HomeMy WebLinkAboutWAT2023-00127 - WAT Application - 6/7/2023 islavoi
• MASON COUNTY
COMMUNITY DEVELOPMENT RECEIVED
Permit Assistance Center,Building,Planning WATV0'o>„3-' ooV oZ
415 N 6th Street, Bldg 8, Shelton WA 98584, II In' _ 7
Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 •:• Elma: (360)482-5269'& 400r 2023
FAX(360)427-7787
Application for Determination of Water Adequacy 5 W. Alder Street
ENV'IRO�'i'��_Instructions NTAL
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. HEALTH
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: Apryia5 f4r.4aJ( Date: j ;.e 07 , 2OZ-3
Mailing Address: 40 C 1,t/,`//ey 1-n J . Phone: (.360) qq6 - JS70
Parcel Number: 3 2-00 3 -1 ( -9 00 Li/
Type of Water System �/ Reason for Application /,,
❑ Public/Community Water System (2 or more it/Building permit ibUOgo23 -- �O( 4 t
/connections) ❑ Division of land:
L Individual water source (one connection), #of Parcels? SPL
WWell 0 Boundary line adjustment
D Spring/surface water
0 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
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
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
This form may be scanned and available for public view at www.co.mason.wa.us.
J:11.H Forms\Drinking Water Revised 1/25,2018
Individual Water Well
Water well report (attached to application). Depth ? 7 ft.
/Well capacity Test (attached to application) ,S gpm s•al 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 capacity test, which provides stabilization of draw-down and recovery data, must be performed
a licensed contractor.
Satisfactory bacteriological test(attach to application). C/ 7/Zo ? Z
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planninq 14( J 15n 1bi 122n
Water use or limitation recorded N/A (�Yes )6
AFIU: 2199M
Well Drilled Date 3/6//XZJ
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 llqwing
reason(s). L�PPR
Reviewer's Signatures: J
O Vr
Environ. Health: DateW3VAZg&I °3 423
47YENviyi, d CSD Director: Date E"/A 2
DJA /HE
A(tH
RECEIVED 12.1L 0Da3 - 6062y 1
ENVIRONMENTAL
HEALTH JUN -7 2023
WATER WELL REPORT oait �td e rN yet- nt No. WE49672 y Unique Ecology Well ID Tag No.
State of Washington kimball
Type of Work Site Well Name(if more than one well):
CI cor.structioa
0 Decommission ==> Original installation NOt No. Water Right Permit/Certificate No.
Proposed Use. LIE Domestic _ Industrial 0 Municipal Property Owner Name Thomas Kimbell
Dcvvretcring C Irrigation ❑Test Well 0 Other Well Street Address 41 E Willev Ln
Construction Type: Method: City Shelton County Mason
X New well 0 Alteration 0 Driven 0 Jetted Cable Tool
r i Deepening ❑Other ❑Dug ❑Air- ❑Mud-Rotary Tax Parcel No. 3200-31-190041
Dimensions: Diameter of boring 6 in.,to 74 R Was a variance approved for this well:' 0 Yes (]No
Depth of completed well 74 at.
if yes,what was the variance for?
Construction Details: Wall
Casing Limn- Diameter From To Thickness Steel PVC Welded Thread WWM or L)EWM
1 U 6 in. +1 74 .250 in. ( j 0 i l I 0 Location(see instructions on page 2):
0 I n in _ in. ❑ I ❑ DID ne /,-'/.of the ne '/.;Section 3 Township 20n Range 3w
❑ 1 ❑ in. _ in. ❑ 1 ❑ 0 1 ❑1 Elin. ❑ 1 ❑ 0 I El Latitude(Example:47.12345)
Longitude(Example:-120.12345)
perforadrws: ❑Yes 0 No Type of perforator used Driller's Log/Construction or Decommission Procedure
No.of perforations Size of perforations in by in. Formation:Describe by color,character.size of material and structure,and the kind and
Perforated from ft.to ft below ground surface nature of the material in each layer penetrated,with at least one entry for each change of
0 K-Packer � Depth 68 IL information. Use additional sheets it necessary.
Screens: A Yes ❑No From To
Manufacturer's Name alloy Material
Type stainless Model No. Br Top soil 0 2
20 in.from 88 ft.to 74 it 2 23
Diameter 5 in. Slot size br till
Diameter in. Slot size in from n to It silt bound sand&gravels 23 60
Sand/Filter pack:C Yes ®No Size of pack material in. sand&gravels water bearing 60 74
Materials placed from ft.to ft.
Surface Seal: it]Yea u ho To what depth'? 18 ti. - -
Material used in seal bentonite chips
Did any strata contain unusable water? 0 Yes M No
Type of wate? Depth of strata
Method of sealing strata off
Pump: Manufacturer's Name frankkn Type:sub
H.P. 3/4 Pump intake depth'.64 ft. Designed flow rate: 12 gpm
Water Levels: Lend-surface elevation above mean sea level 55 ft.
Stick-up of top of well casing +1 ft.above ground surface
Static water level 3 ft.below top ut well casing Date 3-5-23
Artesian pressure lbs.per square inch Date
Artesian water is controlled by (cap,valve.etc.)
Well Tests:
Was a pumping test performed? No ❑Yes i=> by whom?
Yield ------ gpm with R drawdown after hrs.
Yield gpm with ft.drawdown after hrs.
Yield gpm with_ft drawdown after hrs.
Recovery data(time=zero when pump is tamed of-water level measured from well
top to water level)
Time Water Level Time Water Level Time Water Level
Date of pumping test -
Hailer test 15 gpm with 24 ft.drawdown after4 hrs.
Air test gpm with stem set at ft.for his. - Date
5-2-23
Artesian flow gpm -
Temperature of water "F Was a chemical analysis made? C Yes 13 No Start Date 2-23-23 Completed Date 3-6-23
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.
LC Driller D Trainee❑PE—Print Name Dwane Knapp
Drilling Compan KnappUnlhng
`,,r Address 50 E Lesaca Dr.
Signature `]�e ��-� I/'
License No.1706 City,State.Zip Shelton Wa.98584
iF TRAINEE:Sponsor's License No. Contractor's
Sponsor's Signature Registration No.KNAPPDI952B1 Date 3-9-2023
ECY 050-1-20(Rev 08/191 If you need this document in an alternate format.please call the Water Resources Program at 360-4W-61f72.
a,....,,...,.,;rh I,unr;no 1rscs ran r•all 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341.
Thurston County Environmental Health
2000 Lakeridge Dr.SW m Olympia,WA 98502
360 867-2631
TIIURSPON COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected
() /O? / 2_3 9errrn l')?a5011
ITV/J :O(/p�_OPIA
Month Day Year
Type of Water System(check only one box) I .Private Household
❑Group A ❑Group B ❑Other
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID#
System Name: i
!wt
Contact Person: CO W a^^t
Day Phone:(S 4c1 7 4 t- 9 7 4 Z Cell Phone:(
E-mail: Eve.Phone:(
Send results to:(Print full name. dress rid zip code or email address)
-1.613.-50 iftct.11
SAMPLE INFORMATION
Sample collected by(name):
Je—Iv pill((iWy
Specific location or address where sample collected: Specia instructions or comments:
ewllcP� Lti/
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 ❑Distribution System
Chlorine Residual:Total_Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total Free
❑E coli-GWR(A/P)
❑Fecal-Sutrase.Gwl.springs(numeralonl Unsatisfactory routine lab number:
Filtered:Yes No
❑Assessment Monitoring(A/P) Unsatisfactory routine collect date:
❑Other / /
S
4.CPSample 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
❑E.coli present ❑E.coli absent
o rm detected
Replacement Sample Required:
❑Sample too old(>30 hours) 0 TNTC ❑
Bacterial Density Results:Total Coliform _ _/100m1. E.coli /100m1.
Fecal Coliform _/100m1 Enterococci_ /100 ml.
Method Code: SM 9223E ❑SM 9222D Dale and Time Received(, r
❑SM 9215E ❑Enterolerl® 14'1--Z-j l2O
Date and Time Analyzed: 6 - - Z Date Reportect,-
Sample Number(DOH number plus rive digits) Lab Use Only:
0 8 0 Q.W
DP$H m N3 c(revised C��O-ti5�T) 3o 1- (c
5L2Oac3 JA9L{ l
2197994 MASON CO WA
06/07/2023 11:07 AM NOTCE
KIMBALL #187515 Rec Fee: $204.50 Pages: 2
II II.III II I II I 11111 III I IIIII IIII lIII D
Return To RE C E I
77 o si 4 s 6,/ e„,6,1/�1� ENV -7 2023
y� E �r,«Qy LA. 1FRON`4ENTA� juN
SI��1+oh 1,��.� �i Fr�Fs`( HEALTH 615 W. Alder Street
Grantor(s): (1) oni�S GJ, /C I'm h& Jl as, (2)
Grantee(s): (1) PUBLIC
Legal Description (1) PCL 1 OF BLA #07-54 PTN OF NE NE S 33/219
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 3 2 0 0 3 _ 1 1 _ 9 0 0 4 1
5 3 T 20 R 3
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:
Maximum Annual Average Gallons Per Day: q 6Q gallons
Dated on this 07 day of -37-AAetf , 20 2-3.
Signature of Grantor(s):
(1) /�/1ia��� �� t �t'c t , (2)
State of Washington )
County of Mason )
Page 1 of 2
I, the undersigned, a Notary Pub liJn and for the above named County and State, do hereby
c�ctify that on this `l7 1 day of<f i/ J( , 20,70 ,
/14e446,5 /4(rhfk,(/,_J/ 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.
TAMARA L HERRING
NOTARY PUBLIC, #41438 Notary Public n and for the to of Washington,
STATE OF WASHINGTON residing at ( 11fLi ilf )Q /1,(k'//'
COMMISSION EXPIRES
JUNE 19, 2024 My commission expires JI(f'i.( l�l -2c/
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