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Home My WebLink AboutWAT2023-00198 - WAT Application - 5/21/2023 ZoZ�i- 1Ra WAT 415 N.6°Sh MASON COUNTY Shrltm,WA 98584 COMMUNITY SERVICES Sheltm:360427-9670,BxL400 Belfaic 360-2754467,B L 400 wra�sva,usemA„�.xaada �bx.w Elms:360482-5269,ExL 4W Application for Determination of Water Adequacy Instructions pt�Q --� i. Complete Part 1. No determinabilln 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: Applicantl Parcel Identification Nameon Applicant: T195or) -brLJZI— Date: Mailing Address: '1A i3' AIJ'Ur d2 11 -bone: -rimw.,,�O�1W- y4o- +401 Parcel Number., Ulaf-65j1. 66OZ14 �T lJ(111/2l51�I iftc , 10flis+ b Type of Water System Reason for Application >Public/Community Water System(2 or more Building permit 1P1,1 2023- 606Z 9connections) ❑ Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Springlsulfam water ❑ Other(explain) ❑ Other(explain) Replacement or Remodel(please indicate name ff you have more than one residence connected of water system below if applicable-no to this well, check the Publia Community Water signature required) System box. EXtbrlj�(q�,-Ptmo•C1 }'�8M6 ��f11- 1-� Part 2: Water Connection Information rlt- +O tflacc, 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) ❑ 1 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. ❑ 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)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 Phone Signature of Water System Manager Date This form may be scanned and available for public view at www.co.lnason.v .us. I:1Ea FomW Dtiol'vg Ware Revised 7=1 RECEIVED APR 04 2023 WATER WELL REPORT DEPARTMENT Or Noll.of Indent No.WE51438 WA State Department ECOLOGY wi,,rmogy Wen m Tag No.BMT Igo of Ecolonv (SWRO) rapepr\vnrk: ❑. CmWWdin. Site Wall Name(irmom than one well): ❑ Urmea:mubn b OriY:wNhsmllednn NDl Np. Water Right PemAK.di0an No enpoeed Un: atannade ❑lMMrfil ❑Maximal property Owlwr More El KFUSTYN AND SON CONSTRUCTION ❑Den,... l ❑Wooden ❑Tom Wall Dealer, Well Strmt Address 3770 EAST MASON LANE DRIVE W C.'sasucdon Type: Disease: City GRAPEVIEW Com MASON *New well ❑Ahrminn DDrhm ❑kind OCabk Tml ty NY ❑Daprning ❑War Dion D Ah- ❑MuebRpnry Tex Parcel No,22105 1-0U25 Dlmemka: Di.wte1ofbo1im16 k'sa m A Wea a vadelmeappnved for lhu well? OYm Ellin Depea ofromplelM w<116P h Cenprurllon oNella: Well Ifym,wit.,wee the m fA 2/r den Coin, Liner Diawmr From To Tbkksm Sdrel PVC WeNM Three N ❑ 6 in. e2' 50 114 in. ED 1 ❑ ® I ❑ Location(=a insdmctiommn page 2): ❑WWMer.❑BWM ❑ I ❑ 1 / W. — —In. ❑ 1 ❑ ❑ ❑ SE -/ofdbn SE Section 32 Tow nge Township 22N Ra 2W ❑ 1 ❑ —ut — — —M' ❑ 1 ❑ ❑ ❑ Latitude(Example:41.DM5)4734717 ❑ 1 ❑ in. _ in. ❑ 1 ❑ ❑ I ❑ Longitude(Example:-120.12345) 122 95632 Perbr.Xou pYa MN. Type ofpeRo:mw::ue Druler'.La'14Domlra<Ilom Or Decommission Procedure No,aperronfwm_ Svc ofpnWntiom_Inby_kv poop,lion:Dexribebyminn ehanper,sino(wM:ialaN auuem:....d A.WM and Y PrrroMMhom_fl.m_RbalawgouMvuhce nelwofJu wdelulinwehbkrWe ed,wilbmkeslaueenuyfwuch Manrof A Scmm: MYes ❑No DWFeekera Drplh SY Infamudnn. Un-Miacralaheeeif.re'. E Mmufeclurei a Nu:;JCI:mOn Material From TO TYPa SSTWa MadelNw GRAVEL,SAND B CLAY TP (BRN) 0 46 PS ,.mo, 51Y2' in. Slotabe12 in.Dom 5T_ft.m 6P 6 r5 Diewur_ in. Slmrin_ In.Daa_an_R GRAVEL A SAN TP W/B (BRN) 48 59 Sandwnurpck:❑Ya moo siu ofpsckm.nsl_in GRAVEL,CLAY,SAND (BFUN) 69 8o Mnr:iab planel Sam_1 m_ft. D Sugars Seal: ill Ya pNo To whm dep0?1F A. M.urialwMi.seal Uncerml0 DN.N'urnl.cnmefnueurebtewamp Oyes 18No 3 Tm.fw. r? DepeaofmW p Medadefscou sw:eott Pa.,. Manxfinem'e Name Type: ELF. Pump iotekedryM:_R Detipxd Opw nN:_mpm Wateriwwlt:LMawfieekvmbn.bovr mn ua krtl_B. Slick-upoftepofxellcai.g_ R.bnve gwuM.wfia a. Sulirwmmlrwl 24LV ltbrlowmpofu'rllr.xne Date 12N=2 C Arlesuopnu _flan"s,ansch Dan CA Mni onIml4N by (aP.wlw,em) WNlTuum wuapumpinelatperMmrOONo DYesr bywhand 3 Vidd_or.wish_&4nxdawn.kr_M. Yi,W_Spmweh_fl.dnwdownekr_M. u Yi.w_'no wRh d.dnw&_.ftx' M. .� Reeowry dau(am.am Acaprep u vrM off-roes kwl mammd Dom well Iap nw.nrkn0 rlw w.nr Level nw w.ur lxwl nw water Level S a mu erpumT ml -t D.dn am ne,with AL de w awdun efla_M. I Y Alrlrs115 Enews0sn aster" Rkr2 M. JF Dow IVIM022 E Aneviao Dmv_kpm Tempemmrsofwaur_'P wu.ehemk.lenlyakwde7 OYa ON* 81.nMk1211312022 Completed Data 12/13/2022 ] WELL CONSTRUCTION CERTIFICATION: [m:ISUucted kodyora:xept tuPonaTility fineomdmction ofthiswell,Mid iLLcomplietice wiN ell\Vmldvgmv well y rondtucli0nsdeMerds.DLkdahusedavdeae infofmaliwrtpoded above are tmebmy batbnowledge pod belief. ❑Driller am"❑P —Print Name Den Cementer D ll' C TIMS Well Drilling S. \ n a / Address PO Box 1099fi Licuue No.2236 citysmixZip Tumwabar WASES11 LFTRAWEE:S sods U..No Cwwntois Spommer's Sigllon kria,,odso No.TIMSVMD834DN Dale ECYD50-1-2D(Revt1/18) 1/3'ou xrrd rbia doramenfM an ohrmafe/rma4 plwue rwlhhrrytrr Raeercrr Progmmm 360-407.6a71. PeamrsWMhmnxg/wmfsml1711/m Wuhinglml Rday SerWce Pwaoru weAnaprerA dlmAlRry ran troll 477-03-6341. 12197998 MASON CO LEA 05107110Y3 11,56 AM NOTCE J4160N DRYER H0Y51a Reo Fee: 5204.50 Pa as: 2 INIVII�IdVIv��I�IVVIIII��IIIIIIIIIndVIIIIIIVINV111Vllllu Return 7o -- -D o— n L a Grantor(s): (1) l , - I 14 �;2) Grantee(s): (1).PUBLIC �� Legal Description (1) MJADINGS SUNNY SHORE ADD ir3 TR 24 EX 24-A S 44/119 (Abbrovie(ed lomr:i.e./at block,plef orsection,township,range) 1 2 2 1 0 6 - 5 1 - 0 0 0 2 4 Assessor's Tax Parcel: (1)_ _ 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: 14 Maximum ll Annual Average Gallons Per Day: 950 gallon Dated on th �day of 20�) Slgnatu of Grant / (1) (2) Sta of We ) County ofM7pjl--(' 2 ) Page 1 of 2 I,the undersigned, a Notary Public in�and�for the above named County and State,do hereby certdy that o?this day of L 201, 7ASor1 C 10.E�OJ ptr personally appeared before me,who Is known to be signer of the above instrument, and acknowledged that he(she) (they) signed ft. GIVEN under my hand and official seal the day and year last above written. Notary Public Bate of Washington Notary Public In and for State of Washiri&n, OK BEE KIM residing st L41144W ` y-i.� P1 Ar2 NO. 131550 —� MY COMMISSION EXPIRES My commission expires: /°/,-L--o OCTOBER 10,2026 Page 2 of 2 Individual Water Well CkWater well report(attached to application). Depth ft. �r Well capacity Test(attached to application) �rn V 7 )apd. ltr 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 tesk a well capacity test,which provides stabilization of draw-down and recovery data, must be performed by a licensed contractor. C n SI/Satisfactory bacteriological test(attach to application). 7JK� Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.m.mason.wa.us/planninq 14Y 15 16_22_ Water use or limitation recorded................................... NIA_/ Yes / Well Drilled ............... .............................................. Date l�- 1 �� 2-Z 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 only) Satisfactory Determination: This detenninatlon does not address adequacy of the distribution system,guarantee an adequate supply of water indefin"In the future,or guarantee compliance with all applicable WDOE water resource regulations. Recommended approval indicates requirements of Sanitary Code,Ttle 6,Chapter 6.68.040-Determinadon 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 oft