HomeMy WebLinkAboutWAT2023-00116 - WAT Application - 11/6/2023 WATTS Oo
MASON COUNTY
COMMUNITY SERVICES
BUIIOing PNnnine Envimmental Neyrh Community HealM
415 N 6w Street. Bldg 8,Shelton WA 98584,
Shelton:(360)427.9670 ext 400 4 Better: (360)275-4467 ext 400 •- 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: ! r,Xt�/ 1f Sole I7AYG/nKa Date:
Mailing Address: " 771&xj,'rtr1 y!reo4ed.r111t/4Phone:
Parcel Number: AR3 /O- / �' �Qlili3
Type of Water System 1�,/ Reason for Application
❑ Public/Community Water System (2 or more X Building permit
connections) ❑ Division of land:
Jig Individual water source (one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Springlsudace 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 welt, check the PubliclCommunity 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(W FI)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 (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.
rd£H F.,.A sinking Watu Revised 1:252018
Individual Water Well
Water well report(attached to application). Depth I /ll1,/ ft. (b 00
20 Well capacity Test (attached to application) .10 P. 31!1`e& 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.
X Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htn,//4s.cc.mason.wa.uslplannmQ 14_ 15116 22
Water use or limitation recorded........ ...._.................... N/Ap Yes
Well Drilled ............................................................... Date 1 2
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ I 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 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 Gmwth 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
reasons).
Reviewer's Signatures:
Environ. Health: f--itt "W ' �(" "' 1 Date (t r317_73
CSD Director: Date '°I'
WATER WELL REPORT Notice of intent No.WE52723
- ECOLOGY Urigue Ecology WeII I OTag No.BPS-260
Type of Work:
® Cornmeal Site Well Name(if more than one well:
❑ Dmominiation O Original imlellatnn NOl No, Water Right Perse(Certifmse No,
Proposed Use.. N Domemie ❑mdumial ❑Mancini Prop<rty Owner Name Frank g S lee Maminka
❑Onesserm, 0InipYion ❑Tan WeII ❑Other
Well Street Adders 797 NE Blacksmith IX
ContractionnType: a nhod
Ora
S Nnr yellllAli..,..Alim ❑Oman ❑Inld ❑Gbk Teel City Belh'r County Mason
❑Deepening ❑Other ❑Dag N An- ❑Mu&Rsary Tax Parcel No.22310-711
Dimensions: Diametnafborugli io..to in h. Was a variance approved for this well? ❑Yes ®No
Depth ofconpin<d out 176 h.
Consaction Death: Wall If)'m, that nm the variance for?
Cases, Liner Dared r From To Thickness Snal PVC Welded Load
S 1 ❑ §-_in a14 176 ® 1 ❑ ❑ 1 (J Location Dcc instructions an page 2): 0WWMor❑ EWM
❑ ( ❑ _ _ _in. ❑ 1 ❑ ❑ I ❑ NNy'4'4ofthe NE'A;Section 1Q Tmvnslup 23N Range 2W
❑ 1 ❑ — n — — —sit ❑ 1 ❑ ❑ ❑
❑ 1 ❑ _m. _ - O 1 ❑ ❑ 1 ❑ Latitude(Example:47.12345)47.50377
Longitude(Eaansple:-120.12345)-122 91637
Persimmons: ❑Yes SNo TypeofmarfanlmnaM
No.afprrformires_ SimoWomims_in.to_ a Drilier's Log/Conslrpction or Decommission Procedure
Performed rem nlo_fibelow gmundsWhtt Fomrran'Denudes by rulw.rhos..sir[eformmal mdsuanum.and We kind and
Nmm either mmmal in each IWer Fmmmna.vilh se lent one min far each rbalm of
Sa . ❑Yes S No ❑L-Parhn C Days_fi. information. Vu additional slow dnemsap
Manufmator,'s Nonm Maatlal From To
type Model No. Lt Bm boulders cobbles gravel sand sift 0 3
Diomen_ Slmsice—n.fram —file—(',
Diamarr_ 5Im aim_in.t m _h..—A, Lt gray rubbles gravel sand silty day 3 28
Lt brown cobbles gravel and silly clay 28 125
SonNflller Paek:❑Ym also Sirs ofpxk minimal_in. Lt bream Gasses gravel sand silty Gay assume 125 134
Mm<rnl:Plana from_n.m_Is Lt brown rabbles greased sand sift some water 134 150
Sort .e Seat: N Yea Men To xha deplh73Q fi. LI brown gravel sand silt some water 15D 165
Mandal N[d m aml BFNTD ITE CHIPS Lt grayish brown gravel sand silt water 165 176
Didmyn tablewale' MY. Selo
Type onNm'on am oar Dequ ofssmla Lt brown gravel sand GaYaY sift 17fi 177
M<nmd m a[aling similarly
Pump: Mamdxarcr's Name Type'
H.P._ Punrp intake depth:_it DnilmW flare Me:_cal
Water Levels: Land-sedate elewtion above m a w level_fi.
Smirk-ap of lop of uell caning at R above g[mnd tarmac
San,.air lerel 3.310.belmm cop of.,It rooms, Date 09Y M023
Amen.prima Ila per .me mrh Doc
Alarm x-met is amended by (cap.valve,111.1
WeII Team:
WnapumpiuSan p[r(wmed? NNo ❑Yes O by vhW
Yield _am nnh_R.tandems N<r_ten.
Y,sId_goon with_❑ daadom aher_hrs
Ynld_upon wish_ft dawdavn#ar_has
R<wvery acts(,ime=.,,inn pnrnp is mined aR-van I<mel anomaN farm wdl
IrIP m warm treat)
Time Witter Level Lima W4a Laxl Time WamrLnxl
Doc Of pumping tall
aadrr no, dam with R.demdannafier_Far
Air lest 20 pars ordi cow set at 174 fi.fort Ina. Dole 09DM023passion One ee
Trm men
pssuardxner 'F W'nadmismal mysirmada Oyes ON. Start Odle Completed Date
WELL CONSTRUCTION CERTIFICATION: 1 conswend andice accept responsibility flea conduction of Nis well,and its compliance with all Washington well
construction standards.Materials used and the information reported above arc Ime to my best knowledge and belief
®Driller O Trainee O PE-Print Namc Mark W sse DdlingConspappy, RICHARDSON WELL DRILLING
Signal.. Address PO BOA 44427
License No.24M Ci,Sate.Zip TACOMA.WA 98448
IF TRAINEES mor's License No Contractor's
Sp 's Siemens. Retaliation No RICHAW 3210B Dalc09/262023
ECY050-1-20(Rev09118) /Jlnanemahiadoctmmmnl anahenm.Joa.,plane call the talent&so.Program of 360-407-6872
Pernene,ah heare,loan con mill 711/w Weahmg...Relay Service. Persons vlOr aspect('dlrabaliry con elell877A33fi141.
RICHARDSON WELL DRILLING
Aquifer Test Data
Well ID# BPS-260 Owner: Frank Marcinko
Site Address: 797 NE Blacksmith Or
Pumping Well Parcel#: 22310-79-90663
Pump On 06/18/23 12:30 Pump Off 06/18/23 14:10
Date Time Date Time
Reference Static Level 130.20 Feet Pump Size 1.5 HP GPM
Recorded By Time Water Levels
Date112:38
k Elapsed Time Reading In Depth To Drawdown COMMENTS
Since Start Gpm Water
PATRICK 6/18/20230 0100 6 130.20 0.00
2 0:02 6 132.80 2.60
4 0:04 6 133.00 2.80
6 0:06 6 133.10 2.90
0:08 15 137.30 710
0 0:10 15 137.30 7.10
5 0115 21.5 143.40 13.20
1250 0:20 21.5 143.70 13.50
1255 0:25 21.5 1 143.70 13.50
13:00 0:30 21.5 143.70 13.50
13:05 1 0:35 21.5 143.90 13.70
1310 0:40 21.5 144.00 13.80
13:15 045 21.5 144.00 13.80
13:20 0:50 21.5 144.00 13.80
13:25 0:55 21.5 144.00 13.80
1330 1:00 21.5 144.00 13.80
1340 1:10 21.5 144.00 13.80
13:50 1:20 21.5 144.00 13.80
14:00 1:30 21.5 144.00 13.80
1410 1:40 21.5 144.00 13.80
2ECOVERV 14:11 1:41 131.60 1.40
14:12 1:42 131.60 1.40
14:13 1:43 131.20 1.00
14:14 1:44 130.90 0.70
14:15 1:45 130.60 0.40
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Taeema, WA 988 t`5
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2197286 MASON CO WA
05/1812023.03.20 PM NOTCE
MPRCINNO 4185980 Res Fee $204.50 Pages 2
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Grantor(s): (1) Fi-Dunk. A - (2) Situ Maltle #141miako
Grantee(s): (1)PUBLIC
Legal Description (1)<,z- UU -C'�f n- IV,-I ie3 0( SPFt- -�a'l`T�5
(Abbreviated form:i.e. lot block plat orsection, township, range)
Assessor's Tax Parcel: (1) cZ ), �5 I G -Z I -Z0 (.0 (P
TITLE NOTIFICATION OF WATER RESOURCE INVENTORYAREA(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: I rJ
Maximum Annual Average Gallons Per Day: 61 5l) gallons
Dated on this .fJ� ,,.4day of pilLy__ . 20 a3
Signature Of Granto /s�):�
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
certify that on this y 1*44 day of Ya 20 Z�/ ,
Finakwl faze /lorc.MAro personally appeared before me,who is known to be
signer of the above instrument, and acknowledged that Ue(Ske) (they)signed it.
GIVEN under my hand and official seal the day and year last above written.
Notary Public�iJn and for the State of Washington,
Notary Public residing at /dr-r 0r44 v
G State of Washington My commission expires: 7'"ace;x 8. Z0Z.6
MARK LAMBERT —���
comm.E%P.JAN.08,2025
COMM.NO.14S165
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