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Home My WebLink AboutWAT2022-00270 - WAT Application - 2/24/2023 WAT2,22-Z - 0 415 N.6th Street .40747111` , MASON COUNTY Shelton,WA 98584 Shelton:360 427-9670,Ext.400 COMMUNITY SERVICES : Belfair: 360-275-4467,Ext.400 \` . Building,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` Identification Name on Applicant: �V I Date: 2.- vi 175 Mailing Address: 11 b SCi3ku -►241 f a4tul�Phon S 3— Si b' a RZS Parcel Number: '1_!j2 — 7(S�(6k)1 Type of Water System Reason for Application gyp' Public/Community Water System (2 or more Building permit ,\ connections) 0 Division of land: ❑ Individual water source (one connection), #of Parcels? SPL ❑ Well 0 Boundary line adjustment ❑ Spring/surface water 0 Other (explain) ❑ 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. cya, we—L207;r>— DO DOH Part 2: Water Connection Information cones C Complete the section appropriate for the type of water connection being evaluated: (,� Public Water System Name of Water System: _ r 1 1 t I Water Facility Inventory (WFI) Number: ik,/,10---041 1-13 (write "none" for two-party) ❑ 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. ❑ 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 Phone 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 Water well report (attached to application). Depth 19 ft. Well capacity Test (attached to application) 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_ 15X 16_22_ Water use or limitation recorded N/A Yescsvi 4-1 Well Drilled . Date 1Z I Z( /41 � 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: Environ. Health: Date 4V-t/Z- 5 This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 Thurston County Environmental Health 2000 Lakeridge Dr.SW t Olympia,WA 98502 360 867-2631 THURSTON COUNTY COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County Collected s PzcZ3 0 AM Z a6 wM Moen Month Day Year Type of Water System(check only one box) 0 PrivateHouseho ❑Group A 0 Group B Other\eHLAJ 1 • Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: Contact Person:C clo _ 7N Day Phone:( ) Cell Phone:)3 10 ' E-mail s ( C® Eve ( ) WN Send resul to:IPrinr full name address and zip r email ddress) sE" 5taejk-A_ SAMPLE INFORMATION Samp Ilec d b na ): Specific location or address where sample collected: Special instructions or comments: Type of Sample(must check only one box of#1 through#4 listed below) 1.ARoutine 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.coli—GWR(AIP) ❑Fecal—Surface.GWI.springs(numeration) Unsatisfactory routine lab number: Filtered:Yes No ❑Assessment Monitoring(A/P) Unsatisfactory routine collect date: ❑Other / I S 4.1=1 Sample Collected for Information Only Investigative Construction I Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and :ratisfactory ❑E.coli present ❑E.coli absent o oliforrn detected Replacement Sample Required: ❑Sample too old(>30 hours) ❑TNTC ❑ Bacterial Density Results:Total Coliform /100m1. E.coli /100m1. Fecal Coliform /100m1 Enterococci /100 ml. Method Code:gSfyl 9223E OSM 9222D Date and Time Received:mgo SM 9215B ❑Enterolertt Date and Time Analyzed: — 3,3 Date Repertd—l-j5 e- Sample Number(DOH number plus five digits) Lab Use Only: 0 8 0 5 • 00H Form 4331-319(revised 01/16) ,2 — ', 2188192 MASON CO WA 09/22/2022 03:51 PM NOTCE CARGOS ESTRADA #180034 Rsa Fee: $204 50 Pages: 2 Return To IIIH IIIIIII�1111111111IIIl11I 1111111111?1U1!1bEIVED 1 E' -01 0,\.ac SEP 22 2022 615 W. Alder Street Grantor(s): (1) Tc l- s fQ c , (2) Grantee(s): (1) PUBLIC Legal Description (1) Lot8: nc5931-14e >+F# 47V 3- m oFSt.J 5 5 (Abbreviated form:tti.��e. lot, block, plat or section,�� township, range) Assessor's Tax Parcel: (1)J_ a 3 a 1 - 9 5 ' V- 0 r I 5ZQ1 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: 16 Maximum Annual Average Gallons Per Day: 1.V gallons Dated on this u day of -- \ , 20 7/f, Signature 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 ttmdtay of ,te4emb , 2022_ , Co..bs eS1 �--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 a year last above // 1 Notary Public State of Washington Notary Public in and for e S.1 to of Washington, ARIANE M PAYSSE residing at Y n l i n ' MY COMMISSION EXPIRES I2/29/2025 My commission expires: 12/2- ZS Page 2 of 2