HomeMy WebLinkAboutWAT2023-00190 - WAT Application - 5/29/2023 WATana3 0619n�
MASON COUNTY
COMMUNITY DEVELOPMENT RECEIVED
P ItMslsta L ..9ulltlln&PWnniM
415 N 6-Street,Bldg 8,SheRon WA 98584, II II 1 7 ?QZ3
Shelton: (360)427-9670 ext 400 4 Belfair.(360)275-4467 ext 400 fi Elma:(360)482526?e#4O
FAX(360)427-7787 615 W. Alder Street
Application for Determination of Water Adequa"'VII'M
MENTAL
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: Marilyn Walbaum &Jay Dunning Date: 5/29/23
Mailing Address: 11632 18th AVE SW, Burien, WAPhone: 206-691-4390
Parcel Number. 32335-50-00031
Type of Water System Reason for Application�ry
❑ Public/Community Water System (2 or more El Building permit b�1080R! vO84�t
connections) ❑ Division of land:
El Individual water source(one connection), #of Parcels? SPL
EI 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/Communily 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 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 xnnection(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(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 Data 5/29123
This form may be scanned and available for public view at v,ww.co.mason.wa.us.
TA [I Pon»n oanki,Wal¢ Revise!hne2me
Individual Water Well
Water well report(attached to application). Depth t b ft.
Well capacity Test(attached to application) I� 7 8 �� cptl.
I 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).
I/ Water Resource Inventory Area (WRIA)
Development within which WRIA http,//Qis.co.mason.wa.us/121annina 14Q 1016022[]
Water use or limitation recorded................................... N/A4�L Yes 17-1
Well Drilled ............................................................... Dale S Q O
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 Corprinunity 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 approval indicates requirements of Sanitary Code,Title 6,Chapter 6.66.040-Determination of
Adequacy for Building permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
n Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
medals).
Reviewer's Signatures:Environ. Health: \'�!"^�T Date oq ( �
CSD Director: Date 2°
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ENVIRONMENTAL
HEALTH
Davis Drilling RECEIVED
340 NE Davis Fann Rd
Belfair, WA 98528 JUL 2 7 2023
615 W. Alder Street
Test Pump for:
Address:2391 NE Tee lake Rd
Tahuya,Wa 98588
Well depth:163'
Well Tag:ACY 849
Static:70'
TIME W81ILR LEVEL GPM
5 m 85, 18
30 m 86' 18
1 h 86' 18
2 h 86, 18
RECOVERY
1 m 75'
2m 70.5'
3m 7d
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