HomeMy WebLinkAboutWAT2023-00335 - WAT Application - 11/19/2023 WAT 2Da- DO 3
MASON COUNTY
COMMUNITY SERVICES
a,adny rennin%ert.;ra Resah canonirr Rain
415 N 6-Street, Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 40D G Belfair: (360)275-W7 ext 400 O Elma (360)482-5269 ext 400
FAX(360)427-7767
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 Iden,tilIfication fjwm"Vr
Name on APPIiwM (Ln]NAl„ W 2EdeN4-�� � ,F Date:
Mailing Address: L(j0 u/.4kerwad rl AU M& JU Phone: Qi370.5
Parcel Number: id7019- fk-Q=2.0
Type of Water System Reason for Application
Public/Community Water System(2ormom Buildingpennit -jfd262.3 '0l'40
connections) ❑ Division of land:
d individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Springisurface water ❑ Other fexnlain
❑ Other(explain) A���
Elr xi`��� rt Remodel(please indicate name
If you have more than one residence connected of water system below if applicable-no
to this well, check the Pubho Community Water signature required)
System box. - r � remo✓�
Nl4f} I IY1FEs1 AMC WLV
Part 2: Water Connection Information U �p� rl rl&,L tY $f e Cho
Complete the section appropriate for the type of water connection being evaluated: Oft. -00_, fLLLA)
/nI � Public Water System
W
Name of Water System: ZI I • - f� �,J��
Water Facility Inventory(WFI)Number: Y)nn 5-
(write"none"for two-party)
16 1 am the manager of thi water system. The water system has been approved for a services.
There are presently - connection(s)in use. This will be the of 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(Le.: 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)connections)without exceeding
the limits of the water system or any limits set by state nit Jowl regulation. /
Signature of Water System Manage !Date f 1 /Z / 7-3
This form may be scanned and available for public view at www.co.mason.wa.us.
1:\61f Faroe\DnMai Water Revised 1252018
Individual Water Well
tyrivvater well report(attached to application). Depth -;(p
Well capacity Test(attached to application) gpm ✓�� 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).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.m.mason.wa.us/planning 14(__—]15M if=22�
Water use or limitation recorded.................... N/A,=Yes_Oj !�
CN
Well Drilled ............................................................... Dale
Individual SpringfSurface 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 only)
Satisfactory Determination:
rThis 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: 22
Environ. Health: Date �7, (2ti / J
CSD Director: Date 2.f2
Y GIi CI V CL
1Ap state Czed Ne. NOebao1
. t Ypp ' 6 N:II N A S 6 R M B L L R 8 P O R T gpigue Nall I.D. M AC0613
pG•tfi� moor Right PesAle Rv.
'1 T4 JCaealr S[ATR OF NA9NIILTWt ...................................
Mdreae ]6e3 lY1.OYN 1pA0 SN 'haa,,Fa&' p 9F31]- _____
..............................................
. . .. . .. ... .. .. . .. ... ..
]yy ...............•...__._._........
__..
.....................••••••�••�••••••�•�••• . m 1/. vN sec
II stassrm us m O muncY V'/D• __________
lal a'iReBP MIABS® OF xBL1 IOz ...[mt ....... 9Am .MW ..... ...UJm . ........................................
--•-•---.•I301 N®'L Ltn
11 FROM;; UBn: pmm.6C ................................a ______.__._.__.__..__.._.__.
......................................I- color. ch+racMY, .1m of eat.tiel
.. ............... led Rteat Mea[ihe M
{1 SYPn O➢ NOR%: •oIf R,z n:a➢a[ of xell I apd at[uctuof,the
ahem [ES ua ma at Wtfr1toz re atZ the Riith
III ma [IYR oriel I apd MLYte Of tM mtt[Sal io sash aczata peMCr.t".
Nm M64 Nathed: .®1f at least one eat" fot Mch obaege in toanati.
Y
.n............................Z........... _.__.___._..
vimce[ ai all a imnm I----` 1 enoN 'ro
sl 17
,tilled Is h of omplatmd .... .. ... NkTYIAj'
p...... .. .. .. . ...........I BymY N80Mf 6L4 OY`'lQ' IT 16
.......................... mAS ®1.8 ORAVd a MA}R I
6) cORe]nuCl1011 DETAIM:
6 of.. f[wa .1 ft. to 16 ft,
mi, immiled: ' Di fir ft. to ft.
11�0 yag 1
• DI. from ft. to ft. 1 I
________________________.._I
Petfo[a[iom: w I 1
type of pa[fo[atoz used (n In. 1 I
SIZE of paifozzei.
'aZtozaciona trm ft. to ft. I
perforations frog ft. to ft.
parfMatieaa frm [t. to fc_____________ I I
_.___..._.._C ------
for I I
e...: .o I I I
Navufaoeo—V. Rae. n1"" Re.
'B'➢• ft. to ft. I
Di... slat size fYM
Dim. .lot Slat fto ft. co tc. I
I
amel Pack": w Sit(-V[ 4[ivel
O[ 1 I
oZ.a1 Placed fem ft. eo - ft.
______
________ __________
Eat depth? ]0 fI
t
Suzf.t. m&I: T® To ft.
Wtezial used in seal SaSTOUIT. L
vla any a,.. COM.Sn uo:taEle Z.rl
+. alp eC a I 1
Type Of ester) o-Pch e: at:eta
uechoa of .mling strata off ..............I I
........................................N.P.ITI PUNF: Mnutaccucer•e TYP " I
.................................tc.•ll . .
p1•NATf¢ LBV&8: Ta"-euzfe<a elamatlan - . I
0ewe mea sea level I I
static Iemel 6 ft. Eelm cep Of all dca O3/o8/n 1 .
Attmim PemazZ. lee. Pe[ ago. loon vacs
Atteaan —,at cMtto31" by Nork ata.ead WOW, 'en,I.ted a./*./',
. .
_ __ ______ ____ .... ______ _ __ __ __ ...._.....
.. . ..
Ipl NBLL rT[4gfs: vtamdomn ie +w:e:t m.ts[ level le lome[ed Ee1om 1 NSLL CONBTROOTO�CSeRd/OReecept impm+lEi lity fet eon-
eciv l.vel. l ete,otino of this mell, and IzC ltmp3fAM�r1U all
M. a SNmp eae[tmdti n0 I[ yea. OY _z M.. M.1ultm xall --Ze` tiara . .I:daem.t ttoamy Meld
Yield: 9a1./min xicE it. dramdovn after l aM the lnfotacim report" .Fore ate
eoz
Romledge a" Mllef.
Mcome[r a.c. - mcez Lamel 1 NANa AWPL pRILL13N•INT.
Tim Nate[ L.aI Tim m-Z i<va TimiP.t.oa. fia. r ry0[ationl 'Type of PZi.)
ApppP98 B�)`0 A- Ji�ml N.K a0
/ / Eza ptONgpl Licame No. 11a9
.to of test
Bauer MSc 9a1/m1n. tc. dzavdomn efts[ I
A1[ tmt is. 'Walt, m/ atm set at 30 ft. Mtei hoz. tant[aetot's pate vl/09/9l
azCmiaa f30. g.p.a. Na. a cEeaicel analysis hide] SO I Regiet[etivn No. . . ..1D _
Stag .11ta Of rater .......................................... ....
a . . .................................................
rinted From Mason County DMS
Printed from Mason County DMS
Thurston County Environmental Health -
2000 Lakerldge Dr.SW •Olympia,WA 98502
360867-2631
;tD.W�W�
y
ween
COLIFORM BACTERIA ANALYSIS
ecled Tirre Sample Canty
winded
a3 a-:00va,na eA
Type of Water Statem(dleck only one box) ry powle Nousehob
❑Group A ❑Group B wee
Grail Aand Gould B Systems-provide Iran Water Facilities Inwmbry(WFII'
IN
System Name:
Contwdpwsdu
NY phone:) ) Call N":( )
E-dial: q Eve Phone:( )
samo odes W(own M o..endow.ere do We or emal adbas)
--...._._ 262 PF'otmma [.Nh
SAMPLE INFORMATION , -
Sample mllemedby(namo): 5tAi4r W�cx Kl
SpeafmbwarmaadreuwMre sempb elected'. Spadotimbucdanaa axlrrwntx
410 W. L+Orvler�rAa+wc
Type of Sample(must check only one road dt 11rar9h#4 listed below)
1.❑Routine Distribution Sample 2.Repeat Sample(after onset.routine)
Chbdnated Yea_No— ❑Disldbulon System
Chbrru Readuel:Total_Free_ Chbrmabd:Yes_No_
3.Raw Water Souma Sample Chlorine Residne:Tote)_Fee_
❑E.one-GWR(AP)
❑Fowl-seem.owe mwlr xarsrml Unulisbcbry routine led muddier.
d
Fiaered Vac_No_ _ _ -_____
❑Asuument Monilemp UW) Unutiuectm,routine called date:
S
s. Sample Collected for Information Onty
Inveggicire_ 0ombmkc 1RePdks.Y— Near_
LAB USE ONLY DRINKING WATER RESULTS LA USE ONLY
❑Unsallsfacbry Total C Illcrm Resent and BatlaOctory
❑Ecok present ❑E.myabsenl o !lamdelehd
Replacement Sample Ronuifed: -
❑Sample Mold(cM funds) ❑TNTC ❑
Bwteda Dendly Resulle:Tola Coliknn ❑09ml. E.eop n09m.
Feel CoRbrm Ytoom! Enlerodood NBO At
Method Code: M9223B ❑SM 9222D Dae eyMThaRcaved
❑SM W153 ❑Enlamlerl®
o-ae area nme Andwaa. - j- pare Bapmt 'L%
sarokw.EeilmxoWepa Maya) tab Usepa(
D s o L03
opx�aavare,aawama' 313as�k
2obii
2204755 MASON CO WA
1112112023 09:34 AM NOTCE -
JENNIFER NEXLER 0192779 Rec Fee. $204.50 Pages. 2
Return TOD2no i1'e-rr Wexlev-
4'W IW) Wore+r-AAks rd
t21 1 WL A$SYf
Grantor(s): (1) JG.MtLE k X f-1M— (2)
Grantee(s): (1)PUBLIC
Legal Description(1) 12 2 O SI2 YlE SUDLA-` 3�1I I
(Abbreviatedform:i.e.lot, block,plat or section,township, range)
Assessor's Tax parcel: (1) IO —LD,.L�) -
$ 20 R Co --
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA)
I (We), the undersigned gmntor(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: a
Maximum Annual Average Gallons Per Day: 3wo gallons
Dated on this 2 \ day of Nw eW%W-' . 20_2eS
Signature of Grantor(s):
(1) (2)
State of ashingto )
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.y�day of Pb v{M &c. - , 2021,
�P Vj\,(t.✓ W.0 X. JE I/ 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
".....A....
i
p ,....,,q�4� Notary Public i�ng and
�for the State of Washington,
ME
R�H residing at Cww
►• 'e My commission expires:
PUBLIC
Page 2 of 2