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HomeMy WebLinkAboutWAT2022-00162 - WAT Application - 6/13/2022 WAT - �` " ; a MASON COUNTY .I I_ COMMUNITY SERVICES 70 ZZ - 0016 Z, %;, . ,, Building,Planning,Environmental Health,Community Health 415 N 6'h Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 •: Belfair: (360)275-4467 ext 400 Elma: (360)482-5269 ext 400 FAX(360)427-7787 Application for Determination of Water AdequacyENV/RON , EN HEgLT TAL Instructions H 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: Empire Home Construction Date: 06/01/2022 Mailing Address: POB 241, Kelso, WA 98626 Phone:253-753-1530 Parcel Number: 120303190083 Type of Water System Reason for Application 'I Public/Community Water System (2 or more 0 Building permit $10112`°01S! connections) 0 Division of land: ❑ Individual water source (one connection), #of Parcels? SPL O Well 0 Boundary line adjustment ❑ Spring/surface water 0 Other(explain) ❑ Other(explain) ❑ Replacement or Remodel lease indicate name If you have more than one residence connected of water system below if el• o to this well, check the Public/Community Water signature required) iVET) System box. Part 2: Water Connection Information 61 Complete the section appropriate for the type of water connection being evaluated: AI der stye et �Public Water tSSy-stem^, p Name of Water System: M4 rl 1 �u�4 �( ivrAi e s�/l /e Water Facility Inventory(WFI) Nuiber: / (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. Date 06/01/2022 Signature of Water System Manager This form may be scanned and available for public view at www.co.mason.wa.us. Revised I/25/2018 1:\EH Forms\Drinking\�atrr Individual Water Well yWater well report (attached to application). Depth 2 l 0 ft. Well capacity Test(attached to application) 15 gpm >' 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. Satisfactory bacteriological test(attach to application). / I (15 /oi 2 Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planninq 14w] 15U 16U22(J Water use or limitation recorded N/A Yesr F- Z in606 Well Drilled Date 1//iS/C7ZZ. 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 adta sly of water indefinitely in the future,or guarantee compliance with all applicable WDOE water resour a r• .R:i s. Recommended approval indicates requirements of Sanitary Code,Title 6, Chapter 6.68.040-Determin. ,•p� Adequacy for Building Permits are satisfied. Additional Growth Management requirements may pply. 36.70A RCW. �s�'`✓CFp�.s 0 Unsatisfactory Determination: 04 20,1 Applicant's water supply does not appear adequate to meet the needs of its intended use for t44wing reason(s). o�/✓,Qi(`�`c/^ c1fr,. Reviewer's Signatures: C� / Environ. Health: Date `7 f/T7Z3 `of CSD Director: Date 7-R5 ktll 70,9 io be ieplaud b/ p6''i a►1e/1 f Cop from Do F DEPARTMENT OF Noticeof Intent No. \A E'II 6 WATER WELL REPORT MECOLOGY BPU ? Unique Ecology Well ID Tag No. Type of Work: State of Washington Site Well Name(if more than one well): O Construction O Decommission t=:> Original installation NOI No. Water Right Permit/Certificate No. ..,/) y�,� LLL Proposed Use: ❑O Domestic U Industrial ❑Municipal Property Owner Name ,Tf r �yy,„v��/ v07~I ❑Dew atcring ❑Irrigation ❑Test Well ❑Other Well Street Address 60c E -ThS rat •'ay Construction Type: Method: City Shelton County Mason O New well 0 Alteration ❑Driven U Jetted 0 Cable Tool 0 Deepening ❑Other 0 Dug I-1 Air- 0 Mud-Rotary Tax Parcel No. 120303190083 Dimensions: Diameter of boring 6 in.,to 235 n. Was a variance approved for this well? 0 Yes E No Depth of completed well 240 R. If yes,what was the variance for? Construction Details: Nall Casing Liner Diameter From To Thickness Steel PVC Welded Thread 0 WWM orl7 EWM p 1 ❑ 6 in. +1 235 1/4 in. ❑ I ❑ O I ❑ Location(see instructions on page 2): O I 0 in in. ❑ I ❑ CIO sw '/-'h of the ne /;Section 30 Township 20n Range 1w ❑ I ❑ in — in. ❑ 1 ❑ DID �/ f!9` u ❑ I ❑ in. in. ❑ 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345) l • l �I Longitude(Example:-120.12345) ---I ZZ•B55S� II Perforations: ❑Yes ❑O 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 front-ft.to ft.below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: IC Ycs ❑No 0 K-Packer b Depth 233 ft. information. Use additional sheets if nccessuy. Manufacturer's Name alloy Material From To Type stainless Model No. sandy loam 0 3 Diameter 5 in. Slot size 12 in.front 235 ft.to 240 ft. brown brown sa saill 3 3 8 Diameter in. Slot size in.from ft.to ft. 18 178 brown sand w/occasional gravels Sand/Filter pack:CI Yes Ll No Size of pack material in. fine to med sand brown water bearing 178 240 Materials placed from ft.to ft. Surface Seal: ❑Yes U No To what depth'? 19 ft. Material mused in seal bentonite chips Did any strata contain unusable water? U Ycs t.J No Type of water? Depth of strata Method of sealing strata off Pump: Manufacturer's Name qoulds Type: sub H.P. 2 Pump intake depth:225 ft. Designed flow rate: 18 gpm Water Levels: Land-surface elevation above mean sea level_11. Stick-up of top of well casing ft.above ground surface Static water level 170 ft.below top of well casing Date Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.)Well Tests: Was a pumping test performed? t No ❑Yes b by whom? Yield gpm with_ft.drawdown after hrs. Yield gpm with_ _ft.drawdown after hrs. Yield gpm with ft.drawdown after hrs. Recovery data(time-zero when pinup is turned off—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 111 n.drawdown after4 hrs. Air test _gpm with stem set at ft.for hrs. Date Artesian flow_gpm Temperature of water 'F Was a chemical analysis made? 0 Yes g No Start Date 10-12-2022 Completed Date 11-18-2022 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. CI Driller 0 Trainee❑ PE—Print Name Drilling Company KNAPP DRILLING INC. Signature Z7t alf-4- A'n' Address 50 east lesasca Dr. License No. 1706 %% �� City,State,Zip Shelton Wa.98584 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.KNAPPBI952B1 Date 11/1512022 ECY 050-I-20(Rev 08/19)If you need this document in an alternate format,please call the Water Resources Program at 360--107-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. CENTRIC 1786 SE Mile Hill Drive 1111�•. ! . rF a.lr�i `!�/ Port Orchard,WA 98366 .-� ; '.,1r r- - LABORATORIES w�vw.centncanalytical.com - `--. " ��:"�. '``_ COLIFORM BACTERIA ANALYSIS FORMlooliiio - :"���,��' s Date Sample Collected Time Sample I County s N.,.. "�• •i"` - Collected Y-. �' 1 ...... j. Month Day Year DP AI ��5C/� .1..Yrti ...t' .,„.r Iiiikie :. . Type of Water System(check only one bon) f `,''5 •,'�•_,j'. sotto ;- ` ❑Group A El Group 6 Other Pr, V a,i\ S-'"3i:�:�-~- `•- Group A and Group 8 Systems-Provide from Water Facilities Inventory(WA): "•. ;` .. � 410IFF. +^S-; ID# • x. ` �.a, �`_�... System Name: U va // - /✓evUr p ` _. • �fr ` 1.�.•t�� Contact Person: 1. 1n e Lna pj7 `•`�..;-* ., �. s•,- ~f'-; '1. Day Phone: 3u0 val-•704- ,.i _ y r ,._ �.� •,. '_� Cell Phone: :.. -.. •� �r ^., �''� Email: (1Gl.p fflfl lti►�j?.C t'rtRi1.(. Eva.Phone: •- .` _ ..,r-u-, '.. q',._r.�:. Se restdts tr Print f full name,Wpm aad bpe-rna) .i`•..5 :�_ �,I.. �.. � �-v'� • �•_. E• L-_sat. r ,'r _�1 1 1 cx •s:+y ._>.. �'-` E �...�'..-.~'....•�.....J, r .,S N.•t,, i�. ll t SAMPLE INFORMATION '- ys�.,`:r = •._.-.:, r • _''$-._^t—. r Sample collected by(name): /� ` 1-- - - } - 04Oar) e ij f r� •• ,.•, Specific location where sample collected: Special instructions or comments: Coliform Distribution System itiVerAoiclLJPp Sampling Procedure Type of Sample(check only one box) Step One Step Four 1.❑ Routine Dist7ibution Sample 2 Repeat Sample(after upset routine) Avoid poor sample sites such as There may be some liquid or Chlorinated:Yes ❑ No El ❑ swivel faucets,hot and cold mixing powder in the sample bottle to Disb;bution System faucets(with a single lev-er);leaky or remove chlorine_Do not rinse it Chlorine Residual:Total Free Unsatisfactory routine tab number. spraying faucets,drinking out. 3.Source Ground Water Rule Sample - ———_- fountains,janitorial sinks,frost-free Step Five I S I I I Unsatisfactory routine collect date: hose bibs,and faucets below or near To avoid eontatninationtiehile 1 / groundleveL taking the sample,hold the bottle El Triggered Chlorinated:Yes U No 1-1Step Two near the bottom with onehand and 0Ass'mment Chlorine Residual.Total_Free Remove anyattaehments from the hold the top of the cap with the faucet,including aerators,screens, other.Now unscrew the cap. II 4. EnumeratinSutureWverSample IsI I I was hers,hosesandwaterflters.Ift JEco6 OFecat-s.,a�,wrtsrn,=r aeaave�❑ a❑ you choose to disinfect the sample DONOT set the cap down,touch an part that touches the 5.0! Sample Colecedfor Information only. Gam,5 y r(r441 rstn site prior to sample collection,be any P Y sure to flush thoroughly to remove bottle or let anything touc .the rim l LAB USE ONLY DRINKING WATER RESULTS LAB . E ONLY all disinfectant. of the bottle or inside the cap, a Unsatisfactory Total Carom Present and tisfactory ., fy '- Step Six Ir-=1Ecoipresent ❑Ecolabsent ,-1 �s'7..x ,4:-'* H old thebottle under the stream of Replacement Sample Required: • water,be careful not to letthe bottle CI Sample too old(>30 hours) ❑TNTC C - - it- . touch the sample tap.Fill thebottle - . - to the indicated fill line,do not allow Bacterial Density Results:Total Coliform 1100m1. E.coS 1100ml. it to overflow.Remove the bottle •Fecal Coliform _ 1100m1. HPC /1 ml. ' . from thewaterflowand secure the Lab ID.Num -- Sr ry UY r`n f / Step Three gyp' bq Ur`t�0Turn on the coldwateronlyand Step Seven let itrun with asteadystreamfor Complete the lab slip.Note anything Method Code: Date and Time Incubated: at least five minutes.Before �M 9223 B NOV j L, 20.J7 unusualaboutthesamplecollection. collecting the sample,turn the DateAnayzed: Data Reported. water down toathin stream and Step Eight AV 1 2022 ,�(1Y n let the water run for one minute. Secure the lab slip to the bottle with DOH I ab.Sampreb Lab Use Only: If they system is chlorinated, rubberhand.Deliver the sample to 225 ((LA measure the free chlorine and note Centric Analytical Labs as soon as k themeasurementonthelabslip. possible. DOH For'IJ7us1,rho'. S)-rtaaneedtiepbketion In en M.O.forme col 2m.525.0177 neDmY col 711) ris ercl ether pgkifae we we7eb4 tlinw.dch•agwtlrikoierc n. 2199606 MASON CO WA 07/17/2023 12.03 PM NOTCE EMPIRE #188809 Rec Fee: $204.50 Pages: 2 IIII III III III DII IIII I III II IIII I I IIIII II II IIII I I I III 1111 Return To Fltkr; �G l�r�� C LI,E Qb �c>>< 2.L( �c\sue) klA Grantor(s): (1) Er ',-c-c., u.,n.a., nsa-c k - L", (2) Grantee(s): (1) PUBLIC Legal Description (1) L o r 3 0$ 5? gcG Q-T N T . ' S 2 !1 y I (Abbreviated form: i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1) 1 2. b 3 6 - 3 ) - `f 0 G $ 2_ 1 9 G SLi 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: 19 Maximum Annual Average Gallons Per Day: 15 © gallons Dated on this f 3 � day of :, `'1 , 20 2-3. Signature of Grantor(s): (1) �� ' .wj/ 1 , (2) State of Washington ) County of 4423904. ,o4'II 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 13* day of Su ly , 20 , atfi . btkVatt Mambo/ 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 r last ab e w i n. DEENA L DOLBEY Notary Public in and for tha State of Washington, NOTARY PUBLIC residing at -LnjvieW STATE OF WASHINGTON Mycommission expires: t dIaCJ COMMISSION NUMBER 74363 p COMMISSION EXPIRES OCT.25,2023 Page 2 of 2