HomeMy WebLinkAboutWAT2023-00061 - WAT Application - 1/26/2023 WAT 740�5., ceoc, ( J
", MASON COUNTY
II COMMUNITY SERVICES
`w Building,Planning,Environmental Health,Community Health
ill is`
415 N 6tn Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 ••• Elma: (360)482-5269 ext 400
FAX(360)427-7787
Application for Determination of Water Adequacy R Instructions C` �c`1-1
1. Complete Part 1. No determination can be made until Part 1 is fully completed. JAN
?
2. Complete only the portion of Part 2 applying to the type of water connection utilized6. 6 2023
3. Submit completed application, with any required attachments for review. VI/
4. An approved building site plan must accompany this application. • q/fr
Street
Part 1: Applicant/ Parcel Identification
Name on Applicant: Mark Spaur Date: 1/16/23
Mailing Address: 37611 17th PI S., FW, 98003 Phone: 253-709-8145
Parcel Number: 22333-51-00004
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more 0 Building permit
connections) ❑ Division of land:
O Individual water source(one connection), #of Parcels? SPL
0 Well ❑ Boundary line adjustment
❑ Spring/surface water 0 Other(explain)
❑ Other(explain)
la 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) — RAwkoctii .f Akt;-hbv
System box.
Part 2: Water Connection Information ENVIRONMENTAL
Complete the section appropriate for the type of water connection being evaluated:
Public Water System HEALTH
Name of Water System:
Water Facility Inventory (WFI) Number:
(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.
Signature of Water System Manager Date 1/16/23
This form may be scanned and available for public view at www.co.mason.wa.us.
1\EH Forms\Drinking Water Revised I/25/2018
[ . .
Individual Water Well
❑ Water well report(attached to application). Depth 113 ft.
❑ Well capacity Test(attached to application) 10 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.
El Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://qis.co.mason.wa.us/planninq 14>4
15n 161 122=
Water use or limitation recorded N/A 0 Yes I
Well Drilled Date (D '7c'- ` (
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: I r l Date I C125
CSD Director: Date 2 of
~. ..- _ --.
DEP
WATER RIGHT CLAIMS REGISTRATION
WATER RIGHT CLAIM
ADDRESS
COD-
gmmd
2. SOURCE FROM WHICH THE RIGHT TO TAKE AND MAKE USE Or- WATER IS CLAIMED:
(SURFACE OR GROUND WATER)
It+ANK)
A. IF GROUND WATER, THE SOURCE IS ' IL won
'E. IF SURFACE WATER.THE: S O.'URCE IS
3.THE QUANTITIES OF WATER AND TIMES OF USE CLAIMED:
A. QUANTITY OF WATER CLAIMED PRESENTLY USED
(ruBIC FEET P�U_SEC:OND OR GALLONS PER MINUT-1.
'B. ANNUAL QUANTITY CLAIMED-- PRESENTLY USED—
(ACRE FEET PER YEAR)
C. IF FOR IRRIGATION, ACRES CLAIMED' PRESENTLY IRRIGATED
D. TIME(S) DURING EACH YEAR WHEN WATER 15 USED. &11 year
YEAR . 1970
4. DATE OF FIRST PUTTING WATER TO USE. MONTH
FEET FROM THE CORNER OF SECTION
BEING WITHIN OF SECTION T. N.,R. (E.ORW.) W.M.
IF,THIS IS WITHIN THE LI.MITS OF A RECORDED PLATTED PROPERTY, LOT BLOCK OF
(GIVE -4 AME OF PLAT OR ADDITION)
Is of �Ltdinglz Stirm
6. LEGAL DESCRIPTION OF LANDS ON WHICH THE WATER IS USED: Shore
Situate in Has on COwity, Washington
COUNTY
7. PURPOSE(S) FOR WHICH WATE R IS USED: domestic supply for two homes
8 THE LEGAL DOCTRINE(S) UPON WHICH THE RIGHT OF CLAIM IS BASED:
I HEREBY SWEAR THAT THE ABOVE I'v---�FMITION 15 7AU- A'ID
ACCURATE-JO THE BEST OF MY KNOWJDGI AND BELIEF.
THE FILING OF A STATEMENT 0F CLAIM DOES NC CONSTITUTE AN ADJUDICATION
OF ANY CLAIM TO THE RIGHT.TO USE OF WATERS AS BETWEEN THE WATER USE X.
CLAIMANT AND THE STATE OR AS BETWEEN ONE OR MORE WATER USECLAIMANTS
AND ANOTHER OR OTHERS. THIS ACKNOWLEDGEMENT CONSTITUTES RECEIPT FOR
THE FILING FEE, DATE
DATE RETURNED THIS HAS BEEN ASSIGNED IF CLAIM FILED BY C,ESIC-','
ATE0 REPRESENTATIVE. PmNT OR
WATER RIGHT CLAIM REGISTRY NO. FULL NAME AND MAILING ADDRESS OF,AGENT SEIOW,
RECEIVED Start Card No. W070382
Fie oAp4d and First Copy with
Depanateat at ow a Copy JUL 2 y WATER WELL REPORT utd/D vim-vi I-D-a AC J 803
Third Copy—�{eSecond Copy Copy Water Right Perndt No.
HH 11 55 STATE OF WASHINGTON
(1) OWNER: LARBY .L "IV1t"_�.5 ye.s 3811 59 ST. CT.NW. Gig Harbor Wa, 9833`
(2) LOCATION OF WELL: tasty MASON -NE to SW to sec 33 t 22N f1 R 2W w.u.
(2a) S7REETADDRESSOFWELLt«ne..tadacl MASON LAKE DR. WEST
(3) PROPOSED USE: Pik Domestic kdusbial ❑ Municipal ❑ (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION
0- Irrigation
0 Dewater Test Wel 0 Other ❑ Formed=Descrbe by color.cdrad r.she of R+wrtal and structre,and thew thickness of aquifers
and the kid and nature et the maketst In earth drew penetrated,wtth at feast one entry for each
(4) TYPE OF WORK: Owners numberd well change d kotonnoat+ont ,-
(f inert tun orhe) M(TENIAL FROtt To
Abandoned Q New well (5t Method:Dug 0 Bored❑Deepened 0 l
Reconditioned o . F�o .fatted o
top soil BROWN
GRAVEL & CLAY H.P. BROWN R 2 35
(5) DIMENSIONS: Dien.tecd wee 6 Inches. SAND & •CLAY H.P. BROWN 35 49
Drlted 113 feet Depth of completed wet 1 13 ft. CIR A V F.T. & (`LAY H.P.BROWN 45 91
SAND & GRAVEL H2O BROWN 91 113
(6) CONSTRUCTION DETAILS:
Casing Installed:reused 108 •' Diem.from 1 a to 108 tt
unWelededr [J ft.p
Dtam.tonft
Treaded (❑ '' Diann.from 0.to rt
perforations: Yes❑ No t] ---
Type of perforator used •
.—
SIZE of perforations In.by in.
perforationsfrom ft.to ft
perforations from ft to ft.
perforations from FL to f.
-
Screens: Yes® No 0 CST
Man Name (`()(�K > _[.
Type STANLESS Model No. __ 't
Dien. 5 slot we 15 from 108 R to 113 rt. — .. "f'
Diem. Slot size kw ft to ft . -
Gravel packed: Yes❑ No El Size of gravel • ._' r`i
Gravel placed from R b ft Si -Cf
N I -
Surface seal: Yes® No 0 To what depth? ft. _ l� {
Material used in seat )LENT(1NTTF. '-
Did arty strata contain unusable water? Yes❑ No El
Type of water? Depth of strata
Method of searing strata of
(7) PUMP: MarartacbaeesName MF.YFRS
Type: SURMERSTRLF ti.R 3/4_- _
(8) WATER LEVELS• Larel suet elevator Work Started 6_1 8-9 6 l9. C«ndeted 6-7 c-q 6 19
Stove mean Sea Jere+ IL
Static?anal 72 It below tap trees Der 6-2 5— Fi WELL CONSTRUCTOR CERTIFICATION:
Artesian pressor* _bs.per aware inch Oats
Anesim eater a controlled try I constructed and/or accept responsbillty for construction of this weft, and Its
(Cap,vave,sic.) compliance with al Washington well earutruetfon standards.Materials used and
the Information reported above are true to my best km...hedge and belief.
(9) WELL TESTS: Drawdawn le amount water level is lowered below static level
Was a pump lest made?Yes g No❑ it yes.by whom? d r i l l e r NAME C(1(1 T.W A T FAR T N�
Yield: 1 0 gal./mitt with 3 0 ft drawdown after 4 hers. t ltvoA,�r
ION CrTrE OR Perrin
M N Address 6642 CLOVERBLOSSOM LN. NE. ----
ll&
Recovery data(lime taken as zero when pump Aimed oth(water level measured from wee (S License No. 17 73
tvret.l uhLl.rttl
lop to water level)
Time Wafer Level Time Water Level Time Water Level Cordrar:tora
o9a
No.
tration
COOLWD*044DN Date 6-7fi-9fi ,19_
(USE ADDITIONAL SHEETS IF NECESSARY)
Date of test
Saber feel galmkt web ft drawdown after hrs. E is an Equal and Affirmative Action employer.For
Ablest gat/min.with stern eet at h.for hrs. �9y Opportunity
Now g.p.m. Date spe-
cial accommodation needs,contact the Water Resources Program at(206)
Meows407-6600.The TOD number is(206)407-6006.
Temperature of water Was a chemical analysis made? Yea 0 No 0
Thurston County Environmental Health
2000 Lakeridge Dr.SW !Olympia,WA 98502
-'1110k 360 867-2631
THURSTON COUNTY
"' COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
/ I // 1 23 Collected X Mx}S��IJ
Month Day Year
: 0 PM
Type of Water System(check only one box) JSt Private Household
0 Group A ❑Group B ❑Other
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
ID#
System Name:
Contact Person: /f.4Qj 5f 4L 1 i2
Day Phone:(2 )-76,q e f 46- Cell Phone: ?S?j ejili-s
E-mail;50 640 COA,{C,ui 5- .fiver Eve.Phone:( )
Send results to:(Print full name,address and zip code or email address)
SAMPLE INFORMATION
Sample collected by(name): �lkK .J 4 ff�
Specific location or address where sample collected: Special instructions or comments:
444) C.Mt45,nx1G c/72, W,
6,Z4-,(vieu/ ?r85.q(.,
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 0 Distribution System
Chlorine Residual:Total Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total_FreeI IX _
E.colt—GWR(AP)
❑Fecal—Surface.Gwt.springs(numerator') Unsatisfactory routine lab number:
Filtered:Yes No
❑Assessment Monitoring(A/P) Unsatisfactory routine collect date:
['Other / I
S
4.i 'Sample Collected for Information Only
Investigative Construction I Repairs X Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Satisfactory
0 E.coli present ❑E.coli absent o liform detected
Replacement Sample Required:
❑Sample too old(>30 hours) 0 TNTC ❑
Bacterial Density Results:Total Colifomr i 100m1. E.coli /100m1.
Fecal Coliform 1100m1 Enterococci / ml
Method Code:92238 ❑SM 9222D Cate and Time Received:
LJ SM 91513 ❑Enterolert® t- 1 l.2_ (S
Date and Time Analyzed: • cl. rt? Date Reported: L-\Z-Z.3 �
Sample Number(DON number pus five s / la Use 0 ly:
`o s o 'Z�—�' Sbs r✓ays/
ooi Form 4331-319(revised 01116) ' I