HomeMy WebLinkAboutWAT2023-00238 - WAT Application - 9/7/2023 MASON COUNTY WAT & - 00A
COMMUNITY DEVELOPMENT
xmitMslmM Qe ,,Bmwnr,wmmn
415 N 6-Street, Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 O Belfair:(360)275-4467 ext 400 0 Elme: (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 Id ntiftcation I
G
Name on Applicant: I nDate: 1-1• J
Mailing Address: Phone: �}-j• $rj$ • �{qG.'t
Parcel Number: �Ct1VE �L �d00'�� 1a314. 4a• Soo'So
Type of Water Sy em Reason for Application
El �/Public/Community Water System (2 or more }�, Building permit-614 r=15•010(09
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ 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 N 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 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.
❑ I 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.m.mason.wa.us,
1 TH Forms\pnnking Water RrvisM IQSQo18
Individual Water Well
11OWaler well report(attached to application). Depths ya � ft\
,Well capacity Test(attached to application)7N gpm / ��� gpd.
1 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 0 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 htto://ois.co.mason.m.us/planning 14E=11160220
Water use or limitation recorded................................... N/A M(YasL ZZD(� Z
Well Drilled ............................................................... Date 1r• (S
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 determination does not address adequacy of the distnbution 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 6.66.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A ROW.
❑ Unsatisfactory Determination:
Applicanfs water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures: r
Environ. Health: �Iy� r w .vY " ' " ` Date
CSD Director: ��� Date 2or2
WATER WELL REPORT ----
ECOLOGY uJnrwrnm r[ar+o..�rA±aa _.__
ui..uvrer r_^. I.e tlma Iiv.w:+l ay.� _. W6n 0.:wt1'm[JV('vC9uOc tix.
,�I'[w�yy lfe RUCMc .Imisn¢ pY hYA[PY Unv VNC IfQRPtVL —__....—_��.. _...
WA'4ilaf AAdiam tlE.RpMIsx
M R» nkml <IYkiwl co
I " bxnuR - �.IT[I' GrVr �ti M»}4Mi1 19[1Ntt1 M+ 12319100�113a
jnc..a..c oxJ. rtK6e4_-m.ix�_n 'i' wr.vnm..Wm«w fiJlnu.rlr �vo �e Vu
I Mgve(�wPlrsl mlll n '�
t o Ibo-u++ 51[tl MC'w'[Yi
rlj 8 +_ iW :N y x P! U It[uXn(k M NCf 1 £WWMtA iWM
'] 0 U I O NW � � t r se: -v.ln 1a rawJmm?�aeXA[J>M
w IEP SN4 ....
rrrcfxYYr I Y 3V� }peaYp4run atl ��..--'.
P[ro[r' Igl(n[M1»[{bJ IkcMOL[i[m![a[eAX lnaw♦ xiPf[ 4ImMPk�bl �._ie FUI:w.IbaLeE Na.�brX� mwmi
' f inlh rtw AAm PwNurin � ylutRrX. kY p;m xiei mm! M aryeN
1 ^— mmAw. skL Ihro lYv
li Wmn Yvlos M'ai Yknu -.._ ...._._ I fAPtll�i {I+rvn T �.
3 -
rrv[, w m Aw .. a n erownM ] P3
f.-4wPrPmrpµ.. roe. Ali M Amvm -� aq waI - n ZT _
.mw.armw*In.__ n IL .. osAuwP F Y4 oOPlee _ n 16P.--
�AurM1 s[k tY -M aaM
xo n �P8 swWlr 16o tBs
nr —
.wJe ImMnha3krdmY0.:mlWrtma4 fl m� -j
IMy 4wle im. rtMX MTMwX +I WrY18_ -^— • .i
1 ryrmik pnlueuf 1!\ I J M bm
M qXn �3 JnxMa N � —_.—_—
y
p
I
x Xunl,v.ei iron rY.w.olerol iks wm4vel -_.-_ � �J'
1 I
bk 81 pp wNl ndm»M Mwt Yal btbro —
A �
L Pmm _ W x w!e M mA 'v yPp jjRQiB kW ti �5 0— __
W Cl 1.CRVMI CTUA Ct'11TIVICAT1OV: I caNu[Io1 m11Pettg1 mpiniltWTJ TX[[Plue'+[a'u'A IM xel4 uV 4wPdmr.*'^TL tll W W'leyue wii
..x�8:u[[IaP nertMN•.Mu[:Inlr lual w.V.v�IJ::wuN®mwJ[tl[hnv uetruewmYEul kmriNge Nlllb[WI.
\ � AOds[c 3NlfH Onv FMRrM �_
Con[eaa
F(NOV'F f R &/ v mi11 erm rzler[rweJomxe pl H A I/.uer Ra Y nm NA.itl]M"}
♦wl u
h�•u[ ;:Jl :ng...+.uv cU Jl,lin M'.ukgyuz hin'A+nv R'rnm d rym"J:mAiim Pv A:ildUt
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA.98584
Customer: Marc Gi0in Date of Test : 5/2/2022
Phone : 847-858-4902 Well Tag# : BLN129
Well Site Address : NE Ridgetop Court, Belfair Well Depth : 185,
Static : 152.8
Pump Set: 170'
TIME GPM LEVEL RECOVERY
1 Min 3.5 152.8 TIME LEVEL
2 Min 3.5 152.8 1 Min 152.8
3 Min 3.5 152.8 2 Min
4 Min 3.5 152.8 3 Min
5 Min 6 152.8 4 Min
6 Min 6 152.8 5 Min
7 Min 6 152.8 6 Min
8 Min 6 152.8 7 Min
9 Min 9.5 152.8 8 Min
10 Min 9.5 152.9 9 Min
15 Min 9.5 152.9 10Min
20 Min 9.5 152.9
25 Min 12 153
30 Min 12 153
35 Min 12 153
40 Min 12 153
45 Min 12 153
50 Min 12 153
55 Min 12 153
1 Hr 12 1 153
Thurston County Environmental Health
2000 Lakeridge Dr.SW 6 Olympia,WA 98602
360 867-2631
TNUPSION coa,:vn'
COLIFORM BACTERIA ANALYSIS
new Sell le ColbcW Time Sample Goody
to 1 A3,1 �3 �°I `d
Nord, � Y.. �as�,µ 1'�4t
„ son
Type of Water Sydam lderk only on hoxi ❑ Prrvale Household
❑Group A ❑Group B other ILI
Group AaMGmupBSysWms-Pmvoehom Weer Fadlitieslnwmo (WFI):
ID#
SYNN.Name:
Contact Person:
Day Phone:( lad }}_ 02 Ceupwore:l iti
qlPua-
E.ad: ►$' JA $Mi Ew Plene:l�'17) 3
Serodu 1.:(Pd.Mtn e]hasa ard.11&abnad )
Q f{f SJ/I Aj5m 1 CS IXMA1 ),.CQM
SAMPLE INFORMATION
Sample W Iri(n ):,
r I ter
Specific location or add where sample collected Spedalin otborsorcamedhe
I Gi N� eA�ck�� �
Typo of Semple(must deck only on hoe of 01 through"lend teow)
1.Ei,Routine Ohtrit ution Semple 2.Repeal Sample(after oast rougher)
Chlorinated!.Yes—No— ❑Disldhuton System
Chorine ReWal:Told_Free_ Chorend'.Yes_Na_
3.Raw Water Bourne Sample Chorine Residual:Tool_Free_
❑E.wW-GWR(,VP)
❑Fecal-swra.cx� UnsaddaWq roubw Wh humEw:
Rearad'.Yw_No_ _
❑Asussmenl M1or,toq(AP1 Unaalafev"loutue tolled date'.
❑other
a.❑Semple Collsded for Inleirrellon Only
Inwat9atiw Coneuudonl Repairs_ OBrer_
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unuhefrtfory Total Colifolm Presenlend $etbhofory
❑E.wW present ❑E.cDk alondt detacleO
Req¢ement Semple Requited:
❑Semple too old p30 houa)a ❑TNTC ❑
Bacterial Deny Recalls:Total CClftm I100m1. Ewli I1D)dd,
Fecal Colilorm doodri Entemcocd I100 m1.
Mehmd Coc.jtg.W 9223E ❑SM92NO DxeaMllme Re[mwd.
❑SM 9215E ❑EnYrobd® lout-T3
Doe aM Tnne Arayne: c) ' DLe Repwled: o-
aamde xunua llpMrueY W fnaeabl let Un ony.
0 8 0
!:2—
� _—
2201832 MASON CO WA
GITLIN24,g0576 Re-NreeT%U 50 Pages- 2
���u�� 1111
Return To
rk4c.&Ax no-Gt}F 1,rt
,N59 W mo-rdGn DL
! Um4-f
Grantor(s): (1) prh aL A41in (2) r arc ( W,�
Grantee(s):(1)PUBLIC 19 T 3 I
Legal Description(1) Lo+ $ s t-LC,fl�'16-14/PTT1 OF nu) :,E 4 ow so
(Abbreviated Pomr:i.e.lot, block,plat orsec6on, township, range)
Assessor's Tax Parcel: (1)_L_3_ 1 9 - 4 o1 -t5 O O 3 Q
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: I y
Maximum Annual Average Gallons Per Day: G50 gallons
Dated on this, ``day ofC 2t>3
Signature of Grantor..(s):AA
(1) &1 llivll (2)
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 day of for.k{M r, 20af5,
'Pk11rk7Arft 4 14c,✓�� 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 written.
"'tIONH' n Notary Public in and for the State of Washington,
g 'to
EN
- residingat Soh
NOT�q �:_ My commission expires: ( I I Sr
PUBLIG C
Page 2 of 2