HomeMy WebLinkAboutWAT2023-00112 - WAT Application - 5/17/2023 r -.
':VIRONMENT' , • WAT �a — oo}� o�
MASON COUNTY
HEALTH COMMUNITY sERvicEs RECEIVED
Sulking
Planning EnvironmentalwrF Health
Heal&Caran H a
415 N 6"Street.Bldg 8.Shelton WA 98584.
Shelton i;360?427.9670 ext 400 •> Belfair.(360)275-4467 ext 400 0 Erna (360)482-5269 ext 400 MAY 1 7 2023
FAX(360)427-7787
Application for Determination of Water Adequacy 615 W. Alder Street
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 FUTURE HOME SERVICES Date:
Mailing Address: PO BOX 2503 GIG HARBOR,WA 96335 Phone: 360-900"9777
Parcel Number 22004-75-00181 k/'ifil 2 ZOO55500 001
Type of Water System Reason for Application CI Public/Community Water System(2 or more CIBuilding permit Vt.QA9V a —DC 55 9
connections) ❑ Division of land:
li 0 Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ 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 8 applicable—no
to this well,check the Public/Community Water signature required)
System box. W eft 2,�Q ��Q Q c" ,c-
Part 2: Water Connection Information ��CJ
Complete the section appropriate for the type of water connection being evaluated
Public Water System
Name of Water System.
Water Facility Inventory(WFI)Number (l)op
(write'none`for two-party)
E'1 I am the manager of thi water system.The water system has been approved for)_services.
There are presently eY, connection(s)in use.This will be the JQS-'i— 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
Signature of Water System Manager L .4— PC Date .5 11 ao 3
This form may be scanned and available for public view at www.co.mason.wa,tis.
1'Ell Form,Dr inking Water RCN ixJ i'_5,2it18
�- .14
. .
Individual Water Well
❑ Water well report(attached to application). Depth ` It Z. ft.
CI Well capacity Test (attached to application) 70 gpm 7 Oc 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.
0 Satisfactory bacteriological test(attach to application). -77(0/ZO
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planninq 1 PA 15U 16=22=
Water use or limitation recorded N/Al YesPnl/FiV2?C0785
0
Well Drilled . . ... Date P(15/2c/Z_
Individual Spring/Surface Water
❑ WDOE permit (attach to application)
O 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)
ySatisfactory 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
36.70ARCW. APPROVED
❑ Unsatisfactory Determination: APPROVED
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s). AUG 0 7 2023
MASON COUNTY ENVIRONMENTAL HEALTH
Reviewer's Signatures: 1
Environ. Health: Date
'`°'2
CSD Director: Date
s . 1.44.
2200386 MASON CO WA
09/03/2023 10:47 AM NOTCE
CURTIS LANGSTON 4189428 Rea Fee. $204.50 Pages: 2
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CURTIS & DFSIREF LAN.GST D°
1773 McCOMB MILL RD
10501 41--351 AUG 0 4?023
RECE7 frED
Grantor(s): (1) DARLENE PARENT , (2) ARTHUR PARENT
(3) DESIREE LANGSTON , (4) CURTIS LANGSTON
Grantee(s): (1) PUBLIC
Legal Description (1) SECTION 5, TOWNSHIP 20N, RANGE 4k)
_ Sviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 2 2 0 0 4 7 .5 0 D 1 8 1
NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM
I (We)the undersigned grantor(s), certify that the water source located on the above-described
real estate under Legal Description (1) and Assessors Tax Parcel (1) situated in Mason
County, State of Washington, has been designated to serve a source of water to the following
parcels situated in Mason County, State of Washington; herein described:
Tax Parcel: (Connection 1) 2 2 0 0 5 5 .5 0 D 0 0 1
Tax Parcel: (Connection 2) 2 2 0 0 4 7.5 0 0 1 8 1
The system owner is responsible for keeping this system in compliance.
The name of the water system is: PARENT-LANGSTON WATER SYSTEM
This system is designed to provide for two service connections. Planning and design approvals
must be obtained from the department prior to expanding beyond this number of services.
Additionally, a water right, obtained from the Department of Ecology, is required if the water
system exceeds exemption standards.
This system (has/has not) been granted one or more waivers from specific provisions of the
regulations.
Dated on this 2-„1 day of u L `7 , 20 2-3
Page 1 of 2
Signature o Grantor(s):
.\,,c_tAGI t .-..}41AC---'-)
(1) du-f 6,IM)) , (2) i4 10
(a) • o-v. t a-- , (4)/./i, 1'
State of Washington
County of Mason )
I, the undersigned, a Notary Public in and for the above named County and State, do
hereby certify that on this 3r0C dayRf f , 2O2 ? ,
17a--ten.-P64 l-0t , k h�'-r t're personally appeared before me 4 o is
known to be signer of the above instrument, and acknowledged that he (she)oggpsigned
it. GIVEN under my hand and official seal the day and year last above written.
T M WHITAKER .
NOTARY PUBLICA161655 Notary Public in and for the State of Washington,
STATE OF WASHINGTON residing at rer{-OY hafr-0(
COMMISSION EXPIRES My commission expires: DV y()-.0--t(
SEPTEMBER 24,2024
State of Alai) a
County of ..?4., it -
t 10,6 L-t4 l(L.S 174,4 C , Notary Public, hereby certify that Curtis Langston and
Desiree Langston, whdsc names ire signed to the foregoing conveyance, and who are known
to me, acknowledged before me on this day that, being informed of the contents of this
conveyance, they executed the same voluntarily on the da c ame bears date.
Given under my hand this day Qf � 2023
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2200385 MASON CO WA
0B/03/2023 10:47 PM NOTCE
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CURTIS LANC-1STON
7773 McCOMBS MILL RD AUG 0 4?013
PINSON, AL 35126 RECE/vED
I
Grantor(s): (1) CURTIS LANGSTON , (2) DESIREE LANGSTON
Grantee(s): (1) PUBLIC
Legal Description (1) SECTION 5, TOWNSHIP 20N, RANGE 2W
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 2 2 0 0 4 7.5 0 _0 1 8 1
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 2—I day of -31l L y , 20
Signature of Gra tor(s):
1 , (2) dCoNtcr---.
Page 1 of 2
State of Ala ma
County of
T y1��t /f' i i"7( , Notary Public, hereby certify that Curtis Langston and
esiree Lanston,wh6se namcare signed to the foregoing conveyance, and who are known
to me, acknowledged before me on this day that, being informed of the contents of this
conveyance, they executed the same voluntarily on the day the same bears date.
Giv - . u der my hand this I day o-;`_�, 2023 0,,•,,��,'"i,,.••.,••
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Page 2 of 2
Thurston County Environmental Health
2000 Lakeridge Dr.SW t Olympia,WA 98502
360 867-2631 Ith7
THURS ON COUNTY
®=111® COLIFORM BACTERIA ANALYSIS AUG O 4 24?3
/
Date Sample Collected Time Sample County
' Collected REDE�/O ' 23FM vED
� PM 11MonU Day Year (I`C I1
Type of Water System(check only one box) 721rtiousehold
❑Group A ❑Group B *Other:.Pa .
Group A and Group B Systems—Provide from Water Facilities Inventory(W
ID# •
System Name:
Contact Person:Co L,a. ,5Ea%1
Day Phone:(),,iet) (og/.. 5 ' Cell Phone:C.4,305)g/5 61
c.mail.0{^rc�/1S 56,4 V.,(a),/31G!'y,ce",e.Phone:( )
Sepl results to:(Print lull name,address a1d zip code or email address)
so•L I .,btu 100 337,26
SAMPLE INFORMATION
Sample collected by(name):
CC7 K Cf e1a1Qn5
Specific location or address where sample collected: Special instructions or comments:
�3 I E n w,rl�tiu.6/1•J.
5/?.)(4-0-k1 Wc. `sceY
Type of Sample(must check only one box of#1 through#4 listed below)
1.KRoutine 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.cola—GWR(AIP)
❑Fecal—Surface.GPIs.springs(numeration) Unsatisfactory routine lab number:
Filtered:Yes No
❑Assessment Monitoring(A/P) Unsatisfactory routine collect dale:
❑Other I I
4.0 Sample Collected for Information Only
Investigative Construction/Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Satisfactory
❑E.coli present ❑E.coli absent Vc olifonn detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑ _
Bacterial Density Results:Total Coliform /100m1. E.coli 1100m1.
Fecal Coliform /100m1 Enterococci 1100 ml.
Method Code'M 9223B ❑SM 9222D Date and Time Received:
0SM 9215 ❑Enterolert0 -(C' I I to;
Date and Time Analyzed: 'L V ` 7, Date Reported: 1 t,'t 3 4
Sample Number(DOH number plus live digits) Lab Use Only:
0 8 0 3 [ v ( + _ j�
11331.3 I O 01116) 5\ lto1 V
Mile CURRENT V 76 7l, P
• °'� WATER WELL REPORT
Original&IM copy-Ecology,2e°copy-owner,3r°copy-driller Notice of Intent No.W 308010
DEPARTMENT Or
ECOLOGY, Construction/Decommission("x"in circle) Unique Ecology Well ID Tag No.BAR 156
WIN el® Construction Water Right Permit No.
❑ Decommission ORIGINAL INSTALLATION
Notice of Intent Number Property Owner Name Tony Parent
i PROPOSED USE: ® Domestic 0 Industrial 0 Municipal Well Street Address 191 Whilchar Blvd.
0 DeWater 0 Irrigation 0 Test Well 0 Other
City Shelton County Mason
TYPE OF WORK: Owner's number of well(if more than one)2
® New well 0 Reconditioned Method:0 Dug 0 Bored 0 Driven Location ne1/4-1/4 ne1/4 Sec 05 Twn 20r1 R 02w EwM 0
❑ Deepened El Cable 0 Rotary 0 Jetted (s,t,r Still REQUIRED) or
DIMENSIONS: Diameter of well 6 inches,drilledl42 ft. WWM
Depth of completed well 142 ft.
CONSTRUCTION DETAILS Lat/Long Lat Deg Lat Min/Sec \
Casing ® Welded 6- Diam.from +1.5 ft.to 137 ft. Long Deg Long Min/Sec
Installed: 0 Liner installed " Diem.from ft.to ft. Tax Parcel No. (Required)22005-55-00001
❑ Threaded - Diam.From _ft.to ft.
Perforations: 0 Yes El No
CONSTRUCTION OR DECOMMISSION PROCEDURE
Type of perforator used Formation:Describe by color,character,size of material and structure,and the kind and
SIZE of perfs in.by in.and no.of perfs from ft to_ft nature of the material in each stratum penetrated,with at least one enny for each change
Screens: ® Yes 0 No of information. (USE ADDITIONAL SHEETS IF NECESSARY.)
® K-Pac Location 135
MATERIAL FROM TO
Manufacturer's Name johnson
top soil 0 2
Type stainless steel Model No. br till 2 43
Dian.5Slot size 20 from 137 ft.to 142 ft grey till 43 58
Dram. Slot size from ft.to ft.
silty sand&
Gravel/Filter packed: ❑ Yes ® No Size of gravel/sand gravel n 5890
Materials placed from ft to ft. mad sand waterr bearing
bring 90 1142
Surface Seal: ® Yes 0 No To what depth?J 9.5ft.
Material used in seal bentonite chips
Did any strata contain unusable water? ❑ Yes ® No
Typo of wate? Depth of strata
1
Method of sealing strata off
PUMP: Manufacturer's Name Goulds
Type:Sub H.P. 1.5
WATER LEVELS: Land-surface elevation above mean sea level ft.
Static level 2?R below top of well Date 9-16-2012
Artesian pressure lbs.per square inch Date . u It t., L jj t' ''+,' I
Artesian water is controlled by (cap,valve,etc.)
w WELL TESTS: Drawdown is amount water level is lowered below static level n r r n I "..._
I - • v i. CUI[
Was a pump test made? 0 Yes ® No If yes,by whom?
Yield: gal./min.with drawdown after hrs. WAtP►Rc�. _:
R drawdown
r .gram
Yield: gal./min.with ft.drawdown after hrs. DeDarfmont,.s rry.
vwgr
Yield: gal/min.with ft drawdown after hrs.
Recovery data(time taken as zero when pup turned oft)(water level n.casvredfrovr
well top to water level) —
Time _ Water Level Tune Water Level Time Water Level
Date of test
• Bailer test 2Q galimin.with 12R drawdown after 4hrs.
Airiest gal/min.with stem set at ft for hrs.
Artesian flow g.p.m. Date Start Date 9-06-2012 Completed Date 9-15-2012
Temperature of water Was a chemical analysis made? 0 Yes ® No
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.
®Driller❑Engineer❑Trainee Name(tit)Dwane Knapp Drilling Company KNAPP DRILLING INC.
Driller/Engineer/frainee Signature� ...... t C .e .s p Address 50 E Lesaca Dr.
Driller or trainee License No. 1706 City,State,Zip Sheton , Wa., 98584
IF TRAINEE:Driller's License No: Contractor's
Driller's Signature: Registration No. KWiPPDI952B1 Date 9=26-2012
ECY 050-1-20(Rev 02/10) If you need this document in an alternate format.please call the Water Resources Program at 360-407-6872.
Persons with hearing loss can call 7/I for Washington Relay Service. Persons with a speech disability can call 877-833-6341.