The URL can be used to link to this page

Home My WebLink AboutWAT2023-00014 - WAT Application - 1/17/2023 • I WATQ ' COO i Li c` 1��`. MASON COUNTY .;11 COMMUNITY SERVICRRCr...;� �..r..� x Building,Planning,Environmental Health,Community Health 23 „tte,,;,� JAN 1 7 2023 415 N 6th Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 Elma: Mt; (2-)!O t0@et FAX(360)427-7787 Application for Determination of Water AdequaEyNVIRONMENTAL HEALTH 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 Id ntification Name on Applicant: CLV +iZAA S Aup L'eusai_rt 1,16 Date: 1/0 7A2.0{� J Mailing Address: ED, ECA 4 KE 1 k)A 9 '4-5 Phone: ((4 )44-c-.S410 Parcel Number: 22114-7& 9t/74 Type of Water System Reason for Application Public/Community Water System (2 or more Building permit &ORM-5-- 0015� connections) ❑ Division of land: ❑ Individual water source (one connection), #of Parcels? SPL ❑ Well 0 Boundary line adjustment O Spring/surface water 0 Other (explain) ❑ 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: 0,2'(f/CiTy WE L Water Facility Inventory (WFI) Number: Il11(iE (write"none"for two-party) CJ I am the manager of this water system. The water system has been approved for 2 services. There are presently 0 connection(s) in use. This will be the IC'- 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 sta and local regulation. Signature of Water System Manager 2r 491/ Date JAAI I2,,22�23 ( This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Fortns\Drinking Water Revised 1/25/2018 Individual Water Well lif/Water well report (attached to application). Depth /` ft. Ltd' Well capacity Test (attached to application) AO 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. li Satisfactory bacteriological test (attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 141511 160 220 Water use or limitation recorded N/AJ IYesII Well Drilled Date Individual Spring/Surface Water 0 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 76 re) ?0 ,of CSD Director: Date ENVIRONMENTAL RECERI - • €3110O�O o '� doOS3 HEALTH JAN 1 7 2023 WATER WELL REPORT 6 rAldeuetreet Notice of Intent No.WE48789 ECOLOGY Unique Ecology Well ID Tag No.BNA 197 Type of Work: ;:ate of Wa.h.irptor. C Construction Site Well Name(if more than one well): — C Decommission t=> Original installation NOI No. Water Right Permit/Certificate No._ Propaed Use: ?9 Domestic ❑Industrial ❑Municipal• Property Owner Name Jan Oosterveld O Dewatering 7Irrigation 0 Test Well U Other Well Street Address Wilson Way Contraction Type: Method: !l New well 0 Alteration Driven C Jetted a Cable Tool City Graoeview County Mason 7 Deepening ❑Other 0 Dug C Air- C Mud-Rotary Tax Parcel No.221147690174 • Dimensions: Diameter of boring 6 in.,to 140 ft. Was a variance approved for this well. 0 Yes ❑No Depth of completed well 140 ft. Contraction Details: Wall If yes,what was the variance for? Casing Liner Diameter From To Thickness Steel PVC Welded Thread • 0 6 in. +2 135 1t4 in. :❑n I C U I U location(see instructions on page 2): iR WWM or C EW'M O 1 0 _in. _ _in. ❑ I ❑ J 1 ❑ SW V.-'Vs of the SE Section 14 Township21 N Fanbe 2W ❑ 1 ❑ _in. _ _ in. ❑ I ❑ J l ❑ -- ❑ 1 0 in. in. (7 1 7 I ❑ Latitude(Example:47.12345) Longitude(Example:-120.12345)_�_______.___ Perforations: 0 Yes M No Type of perforator used No.of perforations_ Size of perforations In.by in. Driller's Log/Construction or Decommission Procedur Perforated from R.to ft.below ground surfaceFormation!Describe by color.character,size of material and structure,and the W,nd and nature of the material in each layer penetrated,with at least one entry f v each change of Screens: .M Yes 0 No Tf:K-Packer b Depth 133 ft. information. Use additional sheets if necessary. Manufacturer's Name cloy Machine Works Material From To Type Stainless Model No. Diameter 5 in. Slot sae 14 in.from 135 ft.to 140 ft. Top Soil 0 3 Diameter— in. Slut sae_ in.from n.to n. Hardpan 3 20 Brown Gravel 20 40 Sand/Filter pack: Yes 0 No Size of pack material_in. Materials placed from_ft.to_ft. Blue Clay Silty Gravel 40 86 Orange Gravel/Clay 86 100 Surface Seal: eJ Yes ❑No To what depth"20 ft. Brown Gravel&Sand/water 100 140 Material used in seal berdOrtRe Did any strata contain unusable water? 0 Yes 3 No Type of water? Depth of strata _.._._ Method of sealing strata ofT Pump: Manufacturer's Name Qrundfos Type:sub H.P. 1/2 Pump intake depth:_ft. Designed flow rate:_gpm -- Water Levels: land-surface elevation above mean sea level ft. Stick-up of top of well easing_ ft.above ground surface Static water level 102 fl,below top awed casing Date Artesian pressure_Ihs per square inch Dale — — Artesian water is controlled by leap,valve.etc.) Well Tests: Was a pumping test performed? C No 0 Yes b by whom? Yield_gpm with—ft.drawiktwn after_hue. Yield_gpm with—ft.drawdnw•n aver— hrs. Yield_gpm with—ft.drawdown after_hrs. Recovery data(time•sero when pump is turned off--water level measured from well i. top to water keel) Time Water Level Time Water Level Time Water level —" Date of pumping test Bailer test 10 gpm with 28 ft.drawdownatterl hrs. 1L Air test_gpm w ith stein set at_ti.for_hr.. I Date 11/0522 Artesian flow_arm Temperature of water F Was a chemical analysis made? I-7 Yes 0112 Vo Stan Date 09/05/22 Completed Date 11/07/22_ WELL CONSTRUCTION CERTIFICATION: I constructed and'or accept responsibility for construction of this well,and its compliance with 11 P ashington well construction standards.Materials used and the information reported above are true to my best knowledge and belief. • i Driller C.Trainee 0 PE—Print Name Jack Grande Drilling Company Davis Drilling Signature V Address 340 NE Davis Farm Rd License No.258 City,State.Zip Belfair,Wa,98528 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.DAVISDI110OA Catc 11R/22 ECY 050-I-20(Rev OS'19)/J',yuu need this document in an a hernate formal.please cull the Water Resources Progrctrn di 360-407.6.572. Persons with hearing loss can call 7/1.for Washington Relay Nervier. Persons with a.speech disability eon ru/I R77-833-6341. 9 • i i ce51_,Og t R3 - DOCD5 . 1786 SE MJe Hill Dr. Port Orchard,WA i �SPECTRA Laboratories - RECEIVED Kitsap 98366 -. Whe - - ... n•experience'natters COLIFORM BACTERIA hNrtLYSIS FORM JAN0(�� ZUL Date Sample Collected 1 Time Sample County3 Collected U 1 Z 122 d : ( `�pAl ji Pc� 615 W. Alder Street Day Year ( s Type of Water System(check only one box) �}/ ❑Group A ❑Group B Ott,er— --�—VG Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): I°# A ENVIRONMENTAL System Name: 1 ) HEALTH Contact Person: Day Phone:( ) I Cell Phone:( ) - Email: ____ Send results to:(Print full name,address and rip code a-mall) ACk_V.I .dikr,1'..ti.../._. / e 1'1 Cliknctili . —.. SAMPLE INFORMATION Sample collected by(name): Jack— Specific location where sample collected. I Special instnlr7ons or c Yemenis: WO\ k\i&JcA Type of Sample(select only one type of sample from types 1 thro,gh 5 below) 1.0 Routine Distribution Sample(MP) 2.0 Repeat•iam'.Ie(A/P) Chlorinated:Yes No (from disenbu!ion sy;tern alter unsal.routine) Chlorine Residual:Total FreeUnsatisfactory ro;dine lab number. 3.Ground Water Rule Source Sample ——--- - •——--—_ IS I I I Unsatisfactory ra.rtine collect date: 1 I ❑Triggered(A/P) Chlorinated:Yes No 0 Assessment ()VP) Chlorine Reridue:Total Free 4. Surface or GWI Raw Source Water Sample(Enumeration) ! ❑E.coli 0 Fecal Fences Yes to I S I I 5.')gSampte Collected for Information Only LA8 USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and atisfactory 0 E.coipresent 0 E.coil absent Bacterial Density Results:Total Coliform men/100m1. F_coN mDr!J100m1. Fecal Colifortn __- cfu /100m)., HPC _ . /1 ml - Replacement Sample Required: ElT4TCS__ 0Sample too old ❑ Sample Volume Damaged Container 0_ D8ti9VGcr7`LtSn—Ze-. n Recept iempC: IJJabjr0? Method Code S'A92238 or SM9222D ~Date Reported to.2OH Lab Use Only.-— DOH Lab-Sample z25- ‘...i.,,k , (f.-2,_ co,Fon 11331.319( ceit V.M,re&et o� 'R:.0 ra w,uv.,...+.dM od M,pLL(ofonh,Women,M'ul,dBOQ57iJttr"0)�7rYd 77t) F'%eMk,goxr. Spectra Labs - Kitsap, LLC (Port Orchard) SPECTRA Laboratories -Kitsap 1786 SE Mile Hill Dr. Port Orchard,WA 98366 ...Where experience matters Phone: (360)443-7845 JessicaD@spectra-lab.com www.spectra-lab.com Spectra Labs- Kitsap, LLC (Port Orchard) received samples for Davis Drilling on Thursday,November 3, 2022 at 1:12 pm. Unless otherwise noted, all samples were received in good condition and were tested in accordance with the laboratory's quality control procedures. A summary of the samples received are outlined below. Sample No. Description Location Sampled 135467-01 Bon 'e Miller Wellhead 1_02/2022 15:00 135467-02 Wilson Way Wellhead 11/02/2022 10:00 This report package contains laboratory sample results and any attachments listed below. If you have any questions please call (360) 443-7845 or email us at JessicaD@spectra-lab.com. This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at 360-443-7845 and destroy this report promptly. These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced except in full,without prior express written approval by Spectra Laboratories. 11/06/2022 Page 1 of 1 2194784 MASON CO WA 03/13/2023 01:14 PM NOTCE Iillll IIIIII I I��I I II IIIIII IIII illl IIIII IIIII III I I III��I��I\IIIIS 2 Return To 1 4 her z.Oos-!erveif ,0- -eox A1Oq 4/b( OECu� W n 983 z Grantor(s): (1) 'jilt 1.1 Dos-I-enveI d , (2) f1wies4CUD41lO (`de)5kPrfefa' Grantee(s): (1) PUBLIC Legal Description (1) LOT: 4 OF SP #2.160(R) PTN NW NE 23-21-2 S 51/203 (Abbreviated°orm:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) 02 - 7 W - ! 0 1 1 l 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: 14 Maximum Annual Average Gallons Per Day: 950 gallons Dated on this i 3 day of h-Ickr,:-ti,. , 20 5-3 Signature"of Grantor(s): ,` �, (1) , (2) ji tern 4 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 i 3ti" day of -14{tk , 20 3 , 5►►. 1Th.f: a e.ANZ • 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 and year last above written. p AM•)GALVfLLO Notary Pu c in and for the State of 1/4.4 Notary Public State of Washington residing at 401.1 5}cam+-6�:, i(, ; _ y �y�fZ Commission Number 22010456 My Commission Expires My commission expires: _ 31 03/20/2026 zA • A Page 2 of 2