HomeMy WebLinkAboutWAT2023-00159 - WAT Application - 7/6/2023 WAT Z2 o - ODi9j
r, MASON COUNTY
° ; COMMUNITY Y DEVELOPMENT
��0Perm.Ps,S. .e Center.auk ;. C.s ng
415 N 6th Street, Bldg 8. Shelton WA 98584,
S:elton. (360)427-9670 ext 400 Co Belfair: (360)275-4467 ext 400 4 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: Chan Lee Date: 7/6/2023
Mailing Address: 1700 E SHELTON SPRINGS RD Phone: 562-480-8888
Parcel Number. 319023290061
Type of Water System Reason for Application
E Public/Community Water System (2 or more ❑ Building permit -6(1262 3 -00 7/ 4
connections) ❑ Division of land.
❑ Individual water source (one connection), 4 of Parcels? SPL
❑ Well 0 Boundary line adjustment
0 Spring/surtace water ❑ Other(explain)
❑ 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 welt 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 A 5 -20 -O0005 k(=)f?oin?ood j
Name of Water System'. l _ ' tY) 15 cl / <
Water Facility Inventory (WFI) Number. none-
(write"none-for two-party)
Yv 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 a 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 /te and loca regulation.
Signature of Water System Manager ` 7//Z�ete 7/6/2023
This form may be scanned and available for public view at www.co.mason.wa.us,
.1 F.I.L.!rm< Drinkmo Pamr I<.risud r_ill 13
Individual Water Well
NI Water well report (attached to application). Depth 9-S. ft.
ill Well capacity Test(attached to application) 3 a gpm > (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. ).�
IV Satisfactory bacteriological test(attach to application} 7(Z'{ ( W
Water Resource Inventory Area (WRIA)
Development within which WRIA btlfmturs cu.masor wa us'claiming 14:0 15l 16C 22M
Water use or limitation recorded N/A ra_Yes l,(]4F•2ZQTZ6 7
Well Drilled Date 7(21 /Z0(9
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)
XSatisfactory 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 resourceaegulations.
Recommended approval indicates requirements of Sanitary Code.Title 6. Chapter 6.68.040-Determulalwrof
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apoly. e3
36.70A RCW. p 3,5'3,
Unsatisfactory Determination: OCT /
Applicant's water supply does not appear adequate to meet the needs of its intendedlaie.foflhe followirge 2823
reason(s).
DJ4 _'AL la-
R 's Signatures: /// /�7p� "A"W
/
Environ. Health: Date 1 of (6( C3
2
OSD Director: Date ,f2
WATER WELL REPORT "fpA`-•`:" cr. Nome of cost No.Ihn 35512
ECOLOGY uwgn.FMbp IDWenTag No, BJT 930
Tyco of Work �ita.e of..ss .—
p Crdrevo She Well Name lif mart than one won Trbb S
❑Deana,c, Otsego]wallet NOT vet Water PiO Pumit/Cvtif ere Na
Prmmd Use a tans¢ Ci Indedrial 0 Mmkipl palaty Owner Ernst Don SIMMONS;
9 O..me'i.S C4,ipuo ❑ru Well ]Oen Well Soma Address O1d60G Rd. Lott
Cmusoatm TOP.: Makes: MahalIINew mil 9Almoner C.Moen Clad E Ca*Tool City Shalom Canny
0 OccpcMeg ❑Thar %ty Tl Air CI MSAuny Tax Parcel No.31902329OO62
o yJme:Demmer efWing 6 u.m TS M. Wa a variance approved be this twin ']Yu El No
Dept of-mischief.e9 75 It
Cainoreso WSW Wall Ilya.what was the variance fa?
Cain Let Oisraa Foam To Miami Suel PVC.Welded Thn4
3 1 ❑ 5 ♦2 70 .250 in. F] I ❑ 0 19 L auonIns insuudims oo Page TT 3]VOW or O EWM
DLO _ _o,. 0 i El a I ❑ sw W.V.of the 6v' v;Section 2 Towmsbip 19 Range 3w
0 1 ❑ S.it0I0 DIE
9 I 0m o I O DID Iatid4e(Example:47.12345)47.1625575
Longitude fExample-120.12345s-123.0291033
P erf.Wla: 7Ym INo rpm of pat . used 11r1s`r luglCa®veMrOmrrWonPe.fYasf
Nail m� .Slow going odasders
n. Foetus Demobs by cola.chars son M o.Nl and nart me die WWMW
PrxTorblS^^_M1mM1FeI+po°tl oa4ea o.INe oldie cormti In o[f layer p.matf vial a btu an MITT Tot Wth thane¢of
Glom: P Ya 0Ne F.[-Ptlob Depth 64 R iafnmen lsa rbuuoal sheets Li woos,,
MW.w's Nam Pinson Material Fret To
Two Skins makI No Br sandy bop soil 0 2
5 in. SW Mir 2O in from TY Rm is A.
nuncio m Si son in min 6m_a Br silly fine sand 2 14
Br send A trawls bona 14 36
yWflm sock Gya GNa Size of ph media! w Br Roe to medium end V/yewb•awer bearing 30_.. 75
MaLiihpvA hen It_In
S.sAee Seat IE Yea 0No To Non depth?19 tL
Mahe!mind St and bnb4 Unto
on say ono=miflown.sone' 0Yoe 0No
Tn¢ofvaco Dhoti ot meta
Mays of rain mate off
prep MeinImte'tNae four , - Tyre,sub
0P.1 Paso Meade eene:60 a onism 9o.ore.25 rm
—
W S.tI.n a ta{xrc envoys Sorts ono u level M1_
S.k. Slop awncans2 h'bow wound scotwt
Salmvew knot 31 it kin sop Sawn aim Dye 7/1709
Ana pamm_t.pa moats inch Lge
Mm'm M is avdk6 by OW.eta,het
Wel Ten
.•payir{von pafracwei9 No 0Yes CJ b'R& rime.
Yield—rm.zenith_ ..damn ahn wx,
Weld_pus with_hda..a.aw IS. -- .
Vicki—sense IL dmtkv✓after Jai.
Rmrvy dila(thee-me.]a.pump.turned o0 'alga lead immured foam.01
up Ionn kill
f WOLF te,tl Two Wan Lrei Tine Nam In I
ryndpg lI test ,
haim%1 r nM m Man A& en stun n.} �
Aortalpnvih rlvn Snl &R'a_
west on spot
Tegnanne amass_'F Wu achmalwaym.wail? GYe ONo Sap Ooe T9f2019 Completed Dap 7/16R019
WELL CONSTRUCTION CER1IPICATION: I mdaouaa amity accept rnposibility for unlinktim of this well,an is compliance vial all Washington well
caswmm suadark.Mslvials used and The infamabnn reported above Meese to my hest knowledge and belief
El pith 0 Trainee O PE-Print Name Drilling Company KNAPP DRILLING INC.
w Signors eD kr/arty, elicit fO .Ad* Lela®Dr.
50 E Lela Or.
license Na 1T06 City,Sum Zip Shdbn We.96504 IF TRAINEE:TRAINEE:Sponsor i License No. Cmoutur's
Spmmr's Sipes= Rcpmuim Na.NNAPPO195201 Dote 1)22/19
ELY OSU 120(Res Ohl 91//iou heei this 4110.1ePti IIIu alr.mre tier s please call the Water Remotes Program at 369-4O d8)2.
Person don.hearing lost C✓n tall 711 Jo.Washington Rflav Service. Penmn,irk a"web doubt/its .ncall 8%'33.1341.
;'rusted From Mason County DMS
Primed fron'I. Mason County DMS
173o'l Mile Hill lariat '
Puri Of hard 1a A 9aftir
.33ECrnA I.ubomtrieh'-Kitsap 1 .pean, I t-. , _a ca ilk In
COLIFORM BACTERIA ANALYSIS FORM
Cia'a Sal poi:,esed rme Saaahe County � �/�..✓\ �+"
:d
11 9 aa.0 `
, rsooL yrason w
ti.
Ch
Hpe of 9l .Shaer-op craGs, /� 1 r
.a b er r,vnte �1 J3`.
❑ F4 ❑ p y t
„ca„ a c :si peoysters Sauce rpm facto _ I .erwry lee'I l • ` ` c
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r EW Pt9le:
Ella t .2 rPQ(CC, Ktr '44le _
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SAMPLE INFORMATION
5amp4 Caurrn ny,na'rel <1A a 3e/4ete
Y.
SxC.fe t ACL WI.ipio e e'cc ape.,ai rse r..vs a cannnpnts CoII1OCIn Distribution Syst ew
PAil6p &4 Los Z Sampling Procedure
Type of Semple lshed c^M one bar) Step One Step Four
I ❑ .D.ww R.,'p ar Gamin Avoid poor sample sites such as There may be some liquid or
] Repeal Sample tater..Nal recline, swivelfaucets,hot and cold mixing powder in the sample bottle to
encllnsei yea ha ❑Doc bode,sys:m faucets(with a single lever),leaky or remove chlorine.Do not rinse it
c aaaca Res oh Taus_ IN-
_ ,;nsaas`adon romrie lot number spraying faucets,drinking out.
y s..IL a Gaiter:,e L ,w L.L1L. fountains,janitorial sinks,frost-free Step Five
,.; ] sractoly OL,'oe m red Pate hosebib s,aud faucets below or near To avoid contamination while
S ground leceL taking the sample,hold the bottle
„r]
re ornata; yes rvv Step'Faso Lea:thebottom with one hand anc
❑Inrpee= r'Jranne Residua' Hcul tree
Removeauyattachments from the hold the top of the cap with the
❑ s _
faucet inducing aerators,screens, other.Now unscrew the cap.
I 5 I washers,hoses and water filters.If DO COrsetthe cap down touch
❑c ❑ ...0 s0 you choose to disinfect the sample
;,, �,..,: ecollection, any- artof the cap that touches did
site priors sample hly roveP
.yy ,. rcu,ar �,m., ',' L'oHy r/U FTi oa✓ sure loP,ashihorWglll}'m remove bottle orlet an)Ming touch the ran
LAB"SE ONLY DRINKING WATER RESULTS LAB USE ONLY all disinfectant.
of the bottle or inside the cap(
❑Un r n'earl::n low Pranceand X$ lla'cry Step Six
O. „ p„_,,.,. ❑e CI I atse-i Hold the bottle under the stream of
water,,he careful noon le;Ite'oatile
aennce cem Sample new reP; r touch the sample tap. Fili the battle
❑ r .than m:ms'; ❑lrvlc ❑ 4 '" to the indicated till line,do not allow
ilk nl it to everflow. Remove the bottle
t
p, r. =sl.s lee cnlw^� /looms EccW_._ -_. yr' from thewaterflowandsecurethe
Ica nbinP=n uoer. KPC _ .Jl ml Step Three cap.
"Ord I'm°"areaec t,'ti�' Turmoil the coldwater ocly and Step Seven
UG1 Cr WI 2 3 2�19 - letitrunwithasteadystream for Completethe lab slip.Note an}thins
gOille In
2019 at least five minutes.Before Inusual about the sample collection.
SM 9223 B - - collecting the sample,turn the
r,fir hipcovii waterdownto athin stream and Step Eight
2 4 2019 J,_ 2 4 2019 '.etthewater run foronem}nute. Serurethe lab slip to Ile bottle with
If they system is chlorinated, rubber band.Deliverthesample to
a ,p � measure the(reechloriue and note Centric Analytical Labs as soon as
225 jt{) 0.,i_. � - - __.__._. - -- d themeasurementontheLibslip. possible.
tall,.r6LL:m.,+1-411.t .r:n
2203267 MASON CO WA
101'/IIimlll2//112023 10 00gaAM NOTCE 1 l�aQ�i'I
hu ll�IIIIIIIO II Ic Fe•e: 32Ii1'' illllllllllllg 2
Return To II
(than la-
ISI SE PhiII1psRc..I +31d20Za • 001lt4
Shujon WA i&58LI
rr
OCT 13 2023
Grantor(s): (1) Chlin LU-. , (2) RECEIVED
Grantee(s): (1) PUBLIC
Legal Description (1) bi- Ot' SP# tails AFyt571(A
((Abbreviated loan:i.e. lot, block,plat or section, township, range)
Assessors T arcel: (1)}i I I o - a - I o o ID
sow T(9 - R3
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: 114 Maximum Annual Average Gallons i /
Per Day: ('9�• gallons
a Dated on this t t, day of -sc.-vat ,
Signature of Gran s):
(1)l viZ (2)
State of Washington
County of Mason
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 V..,:Wday of (Dc.A' bt_r , 209,5,
CVNOSN L„ee 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 wri n.
oniirr rr 1• Notary Public in and for theState of Washington,
0 j'6 4% residing at Wk a Wl lL-a'y 6
ormw^ ; s My commission expires: I (I/-1 ZU 2
vueLro
�y�iy1�, YOB 0.
hoinimmoo
Page 2 of 2
2138635 MASON CO WA
09,004040 10 56 PM AGREE
5.1ON05 kla4383 Rec Fee E1o6 50 Pages P
IIII IIIIIIIIIIIIII iiIIIIIIIIIIIIIIIIII!lIIIFIIII�JIIII IIIII I'll 11111911
Return to:
•
Name: 1 r . •A 1/r3oW.1S
Address: SC I ,..cf, R .
City, State:Slur ( {-pH L4 9SC5r1 ✓
Document The: ((1Valtt Too I�A✓+ (l✓C. e✓
Reference Number:
Reference Number only required on Satisfaction of Mortgages and/or Deed of Trusts; Release of Liens and Assignment of
Mortgages and/or Deed of Trusts)
Gra tor(s1:
1. 1)4e^`l c . � L•- (i a S(Yh OvviS
2. J
3.
4.
5. Additional grantees on page
Grante�e(s): I
z: Al1A� Su It A i rnfm/Y.s
I grope T) '•2ett_
4.
5. Additional grantees on page .
Legal Description(lot, block and plat name or on, township&range.):
IH°1 St= �tiifCPS R . ( Lo'+1) otE,d got. ( Loll) o'1 51712373 AF # 5774 7-7 PTN o-F
�) u25L s7/59, s7/5v 3a Tic/ R3
Assessor's Property Parcel Number: /
I. 3Ho2- - 3,- �too(oa 1_a-E 4 ,2 Si /5 1
2. 'R 1963- 35- (100Ir I 44I S-7/s7!'
3. Additional parcel numbers on page
The Auditor's Office will rely on the information provided on this form. The staff will not read the
document to verify the accuracy or completeness of the indexing information provide hereon,
Return to:
Douglas&Julia Simonds
8350 SE.lynch Rd.Shelton WA.98584
PRIVATE TWO-PARTY WATER SYSTEM AGREEMENT"SIMONDS WATER SYSTEM"
Ownership of the well and waterworks,it is agreed by the parties that each of said parties shall be granted an undivided one-
half interest in and to the use of the on parcel 31902 32-90062 Lot#2 and the associated water system.
(Parcel#1)149 5E.Phillips Rd.Property Parcel No.31902-32-90062. Lot#2 of SP#2373 AF#577697 PTN of NW SW 57/59.
Property Owner-Doug&Julia Simonds or Future Property Owner
(Parcel#2)151 5E.Phillips Rd.Property Parcel No-31902-32-90061. Lot#1 of SP#2373 AF tt577697 PTN of NWSW 57/56.
Property Owner- Doug&Julia Simonds or Future Property Owner.Range 3,Township,Section 2 for both properties.
Both parties hereto covenants and agrees that they shall equally share the maintenance and operational cost of the well and
watersystem herein described.All pipelines in the water system shall be maintained so no leakage or other defects which may
case contamination of the water,or damage to persons or pro rty. Aftimeyeady payment of$180.00 shall be paid to the
property owner of Lot#2 by the first d Jarva of each r. This agreement isvalid in the State of WA.County of Mason.
Signed:Owner of Propert with well 1 L(' .1 DICri--`'
Printed Name: IA.(i a- tyro 1/4S
Stateof WA./County of Mason �
I,the a dersigned,a Notary Public in and for the above named County and State,do hereby certify that on this Clay oCree,r
20 I rsona lly appeared before me,who is known to be signer of the above instrument,and acknowledged
that they signed it.GIVEN under my hand a rid official seal the day and year last above written.
UZIcilisif k ; , `4vI.Ulnl
ANGELA A VELKOV Notary Public in and forthe State of WA.
Notary Public
Stets of Washington otaryngm IPAQ . C,7License Number 174366 ?/1( AI' qq My Commission Expires My Commission Expires: 3b WZ`
September 30, 2022
2138635 Page 2 of 2 09/08/2020 10:56:13 AM Mason County, WA