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HomeMy WebLinkAboutWAT Application War20,Q{- o016J MASON COUNTY COMMUNITY DEVELOPMENT vermn n.:,nao,e cemo,.a�unhe.r.,, mr. 415 N 6'h Street,Bldg 8, Shelton WA 98584, Shelton:(360)427-9670 ext 400 + Belfaic (360)275-4467 ext 400 O Elma:(360)452-5269 ext 400 FAX(360)427-7787 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 Pan 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 Name on Applicant: Jeffrey & Diane Martinson Date: Mailing Address: 21436 4th PL S, Des Moines, WAPhone: 206-714-4569 Parcel Number'. 22103-51-00020 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more O Building permit B0906 ;4—00,3(a;2— connections) ❑ Division of land: EI Individual water source (one connection), If of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) ❑ Other(explain) ❑ Replacement or Remodel (please indicate name I/you have more than one residence connected of water system below if applicable—no to this well, check the Public/Community Wafer signature required) System box. Part 2: Water Connection Information Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System'. Water Facility Inventory(WFI)Number: (write"none"for two-party) ❑ 1 am the manager of this water system. The water system has been approved for services. There are presently connection(s) in use. This will be the connection. ❑ 1 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 This form may be scanned and available for public view at www.co.mason.wa.us. 1NlH Fomnr Drinkins ,a , Revised 125,201N Individual Water Well Water well report(attached to application). Depths f 1� ft. Well capacity Test(attached to application) — gpm 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 1I �n'by a licensed contractor. IS)% Satisfactory bacteriological test(attach to application). // Water Resource Inventory Area (WRIA) Development within which WRIA http//ais.co mason waus/plannhug, 14r 5= 16=220 Water use or limitation recorded................................... N/AQ/fYes `. Well Drilled ........... . ..........._........ Date Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection ❑ 1 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 W DOE 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. I Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). Reviewer's Signatures: Environ. Health: Date CSD Director: Date z of z WATER WELL REPORT a OI1NLN111 N II OIL III _ a '.t ECOLOGY a I I wvu ll) tag No ©PF188 L•l Cuuvnuctien �ncN 11 N.r.W 11 l: I 'll) ❑ Ik e.n. ._I Nalfalgialli NO]No. _... 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Box 1790 Shelton, WA. 98584 Customer: Jeff Martinson Well Tag#: BPF188 Site Address: 1640 E Benson Lake Dr, Grapeview Depth: 121' Date of Test: 6/18/2024 Static: 242 PUMPSet: 80' TIME GPM LEVEL RECOVERY 1 Min 15 26 TIME LEVEL 2 Min 15 27.4 1 Min 30 3 Min 15 27.9 2 Min 28.1 4 Min 15 28.1 3 Min 27 5 Min 15 28.2 4 Min 26.1 6 Min 15 28.5 5 Min 252 7 Min 15 28.8 6 Min 24.6 8 Min 15 28.9 7 Min 24.2 9 Min 15 29.2 10 Min 15 30 15 Min 20 31 20 Min 20 33 25 Min 20 33A 30 Min 20 34 35 Min 20 34.1 40 Min 20 34.5 45 Min 20 34.5 50 Min 20 34.5 55 Min 20 34.5 1 Hr 20 34.5 . .i._ i... i.Olnrt,rl.•l'. venovanP ' QUO�1h-. dell COLIFORM BACTERIA ANALYSIS FORM 03 18.2024 L =. MASON JLI F MAR I INSON SAMPLE INFORMATION MAX Type of$impk ..-- on su-. Jltimre� ,u. - _. - r L le l0.Vl �: � R^vfir Sampe(40) I r ORINKiNG WATER RESULTS 1 t hviorp• .. x X t9rc`my _ S-op. 8.0I�Zi. �15 z85- 2212747 MASON CO WA 071021 m�YrV i103 1 RyF TEK E .. 99tau 994 59 1..., 2 uim m mi imp uun n�uui iim�mm nl mu�iii m uu Return To t cf• k!-' 4 EyhTK try, _ Grantor(s): (1) )�FFTdrFN iLl��Tt kj� (2)p j P, .4e K Mi4R-T11,SD1� Grantee(s): (1)PUBLIC Legal Description (1)kf=♦v( Sn L4KT 7 I—E ZO (Abbmv"rated Form:i.e. lot, hock plat or section, township, range) Assessor's Tax Parcel: (1)z_.;—' � �-L�-Q -2� 0 TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA) I (We), the undersigned grantor(s), hereby place this notice an 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: 1 _ ((����//�� Maximum Annual Average Gallons Per Day:5_gallons Dated on this�_day of tea— 20_1 . Signature of rantor(s): State Mash ngton ) County of Page 1 of 2 I,the undersigned,allotary Public in and for the above named County and State, do hereby certify that on this 2lday of , 20 y Llqd ,i n g .MG 'n 5�7rsonally a red , fore me,who is known to 6e signer of the above instrument, and acknowledg that he (she) (they) signed R. GIVEN under my hand and official seal the d and year last above written. state of Washington REBECCA A CRIOUI otary ublicn and for to of ington, COMMISSION#64165 /1n My COMMISSION EXPIRES residing at S 165 Foxusry 29,2027 My commission expires: Page 2 of 2