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Home My WebLink AboutWAT2023-00169 - WAT Application - 7/17/2023 WAT & ) - bdk (09 R E C E I\/E D 415 N.6'h Street ` MASON COUNTY Shelton,WA 98584 1.;,11111" COMMUNITY SERVICES juL 1 7 2023 Shelton: 0 elfair.360-275-4467 Ext.400 Building,Planning,Erwironmental Health,Community Health Elma: 360-482-5269,Ext.400 615 W. Alder Street 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. ENVIRONMENTAL Part 1: Applicant/ Parcel Identification HEALTH Name on Applicant: Vince Villeneuve Date: Mailing Address: 4465 Golden West Ct Gig Harbor,WA 98335 Phone: 360.862.3055 Parcel Number: 122162400040 Type of Water System Reason for Application ® Public/Community Water System (2 or more in Building permit e2L0a0 "-ObW7 connections) ❑ Division of land: ❑ Individual water source (one connection), #of Parcels? SPL ❑ Well 0 Boundary line adjustment O Spring/surface water 0 Other(explain) 121 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: Villeneuve Well Water Facility Inventory (WFI) Number: none (write "none" for two-party) ® I am the manager of this water system. The water system has been approved for 2 services. There are presently 1 connection(s) in use. This will be the 2nd connection. O 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 Vince Villeneuve Phone 360.862.3055 Vince Vt!.8uve, Date 4'I1-24L3 Signature of Water System Manager,...„,,.,,,,..,w.>,N>,,:.: 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 `i❑ Water well report (attached to application). Depth ft. El Well capacity Test (attached to application) 15 gpm > $OO 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. EN Satisfactory bacteriological test(attach to application). iil/'/zO z3 Water Resource Inventory Area (WRIA) Development within which WRIA http://qis.co.mason.wa.us/planninq 14_ 15 X 16 22 Water use or limitation recorded N/A Yes x oprzi??ori( Well Drilled kiq Date Individual Spring/Surface Water O 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) 21 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 6.68.04 D termination of Adequacy for Building Permits are satisfied. Additional Growth Management requiremen+l Chapter 36.70A RCW. Unsatisfactory Determination: ®11, 40 Applicant's water supply does not appear adequate to meet the needs of its intend use for tt4/fpll ng reason(s). gS0NC �v2� COON,,, U23 ry Reviewer's Signatures: %�N''vFNTg4 Environ. Health: Date gl?7(29Z 5 NFqhTy This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 M �'" \ ....••..• ..•- .�.�.._..e _ 1 1 26276 Twelve Trees Ln NW Ste.0 �A SPECTRA Laboratories- Kitsup Poulsbo,WA —When rrwerrers o(D14 98370' l--� ��^ (36o)779-514t COLIFORM BACTERIA ANALYSIS FORM �i`, Deb Semple CcAected Time Sample County �( fl iaN•3 ;,.: ma / Collected +' We De/ Vox 2 l p —2q _ \J�-r1.J `(4 O Type of Water System(check only one bar) 0 Group A 0 Groot)B aletfiertlfde Group A end Group B Systems-Provide torn Water Fadtoes Inventory(WI): IOk __ • RECEIVED SyatemName. 10 6K(AP4 3o? e.ttar.� Contact Person:Lot 5 7 2023 Day Phone /,o, O1 1 v7 Cell Rime: • J'1 U� Email: Eve.Phone: Street tetr� tW,.... ,,.Q�� ..�,l 61 5 W. Alder *L2AT1/4-, , criK SAMPLE INFORMATION.- .. - ENVIRONMENTAL Sample collected by(name): 2720v.rt-3 et_ • HEALTH Specific bacon w lle here sample coaad: Special Instructlons or comments: a ( ciX Type of Sample(died only one box) . 1.❑Routine Distribution Sample(A/P) 2.❑Repeat Sample IMP) Chlometed Yee 0 No❑ (tom asatt ulon system Aar uresal rouble) reatefaday rouble lab number. Chlorine Rresiduet Total Free 3.Ground Wailer Rule Source Sample ——— I S I I I Unsatisfactory rorirte collect date: _J I Chlorinated:Yes No ❑Triggered (A/P) Chlorine Residual:Total Free ❑Assescment(AR) 4.Surface or GWI Raw Source Water Sample(Enumeraficn) I S I I I ❑ E cod 0 Fecal -dared Yes PbT 9..ZSnmple Co.erted la Information Only: LAB'' USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Toth Coafam Present and �tactory 0 E.coe present 0 E.eol absent j Bacterial Density Results:Total Colton mprJ100m1.E.cod mpn/100m1. Fecal Coldorm cful100m1. FWC cru/1m1. Replacement Sample Required: ❑TNTC 0 Sample too old _ El Sample Volume Et Damaged Container 0 r j1t 1RYl1I 1rr� li [; lJ l5 0+ lab Rs'renee Nwnbsr i c rin II tfS 7,24, >. -0 / i; F„:i 2 5 2023 Pace f Temp C: ranwe rK OT COI TI SM9Y120 111r 11.1 n.li.lYYwiaL�4 ser er r.rwenr r.�r Y r 1 'a ilk/ ee.w.YWwel M�ue,grp1.1 We eee�. yI, Waal�rM..ra.bt.l+rIrronr ri w,;kw re*ore emir bonellil*alLaniNM1 ad B!_'•`-•.-....� DOH LAD-tiara i• -fa i ilmi./. 010- 03?0 I Thormel whim-a le aellnY.e area M.wp.ry.. noloolly se Wm..,MY Roe Id ar be worse woo Y 14.Mi Pry WON WIN*Pe.*M*die Weida coH ran ww3l.tle rr.e•..enn Printed From Mason County DMS Printed from Mason County DMS ► Spectra Labs - Kitsap, LLC (Poulsbo) SPECTRA Laboratories - Kitsap 26276 Twelve Trees Ln NW Ste. C ...Where experience inatterJ Poulsbo, WA 98370 Phone: (360)779-5141 www.spectra-lab.com Spectra Labs - Kitsap, LLC (Poulsbo) received samples for Davis Pumps on Tuesday, April 18, 2023 at 11:45 am. 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 226037-01 2610 SRWA 302 Source 04/17/2023 12:46 This report package contains laboratory sample results and any attachments listed below. If you have any questions please call (360)779-5141 or email us at www.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. Printer!1/21,0m Mason County DMS Page 1 of 1 Printed from Mason r u Intv DMS L-O 9 -D 7 Vath gPw, , Inc. 340 WE'Davis?aim?id ?lair,'Wa 98528 (360)801-6107 RECEIVED Project 2610 st rt 302 Belfair JUL 1 7 2023 Capacity Test TAG:NA 615 W. Alder Street Date 4/17/2023 Pump 1/2 hp 115v Well Depth +34 -unknown EN 1 v 1 tC N M EN T/1 L Static Water Level 11.6 HEALTH �'1 Draw Down Recovery Time Water Level GPM Time Water Lever 0 min 11.6 0 0 32.7 5 min 31.2 15 1 min 21.9 10 min 32.7 15 2 17.8 15 min 32.7 15 3 15.5 30 min 32.7 15 4 13.8 1 hr 32.7 15 5 12.9 2 hr 32.7 15 10 11.6 3 hr 32.7 15 15 4 hr 32.7 15 20 Capacity Notes: Well likely subject to tidal fluctuations. Depth measurement unable to be taken due to pump obstructions. 81 gal tank on system waterlogged. Printed From Mason County DMS Printed from Mason County DMS OLOadgc,- cogo7 2197014 MASON CO WA 05/11/2023 11:34 AM NOTCE II�I I li III i i bll ite Illu rill N.111111�IUS 2 Return To �V VI RO N IU1 E NTAL DAVE RO DErsok1 M A sotJ CQur�Y H EAC1 D EP1; HEALTH FRb rr D FSK O 0 RECEIVED JUL 17 2023 �� 615 W. Alder Street �I�C6 1/� U4 rantor(a): (1) V , (2) Grantee(s): (1)PUBLIC r� Legal Description (1) 7R T OF GOVT.I L-OT vZ t OF NW via form:Le. lot, block,plat or section, township,range) Assessor's Tax Parcel: ( _LOa - 400 - O 4 Q —— TITLE NOT! OF WATER RESOURCE INVENTORY AREA (WRIA) I (We),the and j•`•net- s), hereby place this notice on record that the described real estate situated ri Mason•ounty, State of Washington is subject to water use restrictions and 1.conditions •1 Rig:•_ on State Senate Bill 6091 and Mason County Code 6.68. These restrictio 4'a •!►••d Lions are based on location of property and/or Water Resource lnven •-'' Ar:L or .;-IA. iXji .Ztt4i. Annual Average Gallons Per Day: !o2 0 gallons Dat.^ on this / / day of r►' 1 , 20 Z 3 . �/ nature rantor(s): (1) J /-" , (2) State of Washington ) County of Mason ) Page 1 of 2 I,the undersigned, a Notary Public in and for the above named unty and State,do hereby certify that on this 11�`' day of MI , 20 Z U V\ `\tht.\►.i<- personally appe• :• • - •reeve, who is known to be signer of the above instrument, and acknowledged th: -) (they) signed it. GIVEN under my hand and official seal the day and y •above written. d) t Van and for the S fr.I of Washington, arled i resid' a Tt.(.°wAc. 1Vc.crowS C ll=0 MY 0011111111011f !i My mission expires: deb�.Nr/ ti Zoe 1111110VAIRY 2W? Page 2 of 2 2197014 Page 2 of 2 05/11/2023 11:34:42 AM Mason County, WA