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Home My WebLink AboutWAT2023-00334 - WAT Application - 11/13/2023 IAT2n2i-0033W MASON COUNTY COMMUNITY DEVELOPMENT P ftftsis�e cm ,, Pmnnmr, 415 N 6`^Street,Bldg 8,Shelbon WA 98584, Shehon:(360)427-9670 erd 400 4 Belfair:(360)276-4467 erd 400 6 Elms:(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:FQ1L a Hrc4rj AuSamk Date: I 1 I['$I Zg Mailing Address: 322—E D4ILP-Lw s R,D Phone: 36 -ha 9'San Parcel Number: 22a t1- 41— odk l o Type of Water System Reason for Application ❑ PublidCommunity Water System (2 or more li Building permit 01" connections) ❑ Division of land [iF- Individual water source(one connection), #of Parcels? SPL Iff- 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 9 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 Facilely Inventory(WFI)Number: (w(te"none"for two-party) ❑ 1 am the manager of this water system.The water system has been approved for services. There are presently connections)in use.This will be the connection. ❑ 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. Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. 1:FH Forms\Dnnking Wwt Rwisod 121,2018 Individual Water Well Water well report(attached to application). Depth 1 1 S R. Well capacity Test(attached to application) 2-0 gpm pd. 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). Water Resource Inventory Area (WRIA) Development within which WRIA http:l/gis.w.mawn.wa.us/planning 14�' 15[=16022[] Water use or limitation recorded................................... N/AQ Yes Well Drilled ............................................................... Dale�TT cl 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 Data 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 adequate supply of water indefinitely in the future,or guarantee compliance with all applicable W DOE water resource regulations. Recommended appmval 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: Applicants water supply does not appear adequate to meet the needs of its intended use for the following reason(s). .�-tl�r_�,v �(f-� Reviewer's Signatures: / Environ. Health:- )�YcCYV� Date CSD Director. Date 2 ofz r i0 �=o6-t ScYe�e►-� WATERWELLREVORT t.In•wl.+a• rrrrrrw 1WECOIOGY a+.rsre rrm*..rw ew lm Mraw"•' �� irvMxl.FIJr.IY.Y.Wt wFNr. war.. aFrr vr.uF• gsplwar...arw <.rrrTF. nrw M ew.r. aa... etr wowTw cq%YII••' _ �.rl rpll _......_.— �.o...� car aar cr a,wor n.Fwrr.RQiLiL90P1P. _.._..__. - e..r.n...r.•L.._� • sr...l.ww.�+rr.wn�rw Orr M•.e...f4.xJ.rf 4 q�ysO..rwOY! e m a... er .. x.s... •ra nrn•Iw Irw. .__--- r a ,•�. _ R r a sin Irrw.ra....•a+w:x trw.0•w r..rNdL'.tw+� o t o �_ — _ —.. a 1 a � � 0 1.'swu.rFF•rlawi - lu IrFra..wImxmr. _ p..rr.YF..�_ Fv.I.�r�,wF_. Fr..prMF.4�.rr�•iy rrwirYVw Mrr1Y._�ts.®.M Ms Mrw. .w.afYFFYrJIwFr.t rrFJJ.FI YMr . F•M O OM firiF w.•IY....rF�x __ .I.IOF. 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M4lM)rl l'{Of.Gn 1 Nib+Na1�.4`Y.�rM.fY.�iJ.Mw�vN�r'yT..i teun•F•.Frbl•YeJ+F•r•r wsF F•..r rwwwrwr•F.FMrw. a r.sIIwe- a.r wy.rrYL.a• eeee- .—.w trwr. .-umlwea Ir.r M+a __ M1��s.n JhMrM•rrr�tFrFriwwlFYrs��.}wt�NI�YLagxpf)) well so Pk Fvf �-rkC CITY of SHELTON -Wit Total Coliform Analysis Form .r' Method SM9222B DATEOFSAMPLING: 1� 12 / MBR TIME OF SAMPLING:?:30 PM SPRAYFIELD TIME OF SAMPLING:_ AM/PM SAMPLE TAKEN BY: Er(e MBR TIME TEST SET: $7G5' apm TIME TEST RESULTS READ: '35- ACC/PM SPRAYFIELD TEST SET: AM/PM Date taken down II -12 -Z3 Temp.of when sample is placed3S 0 Temp.of when sample Is taken out3�i.G TESTED BY: Taken Down BY:� Sample Blank Effluent Effluent I Effluent Total Coliform C 1 /100ml /Sml /100m1 Sprayfield /100m1 /Sml /10m1 /300m1 DATE OF SAMPLING:--/---/_ MBR TIME OF SAMPLING:_ AM/PM SPRAYFIELD TIME OF SAMPLING:_ AM/PM SAMPLE TAKEN BY: MBR TIME TEST SET: AM/PM TIME TEST RESULTS READ: AM/PM SPRAYFIELD TEST SET: AM/PM Date taken down Temp.of when sample is placed Temp.of when sample is taken out TESTED BY: Taken Down BY: Sample Blank Effluent Effluent Effluent Total Coliform /100ml /1ml /10ml /100ml Sprayfield /100m1 /Iml /10m1 /300mi Broth Check Broth is not used the same day;when tested. DATE OF TESTING:_—J_J_ Int TAKE DOWN DATE: Int Blank 1 2 Drops of Influent /loom[ count Lot R Expiration Date MLopthly Positive Control Sample Blank 12 Drops of Influent /100ml I count Page 7-27A 2204477 MASON CO WA t 1/1612020 01 Al PM NOTCE E�nIRIC IBIIIIppNpEL��pISSP R11IUySIEI''f''NI p�a1I9�'�2@�5p�0I4I''II''RppeNNc��F�ppateIpd�: ly�z0C.50 Paeaz: ] Return To II'�IB��WIII IIIIN IIIIW�1111M11�1A111111NaI1111W111t_XII _ Fri I,is&a A—&,4n Grantor(s): (1) Y)'1(1' 4I.CS6P1/) . (2) N& SS F'1'I.kSf�t'VI Grantee(s): (1)PUBLIC ;7 Legal Description (1) N Fi i 66 51�- t K-.ri (Alibmisted ionn:La. lot block plat or section, township, range) Assessor's Tax Parcel: 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 6.66. These restrictions and conditions are based on location of property and/or Water Resource Inventory Area for WRIA. WRIA: 14 Maximum Annual Average Gallons Per Day: q%CC O gallons Dated on this_LA--day of W0_er4&—y`, 20A&. Signature 0 01rantor(s): (1) (2)L%' � 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 certifythatonthis lumdayof A/Wt/nWr 20�, Grie AVso+h a A.lAbcsa Au%4At. personally appeared before me,who is known to be signer of the above instrument, and acknowledged that he(a (they) signed ft. GIVEN under my hand and official seal the day and year last above written. 11111111111//// LSI.(L'� /C e& `G — \. ..N.!!K. ,i,� Notary Public in and for the ate ofSY Washington, '_ residing at M[cfavr 1lorulr�^•' s q-10-poaS My commission expires: ►ueuc ellllae\N1"`\` Page 2 of 2