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Home My WebLink AboutWAT2022-00314 - WAT Application - 11/21/2022 WAT O52--- 003lt\ \ MASON COUNTY rxECVED .ti r.'1 COMMUNITY SERVIC r- ':1. yv Building,Planning,Environmental Health,Community Health'�1V'^t` 415 N 6t"Street, Bldg 8, Shelton WA 98584, NOV 2 1 LULL Shelton: (360)427-9670 ext 400 •:• Belfair: (360)275-4467 ext 400 •o Elma: (360)482-5269 ext 400 FAX(360)427-7787 615 W. Alder Street _ Application for Determination of Water Adequap �,1RONM�N I f',I Instructions .FAL H 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 Name on Applicant: L.r-u (1 a,vtci L. �l �jer- Date: II Ja i a a Mailing Address: 2 j p , Cyo �i S-f- lily()',1 �� Phone: 7,hp-�q---hya:, '� y Parcel Number: / ,3,�--/0-c)9Q7/ Type of Water System Reason for Application El Public/Community Water System (2 or more Building permit f3un a"-oag77 connections) 0 Division of land: ❑ Individual water source (one connection), #of Parcels? SPL O. Well 0 Boundary line adjustment ❑ Spring/surface water ❑ 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. Part 2: Water Connection Information Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System:50)(Q; .. -eX Water Facility Inventory (WFI) Number: n()n t (write "none"for two-party) I am the manager of thi water system. The water system has been approved for services. There are presently connection(s) in use. This will be the ,L 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.:�t recreational to full time). Please indicate on the following line the nature of this change: ire'Ci`��cx-it OrtaJ --jr, Q .-}-irvt� 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 e by state nd andlocal regulation. 4 u 2 Signature of Water System Manager .J /j 4 A / ..1- Date ///a /020 .9. This form may be scanned and available for public view at www.co.mason.wa.us. 1:\EH Forms\Drinking Water Revised 1/25/2018 Individual Water Well LA' Water well report(attached to application). Depth elij ft. ID Well capacity Test (attached to application) 8 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. L9 Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14L115n 16(]2271 Water use or limitation recorded N/A L_J Yes ..1.-7 i l Well Drilled Date l/1,0,‘fler,dYl (,0r\0-o \ 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 • • 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: VW Environ. Health: Date `�Z3/�/ 2°1 CSD Director: Date oLcaoaa- oro7 RECEIVED Sw14ThiWnq&rumpNOV 2 1 2022 340 WE Dcwia farm Rd &f fair,'Wa 98528 615 W. Alder Street (360)801-6107 Project Sally Weber ENVIRONMENTAL Capacity Test 521 Cronquist Rd Allyn,Wa 98528 H EA LT H TAG: NA Date 01/11/2021 Pump 1/2 hp sub Well Depth unknown Static Water Level 66.3 Draw Down Recovery Time Water Level GPM Time Water Level 0 min 66.3 0 0 min 69.2 5 min 69.2 8 1 68.5 10 min 69.2 8 2 66.3 15 min 69.2 8 3 30 min 69.2 8 4 1 hr 69.2 8 5 2 hr 69.2 8 10 3 hr 69.2 8 15 4 hr 69.2 8 30 Printed From Mason County DMS Printed from Mason County DMS K 1 862 001 Thurston County Environmental Health 2000 Lakeridge Dr.SW !Olympia,WA 98502 y eA!' 360 867-2631 THURS'R)N COUNTYeammummeam COLIFORM BACTERIA ANALYSIS Dale Sample Collected Tom Sample County Collected J.1 14 1—?0. �:� o ,1,7 Month Day Yea' Type of Water System(check only one box) ❑ Pnvale Household � 0 Group A 0 Group B pg Other -c r=f—j Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): IOU *Item Name: 5G tallAV.V Contad Person: S 1 it) be-i /Ca-- re wok.— DayPlana:(3G�►af9-7e66 CIP :060) -7146 Email:SiyoArP,9evraI I.corn Eve.Pncne:(3CO WI-cna Send mutts to.(Pont ha name..aaq�eu and op code ar Wad ads'ne) 5 t4 j Lea-1 t 519w6rE l0r rl.Coro_. SAMPLE INFORMATION Sample colected by(name): rrtL) I 6e1- Specific location or address where sample collected: Special Instructions or comments: 5,A I E., CsOnerhA f-"Rd. A-ltyr),Lat. 181S 4 Type of Sample(must dads only one box of 81 through 04 kited babe) 1.❑Routine Distribution Sample 2.Repeat Sample(after uma4 routine) Cttbnnated Yes_No_ 0 Datribulan System Chlorine Residual:Total_Free_ Chlorinated.Yes____No___ 3.Raw Water Source Sample Cnlonne Residual:Total Free_, 0 E.col-GWR(ARP) ❑Facet-sVLre.GMl.spr+gs rounn'A rl Unsal stactory routne lab number FFlkved Yes____.NO..___ __. ❑Assessment Monitoring(kP) Unsatisfactory routine collect date ❑Other J— J_ I'Sampl.Collected for Information Only Investigative._-_ Constrxb0n/Wails_✓— other_..._, LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY 0 Unsatisfactory Total Cokfonn Present and ----W.Satisfactory 0 E cos present 0 E.cdr absent No Cobbnn detected Replacement Sample Required: ❑Sample too old(>30 hours) 0 TNTC 0 - Bacterial Density Results.Total Cotfom I100ml. E.mI, 1100rtt1. Fecal Cokfonn I100m1 Enterococa 1100 ml IDalt Rob.eat4f a twrwe 01110 III . . 6Low,)a2-of ,(77 2190882 MASON CO WA 11/21/2022 11:47 AM NOTCE GREG AND SALLY WEBER #182012 Rec Fee: $204.50 Pages: 2 III II III III III III III III I III II Return To r- ;, (.giber RECEIVED 1`R i F. C_fc,, _4 s+ OA NOV t 1 2022 aci ,� . (,,c�. y 615 W. Alder Street ENVIRONMENTAL HEALTH Grantor(s): (1) f L IA)e bey , (2) &J^A n r7 be Grantee(s): (1) PUBLIC ef',A'Met,t4- c , tw.6 in Cp Legal Description (1) r;,- m t',, re) . Mason Co,utk, (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) -_' - - i r''- ? 1 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: I`-4 Maximum Annual Average Gallons Per Day: i J(—' gallons Dated on this . O day of S•Pp\-- \ner 20 22_ Signature of Grantor(s): (1)✓ � ll.- ��'tf , (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 *.O day ofS cA v v \X ( , 20 2 2 , 3414 * (=�recj—uj Weber 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 d year last above written. ‘.0:1?0essa Notary Public in and for the State of Washington, residing at --Sac) C, t\- v !� o _ My commission expires: OqO 20 a`� N 0PUBLIC -a` O o , ' vast k�N Ill,ll:l,l1,:,` Page 2 of 2