HomeMy WebLinkAboutWAT2023-00032 - WAT Application - 2/9/2023 h(CI:CI v t=U
.4
FEB 0 9 2023
WAT 2.02..3 6' y. #der Street
-tea r 415 N.6`h Street
a - MASON COUNTY 584
Shelton:360 42Shelt9670,Exton,WA .~_. �!!; :...F'a COMMUNITY SERVICES
T N.,___ / Belfau:360-275 1167,Ext 400
Buildng,Planning,Environmental Health,Community Health Elma:360-482-5269,Ext.400
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 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 Identifileation .
, 1
Name on Applicant: Fr(i t 1 1 r .0 ( Date: 2 -8- ZL)2-3
Mailing Address: R.() ,-60)< (y t 1 Phone: 6ip() • ' 1` 02' 1-1,-1 b
Parcel Number: f3ht t4'L-a)4 985 -F W_,bG7- 33 ~ 61W3,--
Type of Water System Reason for Application
Public/Community Water System (2 or more S Building permit�kd 0c:3-,C,Y) 1 ii LI
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
0 Well 0 Boundary line adjustment
0 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 (1 � �ZZ'0 , I
\Iti
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
(-
Name of Water System: 1 lilt( Lt :1)-1
Water Facility Inventory(WFI) Number: ►en L. (write"none"for two-party)
Xf/I am the manage of this water system.The water system has been approved for 2 services.There
are presently I connection(s)in use.This will be the It..2 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.
Print Name of Water System Manager-Fr-64-1Ll`J R tz-f.t(' f y��Phone3W) • 2' rig Li
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 4/27/2021
Individual Water Well
Zr Water well report(attached to application). Depth V ft.
\ I'l)Z
Well capacity Test(attached to application) 1 0 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/planning 14' 15 16 22
Water use or limitation recorded N/A Yes (
Well Drilled Date \\\c IZZ
Individual Spring/Surface Water 1
❑ 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)
,4 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: /1/ Date --I\St-73
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
WATER WELL REPORT oEPAIifMENT Or NoticeoflntentNo. WE49262
ECOLOGY Unique Ecology Well ID Tag No. BNV839
Type of Work: State of washlregton Site Well Name(if more than one hell)
C7 Construction
❑ Deconuaisaioa r-� Original installation NOI No Water Right Puinh/Certificate No
Proposed Lisa a Domestic ❑Industrial ❑Mreucipal Property Owner Name Francis Plotter
th
❑ watering 0 Irrigation ❑Ter well O Other Well Street Address 789 SE Biros Swiger Loop Rd
Construction Type: Method: CityShelton County Mason
PI Nev.well CI.Alteration 0 Driven ❑Jelled 0 Cable Tool
❑Deepening ❑other ❑Du` 11Air- ❑Mud•Rottuy Tax Parcel No. 32027-33-90082
Dimensions: thematic of boring 8 n,to 132 a. Was a variance approved for this well? ❑Yes Cl No
Depth ofeompleaed well 132 a
If yes,what was the variance for"
Construction Details: Will
Caring Liner District's From To Thickness Steal PVC Welded Mused IA WWM or p EWM
(4 I 0 9 in. D Sat2._ .025 in. (6 I O La) 1 0 location(see instructions on page 2)
❑ 1 ❑ in. _in ❑ 1 ❑ ❑ i ❑ SW V %of the SW h.;Section 27 Township 20N Range 3W
❑ I ❑ is — in. ❑ I ❑ ❑ 1 ❑
❑ I ❑ in- in. ❑ I ❑ ❑ I ❑ Latitude(Example 47.12345) 47.188184
_ — —
Longitude(Example--120 12345) -123,053125
ns Perforatio t ❑Yes O No Type of perforator used i
Driller's Lay/Construction or Decommission Procedure 1
e orpcd Rom I.
e of perforations roun s _a.by tit Formation:Describe by color,character,size of material and suvctwe,and the kind and
par6reacd from_A.p__a.below ground star a nature oldie material in each layer penetrated,with at Inset one entry for cash change of
Screens: 0 Yes El No ❑K-Packer =• Depth_a information. Use additional Meets if sucessary.
Manufactuea's Name -- - Material 1 From '1 o
Diameter
am N0 A.to
Diam Brown line to medium sandy gravel,silty, 0
aer SSlotsize in.foam _ _a. Pet.dry 43
Diameter_ Slat see in.funs a.to ft. log 43
Brown fine sandy gravel,silty clay brown
Sannd/PlIter pork:❑Yes II No Size of pack material—_io binding,dry 85
Mannish placed Eon it to A. Brown rnedlrm sand,dry 85 71
Surface Seal: Iv Yes 0 No To what depth+ 20 M. Gray clay,stiff,dry 71 89
Material used in seal Bentonite Chips Gray day,soft,seams of dads silt 89 99
Type of ef wnt contain unusable wale/! ❑Yes ft No
telt Depth of,truce__ ._ Chocolate colored peal,hard,dry 99 102
Type -. ___ 102 111
Gray clay.stiff,dry
Method of sealing stela alT Black silt with day chunks,wet 111 113
Pump: Manufacturer's Name Type Gray day,stiff,dry 113 179
ILp, pomp intake depth: A. Designed flow vale' BPnn Black round and sharp gravel,tight,dry 119 127
Water levels: land-surface elevation shwa,roan sea lend 162 ft Black round gravel,loose,water 127 132
Stick-up oltop of well casing 1 ft above ground surface
Static water level 82 ft.below top of well casing Date 11/9/22
Artesian pressure__tbs.per square inch Date
Artesian water is controlled by (cap,valve,etc.)
Well Inn:
Was a pumping lot performed'O No 0 Yn n--." by whom'?
Yield pprn with a drawdown after hrs.
Yield_____pun with -A.drawdown after.. hrs.
Yield_arm with_It drawdown after hrs.
Rsrovery data(lime-tero when pump is mined off -wales level measured hum welt top to water level) Water Level
Time Water Level Time Water level Time
Date of pumping test ---
Boiler test ppm with_a drawdown after her 1 —
Air ter 34 great with stern sat err 120 a in 1 Pen Dote 1119122
Artesian flow_gpm
Te npeeanac of water 50 •F Was a chemical analtsn nude? O Yes In\o Start Date 11/9/22 Completed Date 11/9/22
WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well.and its compliance with all Washington well
construction standards Materials used and the information reported above are true to my best knowledge and belief
Mel
kJ Driller Li Trainee Li PE-Print may P hian Drilling Company Arcadia Drilling Inc.
Signets / i..---- Address PO Bow 1790
License No.2053 City,State.Zip Shelton,WA 98584
IF TRAINEE, Sponsor's License Na
Contractor's
Sponsor', tw
Signae Registration No.ARCAD01098K1 Date 1119/22
ECY 050-I-20(Rev 09/16) !f vti tired this document in an alternate format.phew cull the Nalco Resources Program at 360-101-6872.
Printed Fr . ,'erypeti mtrh heanrlg loss ear cull 711 jar Washington RekaySerticc• Persons with a speech disability can call877-833-6341.
Printed from Mason Cfwn$ nor'3
1786 SE Mile Hill Drive
Port Orchard,,WA 98366
it, SPECTRA Laboratories-Xitsap www.spectra-lab.com
—Ilion.v:r...rows (360)443-7845
COLIFORM BACTERIA ANALYSIS FORM
Due Sammie Collected Thee Semple County
Collected
11 I 14 I 22 12 45 ou" Mason
htww Oaf r. ---• mvY
Type of Water System(dock any one boat)
❑Group A 0 Group B _ 00
Group A and Group B Sisters-Provide from Water Facilities Inventory(WFr):
ID'
System Nuns:Francis Pinter i
Coned Person:Arleta EIeNe&Arced(a Drilling Day Phone:360.426J395 Cal Phone:
Emet aeletat)arcadlsdrtHing.com Eve.Phone:
Sena mats(Awful ease,widens and rip coda our♦mas)
eMtmearaediedrlllinp.com
Arcadia Drilling.Inc
SAMPLE INFORMATION
Sample collected by(none):Mack _ y
Specific locatcn rinse sample collected SpadrMuerors or comments: i1
Well Heed#BNV638
789 SE Mane Swtgor Loop Rd,Shelton
Type of Simple(dueck only one box)
1.0 Routine Distbuton Sample 2 Repeal Sample(alter unsal.rorline)
Chlo inked:Yes❑ No❑ ❑Dstbulion System
Chdxlne Residual.Total_Free_ Unsatisfactory routne lab number:
3.Source Ground Water Rule Semple —— •.—--—---S I Unaatlstedory rouene called dale:
❑Triggered Chlorinated:Yes El No
No
Chorine Residual:Total_Free
❑Assessment
4. Enumeration SPAY Water Same* ---- t
15 I I
❑E.col OFocal-ewes"ow.ems.►rr-a Y.p 1,0
5.0Seerg1eCAaeatedbri icreeeae�Y•
LAB USE ONLY DRINKING WATER RESULTS LAB ONLY
❑Unsslistectory Total(Alum Present end
❑Ecog present ❑Eooeabsent
Replacement Sample Required:
❑Semple Soo old(.30 hours) ❑TNTC ❑--— — _
Bacterial Density Results:Total CoWorm 1100mi. E.ca h00m1.
Fecal Colima____ __. NOW. NPC_ n nil.
labmr7 `D w� NOV 1 :1 0 �IIn
meted Czar Dale and Time atafnaed:
SM 9223 B NOV 1 5 2012
celeAarirad' NOV 1 6 Dale RapedNOV I v Mt!
DOH tab � Lab the 0rdr
225 .
oari"n�Gfii .rirostii.s« llt�n�iRi{
Printed From teas, ..
Printed from Mason County DMS
•
2192771 MASON CO WA
01/13/2023 10 44 AM NOTCE
FRANK PINTER #183474 Rec Fee: $204.50 Pages: 2
Return To II!11 111111111111111111111 III!III IIII 11111IIIIII 111IIII iiii t E I VE D
FrtZKcS FEB 0 9 2023
51, e,F1 Lt 1,4,1 YcSv-i f 615 W. Alder Street
Grantor(s): (1) Prv'CtinCi S t"t, Ki Ater , (2)
Grantee(s): (1) PUBLIC
Legal Description (1) ---1? E1 c �t,c1 '$A) ?C.L z— 52,7 TAB I3
(Abbreviated form: i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 2_ 14. , l� ;� 7 - 3 - Cl o o g i
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 ,1
Maximum Annual Average Gallons Per Day: qS 0 gallons
Dated on this day of , 20,23_.
Signature of G or(s):
(1) , (2)
State of Washington )
County of Mason )
Page 1 of 2
State of Washington )
County of Mason )
I, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that
on this 1 14"‘ day of J QNUgV9 , 20 23 ,_4YouTC\S t^(). Q�nteY
personally appeared 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 written.
I
„.‘`'� RGFti.,,� Notary Public in and for the State of Washington,
P \REs o9/•••S ''
•"' °Ic<` = Residing at She\ l
i.<: N p: 9 My commission expires: b9` b912olH
• PUB'-' 10;=
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OF WAS,,,,,
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