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Home My WebLink AboutWAT2023-00119 - WAT Application - 5/30/2023 . RECEIVED MAY 30 2023 WAT 2i292 - 0011g 615 W. Alder Street 415 N.6th Street �, MASON COUNTY Shelton,WA 98584 (( ter' . F =i COMMUNITY SERVICES Shelton:360-427-9670,Ext.400 1 Belfair.360-275-4467,Ext.400 Building,Planning,Envirarmental 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: )tur— j2 m l-ES4•1 ` L-� Date: q/K//2-4?-17-3 Mailing Address: 2.627 km(( (' E Phone: 3`Z - Parcel Number: '32(3 2(- 5O- O&1 Type of Water System Reason for Application 4R' Public/Community Water System (2 or more Building permit "?'I 4 2O2.3- W5' connections) 0 Division of land: O Individual water source (one connection), #of Parcels? SPL ❑ Well 0 Boundary line adjustment ❑ Spring/surface water 0 Other(explain) O 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. v,p .fin —0000 `t Part 2: Water Connection Information Complete the section appropriate for the type of water connection being evaluated: l� Public Water System Name of Water System: (T6ii'ki lR 1AJ 1, C1�f c s f( v Water Facility Inventory (WFI) Number: 1/L2 vtL. (write"none" for two-party) lg I am the manager 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 Zi" 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 I Phone 23RF 4(57'1 Signature of Water System Manager �— Date 40// L3 This form may be scanned and available for public view at www.co.mason.wa.us. Forms\Drinking Water Revised 4/27/2021 Individual Water Well ,1c Water well report (attached to application). Depth (/`t\ ft. R Well capacity Test(attached to application) 17_. gpm 7 '00 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/planninq 14 15_16_22_ Water use or limitation recorded N/A YeesX �, � Well Drilled Date JV Kt-i CW (tiflt1 c�.1 h,„AJ Individual Spring/Surface Water D 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) ‘'tSatisfactory 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\Q > Date 6 (/2O(v This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 • Vanguard Laboratory 2635 Parkmont Lane SW s'•' Olympia,WA 98502 360.967.7010 VANGUARD Report of Laboratory Analysis LABORATORY' Collected by: Hawkins Well Inspections Matrix Drinking Water 360-401-5353 Laboratory ID: V230112-4 Sampling Address: Date Sampled: 1/12/23 13:00 Date Received: 1/12/23 16:25 2111 SE Walker Park Rd Shelton.WA 98584 Date Reported: 1/16/2023 Sample ID: 2111 SE Walker Park Rd Analysis Result SURI, N1CL Units 1)1' Date Analyzed Total Coliform& E.coli by SMl 9223B(IDEXX) Batch 1D:V230112-4 Analyst:V.I Coll form,Total Negative I 1 MPN/I00 mL 1 1/12/23 17:00 1:.coli Negative I I MPNII00 ml.. I 1/1223 17:00 Nitrate by EPA Method 353.2 Batch ID:V230112-4 Analyst:RS Nitrate(as N) ND 0.50 10.00 1118/1-- 1 1/14/23 10:00 Notes: MPN:Most Probable Number ppm:parts per million nd non-detect Reviewed by Robert Smalling,Chemist on 01/16/2023 n/a:not applicable SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 01/16/2023 DF:Dilution Factor :•= 1702512017 l r Lottaaroar Page 1 of I MCL Maximum Contaminant Level wr•- 4e0lktormo Samples were reeteved in acceptable condition.The result(s)in this report relate only to the portion of the sample(s)tested.All analyses were perforated consistent with the Quality Assurance program of Vanguard Laboratory.Please contact the laboratory if you should have any questions about the results 2635 Parkmont Ln SW,Suite A,Olympia WA 98502 i Office:360.967.7010!testing@vanguardlabtratory.com Printed From ivlason COUrii tt latxtratory.cont Printed from Mason County DMS • 2197658 MASON CO WA 05/30/2023 09:50 AM NOTCE BRAD ROHE R107260 ROC Fse. S204.50 Pagas. 2 Return To Iif11IIIilfli 1111111iNl111I UII11111111111$111111111E111111 tOgd-) Grantor(s): (1) DrAd 20 he.... , (2) Grantee(s): (1) PUBLIC Legal Description (1) Uhtt ' �l�.,�_�4dd-pea_: 8 - 5 ( -3 (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) 3 2_, D Z I -S - S , 0 P I 52( -- T20 - g3 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 Li Maximum Annual Average Gallons Per Day: /10 gallons Dated on this 36 day of y , 20 23 Signature of Gra to s): (1) ; , (2) State of Washington ) County of Mason ) I 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 3(2 day of , 20 22 , t�t ac y i?c w- 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. °P4 ,N ,(-‹'°, Notary Public in and for the State of Washington, c? NOTARY �Q,�; residing at J �Zsr lnD YaQtzsr-Dk 4-1 21009497 = My commission expires: ) _)36 ) 2.C3 s cc PUBLIC ''•.�F • Page 2 of 2