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Home My WebLink AboutWAT2023-00207 - WAT Application - 8/7/2023 • WAT,34t-3 - 041-07 • MASON COUNTY i' " COMMUNITY SERVICES Building,Planning,Environmental Health,Community Health 415 N 6th 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 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: Robert Flath Date: 8/7/23 Mailing Address: 113 E Terrace Dr Belfair, WA Phone: 360-277-7206 Parcel Number: 32134-31-00050 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more i;f/ Building permit BLD —o0144 connections) 0 Division of land: Ey Individual water source (one connection), #of Parcels? SPL Well 0 Boundary line adjustment 0 Spring/surface water 0 Other(explain) ❑ 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) 0 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. 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 Date This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Re\ised 1/25/2018 Individual Water Well ❑ Water well report(attached to application). Depth 66 ft, Well capacity Test(attached to application) 7/0 gpm 7 t 0 0 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. 47 Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planninq 14171 15L.J 160 22= Water use or limitation recorded............ . N/A Yesr 71-1 Well Drilled Date N/A 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) lSatisfactory 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. (C\V") Date hc((2i CSD Director: Date Arcadia Drilling Inc. P.O. Box 1790 Shelton, WA. 98584 Customer: Prime Location and Solutions Well Tag #: no tag Phone: (360) 277-7206 Depth: 66' Well Site Address: 1161 E Mason Lake Rd., Shelton Pump Set: 60' Date of Test: 7/24/2023 Static 45.8 TIME LEVEL GPM RECOVERY 1 Min 46.1 8.0 TIME LEVEL 2 Min 46.1 8.0 1 Min 45.8 3 Min 46.1 11.0 4 Min 46.3 11.0 5 Min 46.3 11.0 6 Min 46.3 14.0 7 Min 46.7 14.0 8 Min 46.7 14.0 9 Min 46.7 14.0 10 Min 46.7 20.0 15 Min 47.1 20.0 20 Min 47.1 20.0 25 Min 47.1 20.0 30 Min 47.1 20.0 35 Min 47.1 20.0 40 Min 47.1 20.0 45 Min 47.1 20.0 50 Min 47.1 20.0 55 Min 47.1 20.0 1 Hr 47.1 _ 20.0 3Z\3` 1-o°°`fi° Ps'. 1N.j „ , 5 > O Vanguard Laboratory 2635 Parkmont Lane SW, Suite A Olympia WA 98502 yercFAaD 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected Mason 07/25/2023 3 1 5 DAN Abnth Dry Yea Type of Water System(check only one box) � ❑Group A ❑Group B III OtherOther 1 T Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: Robert Flath Contact Person:Arcadia Drilling,Inc Day Phone:(360 )426-3395 Cell Phone:( ) Email: Eve.Phone:( ) Send results to.(Print hill name,address and zip code or e-mail) artetwaarcadiedrining.com AND sueGercadiadnuing.corn SAMPLE INFORMATION Sample collected by(name):Seth Specific location where sample collected: Special instructions or comments: 1161 E Mason Lake Rd,Shelton Type of Sample(select only one type of sample from types 1 through 5 below) 1.❑Routine Distribution Sample(A!P) 2.❑ Repeat Sample(A/P) Chlorinated:Yes No (from distnbutlon system after unsat.routine) Unsatisfactory routine lab number: Chlorine Residual:Total Free 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: Is ! I Chlorinated:Yes No (2)Triggered(NP) Chlorine Residual:Total Free ❑Assessment (A/P) 4. Surface or GWI Raw Source Water Sample(Enumeration) I S ❑E.cob ❑Fecal Filleted Yes No l ! 5.®Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and (g Satisfactory ❑E.coli present ❑E.coli absent Bacterial Density Results Total Colifonn _/100m1. E.coil /100m1. Fecal Colifomt _/100m1. HPC 11ml. Replacement Sample Required: ❑TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container ❑ Daune Race ved Lab Reference Number 7/26/z3 lip57 Vz3072 )- Receipt Temp C': Method Code: Date Reported to DOH r� A Lab Use Only: DOH Lab-Sampteti 285- OON Far.U7,3,G(dita,e 561n•tlrw nns iris Potato et in drove karat or Soo 52tpt21(TOOO Yw?I I) Thor eU 01w Ponsoa so,oa 4 N wwr doh ea 2200511 Mason County WA 08/07/2023 03:24:26 PM NOTCE eRecorded #189534 RecFee: $203.50 Pages: 1 PRIME LOCATION Return to; Prime Location and Situations LLC 113 E Terrace Dr BeIfajr. WA 98528 TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA (WRIA) 1(We),the undersigned grantor(s),hereby place this notice on record that the following described real estate situated in Mason County,State of Washington;to wit: OR 3 21 34 Subdivision Division Lot Range Township Section and having the Tax Parcel Number of: 3 2 1 3 4 — 3 1 — 0 0__0 5 0_ 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 Dated on this O day of ,�+4' _,20 Z'3 . i Signature of Grantor(s): ___ _R4 H — ION 4 w LA Printed name of Grantor(s): __. 01 .f2_'r *P-1 'lit. , Grantee' Public State of Washington ) County of Mason ) I,the undersigned,a Notary Public in and for the e named t ' County and ,State,do hereby certify that on this Q 1 day of_--S[ A ' j .20 . , __ Ip� c 4L ----personally appeared before me,who is known to be the signer of the above instrument,and acknow . . that he(ItiQ N}signed it. Given, under my hand and official seal the day and year last abov•• teviti, . otary Pu 1615 , for the State of Washington, GREGORY A RUSSELL ' Notary Public I Residing at o g{Na. N Zi , State of Washington My commission expires: fQ 2102e.Commission 4 134076 1 My Comm. Expires Aug 14, 1025