HomeMy WebLinkAboutWAT2022-00323 - WAT Application - 12/12/2022 •
yev WAT W 22 - (x)32
MASON COUNTY
tiloa I• '5) COMMUNITY SERVICES
Building,Planning,Environmental Health,Community Health
`H1'N36
415 N 6t"Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 •:• Belfair: (360)275-4467 ext 400 Elma: (360)482-5269 ext 4Q��
FAX(360)427-7787 11
Application for Determination of Water Adequacy
Instructions 6�Sl J<' ' �Q
1. Complete Part 1. No determination can be made until Part 1 is fully completed. '•i/0' ;c.?
2. Complete only the portion of Part 2 applying to the type of water connection utilized. Or
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: e.5 er ���\ Date: NO% 22_
Mailing Address: e , - Phone: S D � • ObO l
Parcel Number: 32O 1 1(I O DO i Q Selkoh u!q c\6•—
Type of Water System Reason for Application
'91. Public/Community Water System (2 or more ti< Building permit
connections) "rwo 'P 41-42/ij0 Division of land:
Individual water source (one connection), #of Parcels? SPL
Well 0 Boundary line adjustment
Spring/surface water
0 Other(explain) 0 Other(explain)
0 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.
Flat vs Part 2: Water Connection Information .,� 10A'
1FNTALComplete the section appropriate for the type of water connection being evaluated: HEALTH
Public Water System
Name of Water System:
Water Facility Inventory(WFI) Number:
(write"none"for two-party)
0 I 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.
0 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
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised 1/25/2018
Individual Water Well
X Water well report(attached to application). Depth 11,3 ft.
❑ Well capacity Test (attached to application) i O 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
by a licensed contractor.
Satisfactory bacteriological test (attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planninq 1411 151 1-Hi122[�
Water use or limitation recorded N/A 0 Yes
2-0
Well Drilled
Date LDY0eCkit4A/
Individual Spring/Surface Water
O WDOE permit (attach to application)
O Method of disinfection
O 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 needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: R\--NtAkici-6V11\ Date \1 1r I7 -5
CSD Director: Date 2of2
Please print,sign and return to the Department of Ecology
Water Well Report Current W168345
L
t ,,, ortgtnsl_ploy,rtamy—o i,.,Ind y_d Notice ofIntent No.
• k'c 61l trey Unique Ecology Well ID Tag No. AEA983
Construction/Decommission
a 0 Construction Water Right Permit No.EXEMPT WELL
ell , 0 Decommission ORIGINAL INSTALLATION Notice
fY 1� 2 of Intent Number Property Name LARRY&BARBARA CLARK
(Q�7 9 Well Street Address 2080 E.AGATE ROAD
PROPOSED USE: m Domestic PUI Iodust al ❑ Murndprd CitySHELTON
❑oowetor 0 trove= 0 Test Well ID Other
County MASON
1.411
y TYPE OP WORK: Owner's comber of well(damn than ano) LQOaUOn 1/4-1/41/4 Sec 1 Twn? R 3W start O.rd.
a El New well ❑Reaada a,ed Method••❑Dag 0 Bared 0 Drwea
wean!
.a.+ ❑Deepaed ®Cable p ttooay ❑Jotted La n8(a,t.r Let Deg Let Mm/Sec
C DThIRNsloi'CS:Dsmeta of well 6 niches,chilled 113 a still REQUIRED)
0 Depth of completed well 113 it Long Deg Long Min/Sec
OCONSTRUCTION DETAILS Tax Parcel No. 32011-11-00010
0 ra Casing El Welded 6 - Dian.from+1,5 e.to 108 a
R efaeed Liner installedDrag.from a to ft. CONSTRUCTION OR DECOMMISSION PROCEDURE
Threaded - Dian.from ft to ft.
E Perforafotx C Yea RI No, Patmti a Deearbeb!cola,character.sits of metaial eat
R and the food and
nature of the materiel in each stratum penetrated.with at leant ace entry for each change of
O Type atperfaitorused mformanoc=hone ail water alommraed (USE ADDRiONAL SHEETS IF NECESSARY.)
1 SIZE of per&s in.by by is.and n of perfa o_a Tfram ft t
Screens: QJ Yes El No 0 X-Pao London 106 BROWN CLAY MATERIAL 0 FROM 4 TO
= Mwarfsd arsNmte IOHNSON BROWN HARDPAN 4 27 .
L Type � stc¢mne 18 from IOBi�adxa R to 113 a BROWN SILT BOUND FINE SAND 27 '
O [ham. Slat size from ft to ft. WITH SEAP 49 '
.a Gravel/Filter padred:❑Yes 121 No ❑size of snivel/mod SILT BOUND SAND&GRAVEL,WET 49 S0
C M'ani&plead&c0 - a to ft GRAY CLAY 50 52
03 Surface Seak:m Yea 0 No To whet depth?19.5 ft. GRAY SILT BOUND FINE SAND 52 68
RI material Iced is sad BENTONITE GRAY SILT BOUND GRAVEL,WET, 68
CO Did any amt.contain maaeble meal 0 Yea LEI No BLACK SAND MEDIUM 76
0 Type of.seem Depth of strata GRAY CLAY BOUND GRAVEL 76 83
CD Medwdofladaseh sad( GRAY SILTY CLAY LENSES 83 105
+5., PIMP:Mao feetzer's Nine 6 0 vt-P> GRAVEL,SAND&WATER 105 113
Z., Type S LAVA 6.124 on LC
tom. 44i N.e
i C WATER I.ZVEI$:I.satdeorfeee aeration above meat sea level ft
1 i Stabs level 50 a below tap dwell Date 6/16/03
L. Atoeai n pressure lbs.pa aquae irch Date
tQ Artesia water is cortsoncd by
I— WELL TESTS Dnerdown is amount water level a lowered below stun level
0 Wm aptrop test rondo?❑Yes ®No If yes,by whom?
Z Yield gellmm.with ft.drewdown alter lie
Yield gaUmia with ft dtewdo nta@e las.
Yield pd./min.web _ a drewdown efta to
O lie nerydaao Noe treat as mu wAa/wrap hawed. *Oar kvd MemvnJfivm well
s top ea%war levdf
Tone Weser Level Time Water Lev el Tige Water Level
Cr)
0
_p Data of tat
V Bala tat 10 gal/man.with -0- ft.dtawdown after 4 hrs.
W Airtest
w eaL/mn►with arm set et afar his
O Mahn flaw &pm Date .
� Temperature of water Was a draicel analysis made? ❑Yes lil No
0.) Start Dete 6/5/03 Canpletad Data 6/16/03
4g WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all
L. Washington well construction standards. Materials used and the information reported above are true to my beet knowledge and belief
Nee(Print) j LS N Drr»a.g Company ARCADIA DRILLING INC.
01 Itillc/5oatioeanntmee Signature Q� 94r � Addnsa 170 SE WALKER PARK ROAD
0 Dnner or trainee Licase No.1222 '', v(' Ili• ; : ': :4
IA
If TRAINEE -so t w,a- t •, r
H Dithers Lkaaee Ne. •• al' ;Cu No ARCADDI09:K1 Dam 6/18/03
Da ll ies slpwn C J••. .
JUL 1 4 Z0,u3 Fteolcgy Equal Opportunity Employer. BOY 0504-20(Rev 2103)
DEPARTMENT OF ECOLOGY
a-
Thurston County Environmental Health
ra\,
THURSION COUNTY 2000 Lakeridge Dr.SW ®Olympia,WA 98502
360 867-2631
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
7 ' /n I 2,Z xAki
;�C�ollected
Month Day Year v -r-z 0 w on
Type of Water System(check only one box) ❑ Private Household
❑Group A ❑Group B M Others 1 % `14\(
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name:
Contact Person: L e s.tr,Z c 130,1 I c 7
Day Phone:(3 bp C/ Cr c 9 Cell Phone:(G(Am
E-mail: C` ti 70,l ho t p.m; I Eve.Phone:( c
Send results to:.(Print full name,address and zip code or email address)
1-42 ii-Q.r'. Oct i l E?.
.2_0.8 0 ecks# A.Sa F
SAMPLE INFORMATION
Sample collected by(name):L e S'ta ., c c .``/
Specific location or address where sample collected: Special instructions or comments:
MSc E. Acs. R („,
�. i(
Type of Sample(must check only one box of#1 through#4 listed below)
1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes No ❑Distribution System
Chlorine Residual:Total_Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total Free
❑E.col-GWR(A/P)
❑Fecal-Surface,GM.springs Inumeraaoni Unsatisfactory routine lab number:
Filtered:Yes No
❑Assessment Monitoring(A/P) Unsatisfactory routine collect date:
['Other
/ /
S
40 Sample Collected for Information Only
Investigative . _ Construction/Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LA USE ONLY
0 Unsatisfactory Total Coliform Present and atisfactory
[:1E.coli present ❑E.coli absent I No Co form detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform /100m1. E.coli 1100ml.
CFecal Coliform /100ml Enterococci /100 ml.
Method Code:IWM92238 [ISM 9222D Date and Time Received: o/-15
❑SM 92158 ❑Enterolertt -3.--2 C- Z. L ��
Date and Time Analyzed: I.l 0 2 L, Date Reported:1-L11 L 'r..�
Sample Number(DOH number plus five digits) Lab Use Only:
0 8 0 ntit7
DOH Form#331-319(revised 01/16) '-1
r•
- _.\
a
Return To 2191652 MASON CO WA
12J1212022 10 10 AM NOTCE
Ca�0 �1 � } BRILEY it16256B Rec Fee: $204.50 Pages: 2
` � �l1 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIFDIIIIIIFIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
.\-vorr u) cs5yy
Grantor(s): (1) 1"--Y-4'Er \\ e , (2)
Grantees (1
)( ) PUBLIC
Legal Description (1) OeE-}-c) T Y N , i0G
S 3�w�yt:,,Fr.,Q(Abbreviatedform:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) "j C 1 - l 1 - C C 0 t 0
SAC MA) 0 tZ krje
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: "t
Maximum Annual Average Gallons Per Day: 95(---) gallons
Dated on this /,\ day of , 20 Z`Z..
Si• ature of Grantor(s):
(1) : '� , (2)
State of Washington � )
County of Mason )
Page 1 of 2
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this 12 day of J Ctn+n , 20 22
Le-544R 5cu 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 and year last abov wr en.
Notary Public • #Th
State of Washington
ARIANE M PAYSSE Notary Public in and ff r t e State of Washington,
MY COMMISSION EXPIRES residing at I V► azt • i,
12/29/2025
•
My commission expires: 2/Zq Z,5
•
•
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