HomeMy WebLinkAboutWAT2023-00359 - WAT Application - 11/29/2023 ENVIRONMENTAL
HEALTH WAT -_ 003�
ECEIVED 415 N.6°i Street
MASON COUNTY Shelton,WA 98584
COMMUNITY SERYMF#_ Shclmn:360-427-9670,Exi 400
2023 lldfeir:360-2754467,Ext 400
Elms:360-492-5269,Faa 400
615 W. Alder Street
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part 1 is fully completed.
2. Complete only the portion of Part 2 applying to the type of water connection utilized.
3. Submit completed application,with any required attachments for review.
4. An approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
O Name on Applicant: " I llsra Cromwell Dale: /1�19�202�i
Mailing Address: 1121 se Phill)bs Roast Phone: 360-9lf-390/
Parcel Number: 72 0 3 5 7500 220
Type of Water System Reason for Application
PubliclCommunity Water System (2 or more . Building permit , —
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ 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
to this well, check the Public/Community Water signature required)
System box. ,,, ( 7-02- 3 —
Part 2: Water Connection Information yv`- VU
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of water System: (n UJ
Water Facility Inventory(WFI)Number:
(write"none"for two-party)
am the manager of INwater system.The water system has been apprAYed for services.
Thare are presently connection(s)in use.This will be the vl 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 and local regulation.
Signature of Water System Manager � Date �� 29 202
This form may be sunned and available for public view at www.co.mason.wa.us.
L1a11 Fmue Drinking Wow Revised4rm2018
Individual Water Well
Water well report(attached to application). Depth�ft.
^{e/Well capacity Test(attached to application) gpm � gpd.
l 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-dawn and recovery data, must be performed
by a licensed contractor.
/`
`� Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://ais.co.mason.wa.us/planning 14T N 15_16_22_
Water use or limitation recorded................................... N/A t Yes*
Well Drilled ............................................................... Date 6
41)
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
D 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
Part 3: Mason 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.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Determination of
Adequacy for Building Permits are satisfied, Additional Growth Management requirements may apply. Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the noetls of its intended use for the following
reason(s).
Reviewer's Signatures: �i1
Environ. Health: `1 ' ' ' Date 2 ,i "
This form may be scanned and available for public view at rco.masa_ r. Ufa rn.wa.usmaso_n.wa.us.
PW2of2
'WATER WELL REPORT Noticeo ITirten[Na W/S768Z
Fin i'" Originali1stcopy.Emlogy,2Mcopy-owacr.JrdcWY-dlice Unique Ecology Well mTag Na. ANm 7613
CostslructioNDecomrnission f'x encircle)
V Construction Water Right Permit No.p"EXE
0 Decommission ORIGINAL CONSTRUCTION Notice /.pFF I`7/LDcAI
of1went Number Property Owner Name PROPOSED USE: Domestic lD Induswial ❑Municipal Well Street es Addrs ))Z) S E r A41 29S 9a
C DtW.M, inigedon ❑Tutweu Comer Cyl SPIEL-TAIJ County: 1NAS0/1I
'PEOFWORK: Owufsnumbttofwell0fmmethanpoe) y 22!! —8WM circle
IucatlOnl/4-I/41/4 S=32 Twnw./R1
Vcw Well ❑Rmondirioned MrrholCDug ❑Bored ❑Driven ne
Deepened ❑Cable Rotary ❑laud [al/Lo WW
fs,Lralo tat Deg Iat Min/S=
DIMENSIONS: Diamemr of well ch.,drilled D' REQUIRED) Long Deg-- E Inn Min/Sec
Depth of complelN well�fl.
CONSTRUCTION DETAILS ` Tax Parcel No. 3 Z0 3 S—7S — on Z2 O
Casing NWdded Diam.Dom ft.to/SIV it CONSTRUCTION OR DECOMMISSION ROCEDIfRE
Instilled` Una insulled Diam.from If to_R. rorrrtadon:Describe by color,chartrer e ,alu of m,.Z and swnwc.and the
C]Treaded Dum.from R m—fl. kind and name of the material in each stratum pmounted.with n lean one
enry for tech change otinformudon.lsdicnk JI wamr encountered.
Perforations: ❑Yu)gNo (USE ADDITIONAL SHEETS IF NECESSARY.)
Type ofxrforamr used MATERIAL FROM TO
SIZE of perfs_in by—ea,aW m of peels_from ft.W_fh W S L 0 S/`iK
Scmtu:�(Yu ❑Nc ❑K-Pu "^'a"" rAAI SAAW It/ /f4'T
Manufaclrcfs Name LIJFSLO rhAj sk — Mea 4-AA V6fw
Type LN Model No.
Diam Slot Siu from /S/B fl.to /�� fl. W L
Diam. Slos Size Ro fLm fl. 4EII't 191V SFA/O
GraveLTlller packed: ❑Yes gNo ❑Sin ofgravelfsand (iae/4V FrL —Z.Lrd Z)
Materials pactill from —ft.
Surtacc Seel: ;KYa ❑No
f a InNVN N
Malerals used inseal 9:; �
f AoICL— e.LA
D:d eny neater canrain unusable wale? ❑Yee PfNo
Tyx of erase:+ Depth ofamu /ti4VV7f COLOrL G'1f+1'✓EV
Method of sealing some oR la T)LV y 1491
PU>lp: Manufaconefs Name AOLI(.OS
Type: S V)5 N.P. /rl W1 C4-04 Q/ f0
WATERLEVELS: land-iwha devotion about mean sea level fl.
s+rir mud 1 )LF n.below top of wen Dale /moo`1( S PA '
Artesian prusurc lbs.pa square most Dare /el — S/
Artuian water is cpnoollW by
a ,valve.de. GAO&AOY GLAYY-3
WELL TESTS: Dnwdown u amount wales 1-111 is IOWercd below sutic level.
W..'—p tea:made'C Yea 10- lf,u.by whom? W W rfA 3 Z
Ykid_1aVmin.with ft drawdown slier Ms.
Yield:_�al/min.with—ft.drawdown after Iva.
Yield gallmb.with ft.dr+wdown aver hrs. fy
Rrrpren dam Lev saken prxrm when pump mmrQ p$lfwmnfsvr(mmruredJrom. _
wvll mp m wvrrr level)
Time Water Level Time Water Level Time Water Leel
-- --/-- Ace.
Dan of ten_y " 3 a� ~a
Bailer mn,.�k g+I/Mn wim fl.drawdown.fml--Z�hr .
Attest_-_fah/min.with Nem set al (L for hrs. 1
Anesnn riper. Rp.m. Dat< Ssan Dau S�Z��o�' Completed Date
Tanperature of wata_W as a chemical analysis made? es ❑No
WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance With all
Washington wel I construction standards.Materials Used and the information reported above arc=to my best Insow1 ,T)Ml�edge and belief.
ODller CEngineer CTrunee N- fPdas — Drilling Company -r)MS W61.L AILILI Arr
Dnlier/Enginea/frainee Signal Address 80 L%Z' 'IlL3 fo
Driller or Train=License No. 3Z City,State,Zip
Registration No
Ecology is u FAuai Opponunity Employet. PRY WO-L30(Rev"])
Printed from Mason ODur ly DMS
ENVIRONMENTAL �L�aO�l�t7� y�J j
HEALTH 2204982 MASON CO WA
11/2912023 0222 PM NOTCE
TIMOTHY CROMWELL #192962 Rae Fee S206.50 Pages: 2
sRfetam Ta 1 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIRECEIVED
L'2ati--d
111 k DEC 12 2023
Sl2e�fo.L WA ff5gr+
615 W Alder Stree',
Grantor(s): (1f Jft r0PKt P1 (2)
Grantee(s): (1) PUBLIC /
Legal Description (1) ) 2 oZa, Or
(Abbreviated form:i.e.lot block,plat orsection,township, range)
Assessor's Tax Parcel: (1)'2 0 3 5 --1 5 -Qo a 0
535 T20 R3
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 6.66. These
restrictions and conditions are based on location of property and/or Water Resource
Inventory Area or WRIA.
WRIA: I
Maximum Annual Average Gallons Per Day: -/U gallons
Dated on this 9* day of ko y&jL b e r . 20 23 .
Signature ntor(s):
(1) (2)
State of Washington )
County of Mason )
Page 1 of 2
I, the undersigned, a Notqry Public in and for the above named County and State, do hereby
certify that on this-.2:0 ay of fJO VDtn 121!1— , 20.25,
'r mn 4M CVO m wre I ) personalty appeared before me,who is known to be
signer of the above instrument and acknowledged that he(she) (they) signed it.
GIVEN under my hand and official seal the day and year last ab a written.
Notary Public in and for the State of Washington,
`:•� z��F�y9S residing at
My commission expires: 11 �2°I YG�1
j PUBLIG
nnwm0oO"`��
Page 2 of 2