HomeMy WebLinkAboutWAT2023-00253 - WAT Application - 10/23/2023 WAT;V3 -_ 00�3
MASON COUNTY
COMMUNITY DEVELOPMENT
ter I ssl[tawe ren.,,BWidlnpvi
415 N 6-Street, Bldg 8,Shelton WA 98584,
Sheaon: (360)427-9670 ext 400 O Belfair:(360)275-4467 ext 400 4 Elma: (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 buildina she plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Dan & Sara Hess Date:
Mailing Address: 18623 ELDERBERRY ST SW, PdPhone: 360-790-8007
Parcel Number: 31904-11-90020
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more O Buildingpermit 8&bpo,51-3-0/137
connections) ❑ Division of land:
O Individual water source(one connection), #of Parcels? SPL
El Well ❑ Boundary line adjustment
❑ Springisurface water
❑ Other(explain) ❑ ReplacOther ement )
❑ 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 PubliciCommunity 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:
(mite"none"for two-party)
❑ 1 am the manager of this water system.The water system has been approved for services.
There are presently connections)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)connections)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.
J 1EB Forms\Drinking Weer R isd I=018
Individual Water Well
Water well report(attached to application). Depth
^
1111ell capacity Test(attached to application) J `� gpm 7 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.
tisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htto://cis.co.mason.wa.us/olanning 14� =116�22�
Water use or limitation recorded................................... N/Aj�YesA;�
Well Drilled ............................................................... Date 1 7
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 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: 2
Environ. Health:� Date t� �23I2 l
CSD Director: Date 2°f 2
�-o &"Ovjj !,y-Auk
WATER WELL REPORT DEPARTMENT Of NMw ofUrtent Na. WE49709
ECOLOGY Ua qm&o o�WeRIDTag No. SNH769
Typeof Wmk State of Washington
p cmmmtam Sim Well Nmae(ifmorc then one well):
❑ Dc—ieam b On®ml--petite NOl No. Wtlm3Ught PemdUCer55cate No.
P"cad Uu: ODmmedc ❑Womiel ❑Meaiipal Property Owam Name Den Haes
❑Dewetetsg ❑Gnpcm ❑Tmtwell ❑O:hv
Well Street Adds 0 SE Ellis Rd,Lot 2
*New dm TYpa: 0 Dn,e:
O New well ❑Attend® ❑Daivev ❑Jmed ❑Cable Tool City Shelton County Masan
❑Deapmuog ❑Omar ❑Dug m Ae- ❑Mud-Rama, Tex Pmcel No. 31904-11-90020
Dimemiom: Diememrcfbming 6 a.,m 78 _@
Depmofmmple:dweu 79 g W%tevensnee eppmvN fortfiig wdlP OYas OO No
Coto 6.Decal: wen If Yes.whet was[he vmienw foil
Ceeag lieu Diemmu From To Tbiebeass Steel PYC Welded Tired
m I ❑ 6 in. st m 25 io. O ❑ ❑ ❑ 3.00edon(sw Guhuctionswpage 2): mwwM oEWM
❑ ❑ _in _ _in. ❑ ❑ ❑ ❑ NE V/offe NE %;S:en. N4 Townstip 19N RAW 03
❑ ❑ _m _ _ _m ❑ I ❑ ❑ ❑
❑ ❑ _m _a. ❑ 1 ❑ ❑ ❑ latimde(Example:47.12345) 47.16899
Lmrgibele(Ekampie:-120.12M5) -123.05658
Peet dote: ❑Yee Otte Typeafpmfvevamd
No.ofpufinetiom_ 3ke ofPedaeaiom_io.ry_m
Dru Driger'e LoglComt.vation or Oecammimiov Procedure
PeamNedfi®_@m_BEemw pouW surface Fa�metim D .,"cobr,aMnam,au afineaaia mdmmrme,mdmetiM om
mm:a arms termed m a.an Inver pmanmed calm.t lam:am avey fm wL abmp or
sa.ama: 9 Y. ❑Na o x-P.aka, b Depm 73 g iafia.ammuaa um aaaam.l:beau iraaamemy.
MaeAevty aNeme JM. Material From To
Type Slemleu Steel Modal No.
D,mvemr 5 m ,ngea .018 m.,,® 74 @m 79 g Top soil,gwel 0 1
Diemew_ iv. Slmeca_ -term a.m_D. Send, meal sit,bn, N.A 1 10
6aadUnJA,pmk:❑Yes E No siaea'aak muual_a. Stand. revel,sill,bn WNsoft 10 53
Melaiem pleeel8am_@m_@ Sand, ravel SIR,bromIltard cab 53 fi4
suer msem: o xm ❑No Towhu dWm9 16 @ Sand, ravel,SM,bno rdwft, 64 76 cab
MemAl made cal B.nWb Granular Bend siR,vA 78 78
Die evY eam c®rem mwabk wemR ❑Yu ONo
Typeofwatdt Dapmofeem
Merbodofmalinstramoff
Puma, Mmugemu'a Neme WA Type:
NP._ I'mpamke deplA_@ DenlatI&wme:_Spm
Wamrl.wck: l.aa.msaa ekvetam shwa me nukvel_R
Stack-upoflopofwelleauog +1 4aWv R 1auNae
Statacwuealevel 38 gb4ow mP ofwaL wtm9 Dm W172DP2
Arv®ao P:mame_165 puagoueimY Dee
Asuven wemru roveo6adM (cap,vah;era.)
Weana ap�.,xa Wmpagtm perty®Ml Otto ❑Yw b by wbom9
YaldYield_ , R_fl ft.dnwdowv d`ad —idea_hn
_g Net calm_ idea—M.
Yuld_pmae calm_R dnwdawa eBar_tee.
Reeoumy dm(tom=too wMv pump a heaved off-weer level mwzived dote well
Tinke waa
etr Time -level Time WM level Tau Watminel
Dm of➢�aemu' —
Bmbmn_gpmwim_8 d:ewdewvaM_bra.
Aumk N gpm calm rtm.«e n 9.ter 1 an. Data Bn7rz622
Te meimow a _e
Tm pm
mumme ofwmr_°P wuadmoid euelYdn mdCf ❑Yee Otto Start Date 8/162022 Completed Dam E172022
WELL CONSTRUCTION CERTIFICATION: I comtructei aM/oreccept rcsponvbitiry fa era Mmdov oftbis web,end its complimw with ell Weshmgtm will
appgmw5misrn 1mds.3dffim,Wsu"dwnd mkmmafimrepMedabovearctrmtomybartlowwla pmdbelief.
I7lhillu 1)Trei.❑PE-Priru Name Chris Jones DnllinA Company Moerke 8 Sons Pump and DDllln0
S'gnma Cie-,_ Addreas 1162 NW Slate Avenue
❑eeoaa No. 2253 Ciry,Steve,Zip Chehalis,WA 98532
IF TRAINEE'Sponaoi s Lanai No. Coetrmtor'a
Sporn ' Sppadiae Reaishation No. MOERKSPOMN5 Date W172022
ECY050-1-20(Rev IlAB) 7fYoaneed thudocuma immalkm form pM=callrhe WaterReao=u Pragrarnat
3604074872. Pmmmwlahhemmgbm.m0711ft Wahiagton Relay.Service. Pareouwnhaaveechduahfkrycanw)1
877433-041.
Vanguard Laboratory
2635 Pmkmont Lam SW
Olympia,WA 98502
360.967.7010
VANGUARD Report of Laboratory Analysis
LABORATORY
Collected by:
Moerke and Sons Metric Drblkio8 Water
360-748-3805 UWr.ory lD:V221013�
Semlei.,Addrerr: '/ Date Sampled: 10/132214.00
0 SE Ellis Rd — 15,0 -IS S1S TLC r46ftow$ LAJ Deb Received: 10/132215]0
Sh Alan,WA 98584 Date Reported: IN142022
S Ie ID: LOT2
Analysis Result SDRL MCL Units DF Date Analyzed
Total Conform At E.call by SM 92238(IDEXX) Batch ID:VM10134 Analyst Vl
Coliform,Total Negative 1 1 MPN/IW mL 1 10/1312216:00
E.mli Negative 1 1 MPWI00 mL 1 IW13M 16-M
Nknte by EPA Method 353.2 Beach WN2210134 Analyst:RS
Nitrate,(a N) 0,959 0.20 10.00 ng/L i IW13M 17:45
Nobs:
MPN:Mna lho6sble Nmnher
pmn:p per,mlRw
nd:nondnen Reviewed by Robert Smalling Chapin on 10/142022
o1w mat epplimble
SDRL:Sbm Dnwnan Repoa'um LaWt AppmvN by Tod hJurace,Operetiore Managrr as 10/142022
OF:Dilu4w Fatm
albWr
MCL:Mmdnmm Cauem'vi®tleeU Poge l of I
Semple were ercdin rcrepbblewndiaan.The nadgs)inas apoa reline owym th paaanofthc semple(e)RnW.Ali mellaer win ped'mmed wotisam
withdm Qulity Aamaoce Om&lm ofVmmard l<bmabry Plweumaameiebomloey iflou should lays mry9ucsdoreebmadereeWts
2635 Parkmont Ln SW,Suite A,Olympia WA 985021 Office:360.967.70101 wsting@vangnmdlabotafory.com I
www.vaoguardlabmwdsory.mm
2202455 MASON CO WA
09I2112023 12 30 PH KTOE
III IIISI IIHilliII WNIIIIIIk�1111111oil1111d
Return To ��T'V r 1�� S
(eV� eU8 S 7 Sw
r1 ocM sT�n wa4
Grantor(s): (1) Di+A116L j"�SS , (2)
Grantee(s): (1) PUBLIC
Legal Description (1) t VT,'. CFSP#3l4j
(Abbreviatedform:i.e. lot, block,plat/or section, township, range)
Assessor's Tax Parcel: (1) �-1[—
So�{-T19 - 123
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 /�
Maximum Annual Average Gallons Per Day: q50 gallons
sit
Dated on this L day of SEk( 20�3.
Signal fGrantor(s):
(1) ✓� (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 of5—, b v ,20�,
�c�{� G personally appeared before me, who is known to be
signer of the above instrument, and acknowledged t at he(sh ned it.
GIVEN under my hand and official seal the da nd y r la a ve r t n.
otary P and the State of Washington,
`�.�Gyn9TANTO,, residing atMAlOr1 �.bvv`��
`�,�P;•.�sston f�ej,y'.� Mycommission expires: 5'—/0- 2-7
fit
:ti �HOTAaY z
''o�rFo WPSNa,:
ii
Page 2 of 2