HomeMy WebLinkAboutWAT2021-00270 - WAT Application - 3/20/2021 MASON COUNTY
COMMUNITY SERVICES
HEA�I hi BuildingPbnnin EmirmmentalHwlthCommunityHeelth
GM` 415 N 61h Street, Bldg 8, Shelton WA 9B584,
Shelton: (360)427-9670 ext 400 •i Beltaic (360)275-4467 ext 400 !a Elma:(3W)482-5269 ext 400
FAX (360)427-7787
Application for Determination of 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 system utilized.
3. Submit completed application,with attachments to the health department for review.
Part 1: Applicant/ Parcel Identification
Name on Applicant Pd1((CMV1t WUX\k Date: I ZD 12 1
Mailing Address: Pb'Sox I`1D2She-)%b WR 25S$ - Phone: 31PO -912-0444
Parcel Number:: 57 02`I 'U 3 -0003 0
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more Building permit !3L'OR.0 a1-o09a5
connections) ❑ Division of land:
I Individual water source(one connection), *of Parcels? SPL
K Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement(please indicate name of water
If you have more than one residence connected system below if applicable—no signature
to this well, check the Public/Community Water required)
System box.
Part 2: Water System Information
Complete the section appropriate for the type of water system 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 connections)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)connections)without exceeding the
limits of the water system or any limits set by state and local regulation.
Print Name of Water System Manager Phone
Signature of Water System Manager Date
J:\EH Fmm%\Drinking Water Bevix 1192021
Page 1 of2
This form may be scanned and available for public view on the Mason County Web site.
Individual Water Well
�I Water well report(attached to application). Depth_ i0� ft.
Well capacity Test(attached to application) A gp 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 Zen. Results from these tests will be accepted.
If the water well report cannot be located by Zen.
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.
�1 Satisfactory bacteriological test(attach to application).
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
Departmental Use Only: Do not write below this line.
Part 3: Mason County Public Health Evaluation
`B�tisfactory Determination:
Applicant's water supply does appear adequate to meet the needs of its intended use. 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-Determinaton of Adequacy for Building pennies 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 needs of its intended use for the
following reason(s).
Reviewer's Signature: Date
J:\EH R.'Dunking W.1, ReA.d YM021
Page 2 of 2
This form may be scanned and available for public view on the Mason County Web site.
WATER WELL REPORT MDEPARTMENTOF Nmiaoflntmr No. WE36431
ECOLOGY Uni9x Ecobgy Well ID Tag No, BLH565
TYPeofW L RaMafsonta Bien
W Carea:maime Site Wall Name(ifmnre man one.11).
❑ Ihttmmiaaion b Oneiml imin ion Not No, Water Right Permil/Cenigcale No.
Prepeaed Use; GOmseen, olrtlmniel UMunicipal Pmpxoty0amer Name Addanne CadWGll
❑Dawmenrp Ornwim ❑Ten Well 0(3han
Well Shen Address 3121 W Li61e Euwl Roast
Cmhxtlm TYpe: MNhad:"NewwNl ❑Anon ❑W.- Marine! OCAli Tool City SheRM CmnIY Manion❑Deepening ❑ m
❑Dug ®Ain ❑MWadmy Tex Parcel No. 5202443-00030
mose,lees: Dimnnnofboung 6 brso BO R. Wan a variance approved for this well? 0Yes ENo
DegM1ofcmmpined well M ft
cxurrxtNr Pndla: WWI Ifyes,other was the vamenti,for?
Caring Las Dian From To Tluckxh Sent PVC ei Tteetl
13 ❑ 6 in. 0 vp_ .260 or 13 1 ❑ M 1 ❑ Location(we instructions on Inge 2), fit W WM or❑EWM
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010 _ _ _ —_ n. ❑ 1 ❑ 010
❑ 1 ❑ —n — ^ ❑ 1 ❑ ❑ 1 ❑ latitude(Example:4].12N5) 47.2MIM7
Perfoomes: MYes ON. Tyreofmidi rmeed Pre-310tledlRler Longihdde(Example,4M.12MS) -123.2515232
Nww"erbnbom_ Siuof,mriniers_in.by_in. Ddller'r Lag/Comwetbn or DeromMWon Prxedaa
Peurnred from 20 it us 60 R.below grwmdsnr Pmrelio^'.One^hebyenter,clureuer,sin ofrrxerial and resume,and the Boded
maw offl e m aniel in each ism penermrM,with at Wn he entry for neh ehmye of
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Swxd1FH,s,Whon_fl. DIaM shale,WH.frair 35 36
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Weser LesN: Used-oufeceeleinier ebow,mon.are lent 243 ft
Snick-apofnpofwellcezing 2 fl.abovegwMaurGz<
Samkwnmrkve100 fl.Eelow mopafwWlcuMg 0.x 44-3-2020
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p—a.,dw Uime=one when P.,6 nmN R-wiser level meuutd home well
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Date oftiumpiag ael
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Arisen flow_gpin
Temlrmweorwndn 53 'F waaacbemicduulyzhrmdep ❑Vn ONo Seen Dee 4-2-2020 Completed Date 4-3-2020
WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for colrometim oflhis well,eM its mmpliarma with all Washington well
exemolwrion Wharr s.MRteneb reed and the mfermrner opmad above ea hue W my brat krmwlWl and belief
an)Dollar❑Trainer❑PE-Find Noomgontemay Phythits Drilling Company Areadla Drilling Inc,
Shuman. Address PO Box 1T90
6bense No 2053 Ciry,Smte Zip Shelton,WA 98584
IF TRAMEE:Sponsors lien o. Comrector's
Sponsors Stammerer Registration No.ARCADDI098M Oak 4-6-202D
ECY050.1-20(Rev09/I9) jypuneed dris dprumem in mr nlhmanfarrme Pieces mil the Water Femnrcea Program of 360401fiB23.
Person Mth hearinglpss can call lllJw WasMnBtw Relay Servire. Persoru rvishaapeeclr dbabili7 con cal18A�33fi341.
'�l SPECTRA Laborataaiea-IO�P PortONurd,W k9i%6
• ._ � wwwspecha-lab.com
.,,,..o.,w...p.. (360)443-7845
COLIFORM BACTERIA ANALYSIS FORM
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Syscem Nam Addanne Caldwell 3121 W Little Egypt Rd,Shelton
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SAMPLE INFORMATION
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Spedficbutlmaherewwa* l acl: Spetla lnWuman aropmmads:
Well Head Me 565
Type d Semple(chest my one band
1.p Rome DWdbudm Same T HepMSwpe(abum muNef
ChIm M:Yee❑ No❑ ❑Detaulm Sysimi
Chlorine Restlual Tola_Fne_ Unsah4gay mine lab number
3.Source Cm Weer Rue Smek __---
Is I Unamdectay rw#m sleet &te
❑Tdpgaed OftioWYes❑ NO[]
❑Aweavnenl OMe%ddd tTda_Frm-
1. Emiwaon Swi.Wee,sands
❑E.ml pFacapa.ro,wa,~w Y.❑ w❑ I S I I I
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LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑IaeelKNcbry Teel C PmemteM AI Sa6gaMy
❑E.coFaeseni ❑EwJal and T
Replacement Semple Required:
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2159391 MASON CO WA
m/1512021 10.30 AM NOTCE
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Return to:
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TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA)
I(We),the undersigned grmmr(s),hereby place this notice on record that the following described real estate situated
in Mason County,State of Washington;to wit:
OR
Subdivision Division Lot Range Township Section
and having the Tax Parcel Number of 52 n a H — q?.) — 000-J0
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 WRL&.
WRIA:_ Maximum Annual AverageGallonsPerDay:
IS a5n
Dated on this day of �•1V�R. .202,
I�p,01
Signature of Grantor(s): yW�—�� n (c�—,/1 �1 —
Printedoameof(mutor(s): 1'1 Y1�(J�t VIA 1� ( L(SWe t
Grantee:Public
State of Washington )
County of Mason )
L the undersigned,allotary Public in and forthe abovenamed County and State,do hereby certify that on this
IfJ
" ac annt P CA4U)C11 nwanoll day of )um2 20j1 M YaPPeared
before me,who is known to be the 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 above tt®�. pe IwI
o tarues444444 f�t't— ✓K
geeSM PAk •a�5 Notary Publici�n�ayndd for
��th..,,e..St of Washington,
Rmidingat VYlatyTyr' C`
oTARY �Ra e• MY commission expires: I Z Z 2 0 2 f
e �• i i
�PUBLIC sr�azz
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