HomeMy WebLinkAboutWAT2022-00314 - WAT Application - 11/21/2022 (2) WAT OO)\1
.4701, MASON COUNTY
COMMUNITY SERVICBS
t;. Building,Planning,Environmental Health,Community Health
415 N 6tr,Street, Bldg 8, Shelton WA 98584, NOV 2 1 LULL
Shelton: (360)427-9670 ext 400 •3 Belfair: (360)275-4467 ext 400 •:• Elma: (360)482-5269 ext 400
FAX(360)427-7787 615 W. Alder Street
Application for Determination of Water Adequa `�`vl,l r�ONMEN y ,I
V
Instructions H FALT.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: OrpTrJ (�ruj L. �llenel' Date: `t 1 a 1 ao a a
Mailing Address: I F Cyr)or.[S-f ! ' 1 r Oa Phone: .:c-
la-�ao�l
Parcel Number: U y
l�.3��-
Type of Water System Reason for Application
IN Public/Community Water System (2 or more ) Building permit e7Unaaa3v-0i(I77
connections) 0 Division of land:
El Individual water source (one connection), #of Parcels? SPL
131. Well ❑ Boundary line adjustment
0 Spring/surface water
ElOther(explain) 0 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.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: 20 e f
Water Facility Inventory (WFI) Number: f(511 i
(write "none"for two-party)
217 I am the manager of thi water system. The water system has been approved for 2 services.
There are presently connection(s) in use. This will be the ,2Z connection.
El 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: IrteCreoult/Ono p 4r) �r�OQ '-Hrhi
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 st to nd local regulation.
Signature of Water System Manager Date 1//A/
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
Water well report(attached to application). Depth EY ft.
a' 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
by a licensed contractor.
l Y Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.uslplanninq 14r 15n 16n 22(-1
Water use or limitation recorded N/A Ell Yes .k i
Well Drilled Date A ' ' -"1'1 03 In t h1 V\
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.
L 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 `I —S/Z 3
2°r2
CSD Director: Date
OLcaORR- oN77
RECEIVED
Daviiiikillinq&Pumps NOV 2 1 2022
340 Al Davis Tartu'Rd
Rey air, 98528 615 W. Alder Street
(360)801-6107
Project Sally Weber ENVIRONMENTAL
Capacity Test 521 Cronquist Rd H EA LT H
Allyn,Wa 98528
TAG: NA
Date 01/11/2021
Pump 'h 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
I
Printed From Mason County DMS
Printed from Mason County DMS
•
186Z44 --
Thurston County Environmental Health.
�{{�` ' 2000 Lakeridgc Dr.SW !Olympia,WA 98502
K. -• 360 867-2631
TNurtsTO4cOUK Y
T� COLIFORM BACTERIA ANALYSIS
Dale Sample Collected Time Sample County
Ceieckin
1114 k,?10032.. q in
OXNA 114. ,r7
Iketh Day Yea
Type of Water System(check only one box) 0 Pmate Household
I 0 Group A 0 Group B Other 3 u"'�(.
Group A and Group B Systems Provide from Water Facilities Inventory NrF4:
•
10# — — — — -- ------
System Name' ,503e1� v.
Contact Person: .d(" 1.00:,b€r/e.e &4'ki'
i Day :(30)aj9-7466 eP�.:(360)RR, 7
E-mail:51 ywbrLF',9 I.corn r1 Eve.Phone:(3e.C))d1/-Gi7aa.
Seed resets to(Print he name.ad sa and to code or eras address)
Set.le (xis-1A:ivu-- —
liW r1..com
SAMPLE INFORMATION
Sample collected by(name):'
Specific tecaton or address where sample collected Special instructions or comments:
5cA 1 E, efe.- s.:S 4-RLC.
Allyn,Lat• 785 4-
Type of Sample(must check only one box of#1 through e4 listed below)
1.0 Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes No 0 Distribution System
Chlorine Residual:Total Free Chlorinated:Yes__No__
3.Raw Water Source Sample Chlorine Residual.Total__Free_
0 E.cob-GWR(NP)
❑Fecal-rare Cm so,rgs it an i.ni Unsalatactory routne lab number.
Framed Yes No. , -.
❑Assessment Monitoring(NP) Unsabsfadory routine oolect date
❑Other ____J—f
Sl I L
4Sample Collected for Information Only /
Investigative— CortstNctan/Repairs_✓ Other
il LAB USE ONLY DRINKING WATER RESULTS ��LAB B USE ONLY
❑Unsatisfactory Total Colitonn 4)�Present and +tlafacfoy
❑E cos present ❑E.cea absent
No Cofform detected
Replacement Sample Required:
❑Sample too old( 0 hours) ❑TNTC 0
Bacterial Density Results Total COW) 1100n1. E.00a I10Orrd.
Fecal Cordorm_�J100m1 Enteromca 1100 mi.
r
DOH Fans aa3r.31e(wad 01n6) 50' 1 1 ,
III 0 <
6L99.6a2-o/ 4/77
2190882 MASON CO WA
11/21/2022 11:47 AM NOTCE •
GREG AND SALLY WEBER #182012 Rec Fee: $204.50 Pages: 2
II II III II III I III I II II II IIII IIII I I I II I I II IIIII IIIII III I III H
Return To .1 ���p
rxp.1 h S',11 L°k.be r RE C
? I F. s t rt-c Nov t 1 2022
AtL;A 615VVAlder Street •ENVIRONMENTAL
HEALTH
Grantor(s): (1) a.-tt'y L. We be , (2) &(-°' n1�' ,g' t4.1 Ct,7 b r
Grantee(s): (1) PUBLIC f �;;,�h�
er+,cn o� Cic,eorwnec 14 02 c+� _Sec4icn - Z,! p
Legal Description (1) k ',;-rrh FZ,,.,,,, tom' wl . Mn5on Ce,u1 kle S11:,-1 •
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1)_ - ' r ( ,i� -7 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: 1`4
Maximum Annual Average Gallons Per Day: 1 5 0 gallons
Dated on this 7>(.D day of Sep li--' `Mht'r'20 Z?.
Signature of Grantor(s):
� J
(1) .�4 . /
� L ? , (2) A-4-e-f-iL�`'
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 ofSP? - rA'r , 20 22 ,
3c\11L.s t (=trec r{t,j W ebec 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.
�.�`',,, 0a/cte;
,�«essa Notary Public in and for the State of Washington,
,^^M EXP. n L,s
9 = residing at k kA-Soacp
o TA My commission expires: O 1- 30 . 20 D-1
Uc' ---
WA S‘-\\N
'14I,Et1:,,tt
Page 2 of 2