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Home My WebLink AboutWAT2023-00306 - WAT Application - 10/24/2023 WAT�';--1610 415N.6°Street MASON COUNTY Shelton,WA 98584 COMMUNITY SERVICES SMI Bdfai:e6o-bn-967o,Me.400 elfer:360-275-4467,Ext.40 Q ®,raeypynyp¢,x+m,�minsitl�c .agxdtl, EIme:360-02-5269,E#.400 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 aperoved building site plan must accompany this applicator. Part 1: Applicant/P rcel Identification - Name on Applicant: / Date: 96L, •a�J Mailing Address: I4j4 Ist �VE U� t�� 1 Phone: '.2q5• Parcel Number: 0kxIos- 5I I C I�� LJA q 0113 Type of Water System �r Reason for Application XPublWCommunity Water System(2 or more Building pennit- jl Ci�-J-0IOL-7 �ry connections) ❑ Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface 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 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 Sy�st�eym� ' ,`r �. Name of Water System: Lae, ram^*" 01115-fl•4— Water Facility Inventory(WFI)Number.. I rIE (write'none-for two-party) xrI am the manager pf this water system.The water system has been approved for A services.There are presently I connection(s)in use.This will be the-A—cannection. ❑ 1 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 I �Q) &' W15 Phone QoLe •q Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. ]:\EHFa \Dnnking Wa _ RevivA4 7MM Individual Water Well Water well report(attached to application). Depth 0 - ft. Well capacity Test(attached to application) 26• q 0 opm gpd. The well driller often performs well rapacity 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). Water Resource Inventory Area (WRIA) Development within which WRIA htti2i/als.m.mason.wa.us/planning 14X15_116_22_ Water use or limitation recorded................................... N/A Yes / Well Dnlled ............................................................... Date VY��,y)QwYi Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection ❑ 1 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 on/ ❑r' Satisfactory Determination: / This deternination does not address adequacy of the distribution system,guarantee an adequate supply of water indefinitely in the future,or guarentee compliance with all applicable WDOE water resource regulations. Recommended approval indicates requirements of Sanitary Code,Tide 6,Chapter 6.68.040-0eternination 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: Date This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 ofZ Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Mike Williams Well Tag M: none Phone: 206-295.9588 Depth: Lowest Point tagged 60' Well Site Address: 4000 E Mason Lake Dr W,Grapevlew Pump Set: Date of Test: 44659.00 Static 21.1' TIME GPM LEVEL RECOVERY 1 Min 14.2 24.50 TIME LEVEL 2 Min 14.2 25.50 1 Min 26.60 3 Min 14.2 26.00 2 Min 25.00 4 Min 14.2 26.05 3 Min 24.60 5 Min 14.2 26.15 4 Min 22.80 6 Min 14.2 26.30 5 Min 21.80 7 Min 14.2 26.30 6 Min 21.65 8 Min 14.2 26.35 7 Min 21.50 9 Min 14.2 26.40 10 Min 1 14.2 1 26.40 15 Min 14.2 26.45 20 Min 14.2 26.55 25 Min 14.2 26.60 30 Min 14.2 26.80 35 Min 14.2 26.80 40 Min 14.2 26.85 45 Min 14.2 26.85 50 Min 14.2 26.85 55 Min 14.2 26.90 1 Hr 14.2 26.90 I P Printed From Mason County DMS Printed fmm Meson County EMS Vanguard Laboratory 2635 Parkmont Lane SW,Suite A Olympia WA 98502 VA'"' D 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM pale Smlple Cd *d Tme Sample Caunly 12/29/2023 cpwnebu •w MASON We on Type d Weler Sysbam(deA ady are boa) ❑GmupA ❑Gmup8 SOdla Group A anal Gwp a Sydeas-Pmuide horn Wakr Faded.Invent,DWI) : Sydann Nan, MIKE WILLIAMS Contact past:Amadia 0611irg,Inc DWPhme.(360 )42f43395 CN Phaa:( 1 Emet Eve.Phane:( I Setl r W 6 tl:(hlnr NII ram.aMress atl ip¢G a smi9 aMa�an-saaINllleN cqn qN0 jmnQarcaStl'larq.[an SAMPLE INFORMATION Sam*CAeded by ln.k MAX Sper c locaEm ad"temple m0.ctan! Sp Iwashudionsoroonmma: 4000 E Mason Lk Ur W,Grapeview TM of Sample(send mq one We of sample fan tryes 1 tunto 56ebe) I C]Routine Distebutlon Sam*WP) 2.❑ Repeat Sample(WP) Chbrinam! Yes No pmmdembw solam Verum Mums) UnsaesfactM utn.lab wmbx Chlorine Raw":Told_Free_ 3.Gm�ad Water I ter Run rw Sou � Sample UnsalnsadaY mutim wtetlddx L_S I I-1 Chmindad:Yes_No ❑TrSered(Am) Chlorine Resdust Total Free_ ❑Assessment(WP) 4. SuNau orGWl Rev Smme WM,SempM(Emmaaem) ❑Ems ❑Fm J 5.®Same Waxled br adamaae Dory: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsa4afamery Told Cardam present and ®Satbislory ❑East Present ❑E. aadanl Dement]Density Resues:Tdal Cdaam 1100m1. Ecof IIWmI. Feml Cdfam 1100mi, HPC Nd. Roo",and Sample Required: ❑TNTC ❑Semple mP Pal ❑ SamplevWnN ❑Damaged Comeier ❑ DaNlrvne Rece'rrea- ue NanMr 12/29/2316:00 �1 Ranaq Temp e, 8.1 SM9223B ow wmradr,DDH tl/8 lore uN a+y: DOH laasaniAaa 285- u14�- �23 -b03o to I.�)I.UA.Cc.w�9 2204171 MASON CO WA 11/03/2023 01 08 PM NOTCE WI LLr BM3 1192336 Rao Fee $204 50 Pages- 2 Return TO t' ;V,%:_ (I)tl(lawth IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Hw Illik Ala W 4301 RECEIVED 616 � �)� 96t1� NOV 06 2023 615 W. Alder Street Grantor(s): (1) rij 1�9 L.S.1I 1&» b , (2) NOV 62 Grantee(s): (1) PUBLIC 013 Legal Description (1) 1 O} 91 ue A'u _ .�_ RECf(VED (Abbraviated form:i.e.lot, block,plat or section, township, range) Assessor's Tax Parcel: (1),A a. t 0 5 - 5 1 - D O O D 13 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 11or WRIA. WRIA:1 Maximum Annual Average Gallons Per Day: 6D gallons Dated on this � ah day of(�, 2023 Sign Grain it \` (1) io I State of Washington ) County of Mason ) Page 1 of 2 � Y I, the undersigned, a Notary Public in and for the above named County and State, do hereby ertify that on tthhil�s tDr day of 6 , 20,Z,, �1f{, w:0'-C-& r 5 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 apd�ea� written. Notary Public in and for the State of Washington,NOMPwillic $pY of " residing at '&DX S�{}-Gsrr�Ce�l+owtSyu.rf ryiarMwv' My commission expires: 74VZoe Page 2 of 2