestan pressure --
Artesian water is controlled by...:._....;_._..._.._._......_._.._.._._.__.... - _ .. .
' . '(Cap.vsl4t,etc.) '
) WELL TESTS: Drawdown is amount water level la -c �7 �1—�l --
Ui 9)
lowered below static level Work tttartedS.B4.i.e._. 2.4_.19_.1_4 Completed...._wcl.$.P�t.a___3yil♦?.4_
7as a pump test made? Yes 0 No XI If yes,by whom?.. ...... ..
r ie1d: gal./min. with -_ ft.drawdown alter hrs WELL DRILLER'S STATEMENT:
This well was drilled under my jurisdiction and this report is
true to the best of my knowledge and belief.
tecovery data (time taken•as zero when pump turned oft) (water level
measured from well top to water level) '' -
Time Water Level Time • Water•Levei1. Time Water Level NAME'TYQ•�..-p.u.Rlj�._:.dx...QT.I lrstion) 11_e
(Person. Arm. or corporation) (Type or print)•
ihddrt+SE. P... -a..._j3.ox:..3::..:..A.l1.y..n
1.
Date o!teat .._._.__..._.-.........._..._.._..._._�. (Si�aed]-
Sailer test 1.4...gal./min.with_._�..�..__ft. drawdown after_._._l__...hrs. {Wall Driller)
lrtesian Row.-.---._......_.......-.-._.._..__;.pea Date-....._..-•.--__.____._.._._.... L/
Temperature of water_..»...._..Was a them!I al analysis made?Yes❑ No 2(J License No D L Date 19.._._
IUSE ADDITIONAL SIDEEIS IF NECESSARY)
S.F.No.7?SB-OS-(Rev.4-71).
•
Vanguard Laboratory
',,*#.; i.! 2635 Parkmont Lane SW
'r':si
Olympia WA 98502
360.967.7010
VAN UA 4�� Report of Laboratory Analysis
LABORATORY 1'
Collected by:
Hawkins Well Inspections Matrix Drinking Water
360 401-5353 Laboratory ID: V230221-2
Sampling Address: Date Sampled: 2/21/23 1 1:40
30 E Benson Lake Dr Date Received: 2/21/23 12:30
Grapeview,WA 98546 ! Date Reported: 2/23/2023
Sample ID: 30 E Benson Lake Dr
Analysis Result SDRL MCL Units DF Date Analyzed
Total Coliform&E.colt by SM 92123B(IDEXX) Batch ID:V230221-2 Analyst:VJ
Coliform,Total Negative 1 l MPN/I00 mL I 2/21/23 16:55
E.colt Negative I 1 MPN/I00 mL 1 2/21/23 16:55
•
Notes:
MPN:Most Probable Number
ppm:parts per million
nd:non-detect Reviewed by Robert Smalling,Chemist on 02/23/2023
n%a:not applicable
SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 02/23/2023
DF:Dilution Factor
'�T- 17025:2017
MCL:Maximum Contaminant Level eccREn[reo
S;;' usoRsmgr Page I of 1
Samples were recieved in acceptable conditiot.The result(s)in this report relate only to the portion of the sample(s)tested.MI analyses were performed consistent
with the Quality Assurance prograiMs of Vanguard Laboratory.Please contact the laboratory if you should have any questions about the results.
I
I
2635 Parkmont Ln SW,Suite A,Olympia WA 98502 i Office:360.967.70101 testing@vanguardlaboratory.com l
www.vanguardlaboratory.com
2198572 MASON CO WA
06/21/2023 09:58 AM NOTCE
FORRESTER *187970 Rec Fee: $204.50 Pages: 2
III II IIIIII III III IIII II IIII IIII I II IIIII II II IIIIIII III IIIII IIIII III
Return TTo ,� RECEIVED 'q'n i K R() -0000 a f�
Pies h n 'cPrin; ' tome -kr '� � oao v`1.a - 0087(Q
3o PCgenson goca JUN 2 7 2023 ENVIRONMENTAL
Grafe . , ' z4 9g517y ;15 W. Alder Street HEALTH
LEA]
JUN 2 8 2023
Grantor(s): (1) 1.‘A 610 'rres4er' , (2) RECEIVED
Grantee(s): (1) PUBLIC
Legal Description (1)
(Abbreviated form:i.e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1) d 2- s..� .�- 5 D- D 0 () 3-
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA (WRIA)
I (We), the undersigned grantor(s), hereby place this notice on record that the described real
estate situated in Mason County, State of Washington is subject to water use restrictions and
conditions set by Washington State Senate Bill 6091 and Mason County Code 6.68. These
restrictions and conditions are based on location of property and/or Water Resource
Inventory Area or WRIA.
WRIA: ` LI
Maximum Annual Average Gallons Per Day: ` 50 J gallons
Dated on this I day of )ucve , 20 23 .
Signature of Grantor(s):
(1) , (2)
State of Washington
County of Mason
Page 1 of 2
0
r
V
I,the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this 12 day of ( U n , 20�j ,
(q.cce\-„,„ ceSkc'cj, `'p�feicfe personally appeared before me,who is known to be
signer of the above instrument, and acknowledged that he(she) (they) signed it.
GIVEN under my hand and official seal the day .,. - -st above written.
N �1ic in and for the State of Washin ton,
residing at ilk C�
QSt•; `S;ioN F�;A,y �,,= My commission expires: 18
hozio
o NOTARY '11,% 'i
s
- : 171724 i i
"s tP • PUBLIC .. a
''''71.i'%?•1/?.8./2.0iai
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