HomeMy WebLinkAboutWAT2023-00223 - WAT Application - 8/20/2023•mmo.
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( Il. °:\, MASON COUNTY
COMMUNITY SERVICES
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%p� tiI� .,. Building,Planning,Environmental Health,Community Health
t,>. �10'
415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 :• 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 building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: —4171. (Ai.Act:: Date: e l /...d3Z3
Mailing Address: Po B.. /72,2_ Ae ;i+y- Phone: 360 poi -5 32.
Parcel Number: f,.) o s— Jc ocA(h
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more %.Building permit vl(1 20212 -00984
connections) ❑ Division of land:
Individual water source (one connection), #of Parcels? SPL
Well - 0 Boundary line adjustment
0 Spring/surface water 0 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/Community Water signature required)
l 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)
0 I 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.co.mason.wa.us.
J:\LH Forms\Drinking Water Revised 1/25/2018
4
Individual Water Well
` 7' Water well report (attached to application). Depth 679 ft. ? g°
0 Well capacity Test(attached to application) /Y gpm Q /a- 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.
Satisfactory bacteriological test (attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://qis.co.mason.wa.us/planning 14_ 15 16_22
Water use or limitation recorded N/A Yes
Well Drilled Date
2 / _ )/ lc(
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
1 Relationship to Applicant
• •
Part 3: Mason County Community Services Evaluation (staff use only)
atisfactory 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).
Revieewer's Signatures:
p (E' r ) ( ( c/Z-
Environ. Health: Date
CSD Director: Date 2"r
i
1/13/2020 Mail-Mike Davis-Outlook
L - ---c--- •
WATER WELL REPORT tl1 PA R I*f v: o r Notice of keen M .WE36742
i ECOLOGY Unique Ecology Well In Tag No.eua„6
type of Wake state of Wtthlost.w+
{ If cornea** Set Well Nathrtifmom than one well: ,
_: 17pcwnrrtbtaion fkigiiut nwuDdauto NCN No.. Water flight permitiCatifica6:No. -------
* t4':'' Prepaarel Ufrn *Donau U ladaorial :a Municipal Ihoperfy()wffrr Nan*
Tqn L itx Oct
U Oe.*w*4 C'Monne U Tar Well iJ Other
Nell Sitrtec Addressfora NE Aiderare�k 1. as
CasearaHhin yrpr ' Gfy Cotatty tHesflrt
Nesrssa3l:' Attention C Donee C Imo! !N Coble Tall
t C tyieepeniep C flthcr._ "a Dug 3 Ain t_".l ud'Rotar!' us ikiodNo 12205-75-00010 .
INr.atsua.: ()wnx xr of tortny 8 a.,to a Vasa voilaeme approved fin this well? 0 Yet I No
Depth of conpiexci welt 69 a,
{ tf yes.what wax the t'erionce foe
C.aaanhee.ft Donau won ----
'3 Cali* L1Lr Humeri Iinm fe Thiekactn Send PVC Welded Mon '
b 111 l El 6 in. t 79 114 M. M 1 0 VO I D Location(sec irutmctig os on page 21: Ids 11 W M a 0 f W M
E 1 CI ad DI' r3 I O ° I of the ,'y�'J.,5echoh 5 Townt)ti YIN R 1W
3 1 0 in. in. ❑ I a L9-1 .0 ` ,r -17-� p` —
0 I El _M. — _in a i a ti I a Iafitudr(kaaattpl 47.12343)
l.onginkde(EXsm see:-I V.12345)_ .__ _____
Porforollimem 0 Yee IR No Tope of perfoeator toad__......__.__.._._.a,..____. 'w__.._
No of porforafions Sur of perfrrratmae is by is >ht `a Log/Construction ar Detorftwtbderr Procedure
Performedfrom ___ft a A.below,
ground ttafa c 1 f-sxmttion-Detailso by(Am,sluraxtes.cur.of material had ontology.end the kind and
swore of the tomtits!in each foyer pcneo ttal.w lk at kvat;no ruey fa each chants'or
Steles: i!f Yes n Se �a K-Packer Depth 76 d tnfntmarion. Use addnionalahees ifnaec.:yy
? Maritillictierar e Natm 49W Msrldns Worltd Mimeo! 'Plain, To
Type stainless Model No. " _
Dranxtsr 5 M Sea sore 6 at.fmm 711 A.ra 65 a~ Dark brown loose sand and_g_nvel 0 15
nuieti v in siateice in,from�,.R.tt! 9. Light browncon�iomerete 15. 40
i roosid tyrrpeck:C,Ye* S No Sire of peck nnnriai in. Brown sand and pr8V4i 40 65
Msta4ek plead boat 1t to_ n. Brown clay 85 75
Brown sills sand and water _ 75 95
Sorbet$oak a Yee G No to ulna depth?25 it Blue day 95
t Motorist twat in btol btertlortrae
Dui any ova mane aataabto wool' C.Yec 4 No
1 Type of water' Depth of mtron
Method of ceatiog straw off
Pimp: Mrtuf eener's Name caundlOAi Type sub
N.P.1/2 Pwtp Intake&ion:85 n. moaned ftm osec.10 I Warr Larvik Larvik t.aal-wrtacs elevation abo.e maxi sea levet_a.
coon ft
Stitt-all of sup of well coabove ground t efeoe
Some wafer keel 70.5 it below top of welt caging Dote 12/2009 s---
Arrramt pressure gm per gene glob Due
Munn water n avnwnakd f' (cap..wive,etc...
i
Well T'eai:Wu$pnatpeng test pet forint t' 0 No V Yn c by wfiemr Side Y
11 Yetd 1.5 wen with 16 6 dnwAtwn otter 5 her,
''i Ymld gptnwith A.dtaodownonte link
j Yietti_apn with—,ft.dravnknvn nfkt*hoc
Anvwrrydataatinm-Avewbenpwt tistoatrtdoff-wow kseltnea.tned from Weil ^..__
op to water ksei) ,�._�
Time Water Law] Time Water Ireel Ttme Wilier level -- "'
T rtM 79 4 min 76_3 3
2 non 78 6 min 75.5 1Q_nv_ 72
Poe 70.6
. 3 mat 77.11 _� _____
Dote of ponying iest 1=249__
£toti T_—
Rider h+t gym whit A drowdoon:An_T D eo 1 I
Air leO _ teem cot rpm w tb tee cot Cr_T___ft.Ito M_,Ma 1^Do t
Aroma'how_will
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lomperotior ut water--,'I Wm a chemical onatysu mule° ®Yen 0 No Stott nuts 10113119 Completed .I2f10119
4 ,i WELL CONSTiRUCTION CERTIFICATION: 1 cantstn,cted and*accept respantabilfty fix construction of this well,anti its militant Washington well
i conatnhnion.standards.Materials used and the information reported above ate tote to my hest knowledge and bend.
t+'Millet❑Trainee El PC-Print Name Emily Davis __ ()tilling('oenpany-Davis DriMtng
j SignatureCtioc ---- ----- Atkhrx+340 NE Davis Farm Rd —
lactase No.3142 —� City,State,Zip Buffett,WA 98528 i
IF TRAINEE:SpOosor'e License No. Contractor's
_Sponcer'x Sigfawne .Re/is,mim No.DAVISD11100A Uafc DEC 2019
ICY 050-I.20(Rex(nlr 19)lJyvta salt env dui angst in tea sifternntt f+arrrut.please cull the Wok,'?Imams Programa/.160.40Xfitf7?.
•
Per-minx work krrrrrag leaf,,can rail 7l1 jnr ll mki,pftwr Rekrc Se rvicr. Prisons with a spleen rffsahilin-.on tall f177.833-6 t4l.
Si
https://outlook.live.com/mail/0/inbox/id/AQQkADAwATYOMDABLWE2MDctYjOwNCOviM' AltMDAKABAADhdyn5pNsOeljgoATo65EQ%3D%3D/sxs/AQM... 1/2
. . . •.
Davis Drilling
340 NE Davis Farm Rd
Belfair, WA 98528
275-5367
Test pump for: Lincoln
Pump: 1/2 h.p.sub
Well Depth: 89'
Static Level: 70.6'
Date: 01/02/2019
Well ID: BLN116
Draw Down •
Time Water Level Flow GPM
0 min 70.6' 0
1 hr 80.4' 1.5
2 hr 80.4' 1.5
3 hr 80.4' 1.5
4 hr 80.4' 1.5
5 hr 80.4' 1.5
Recovery
Time Water Level
0 min 80.4'
1 min 79'
2 min 78'
3 min 77.1'
4 min 76.3'
5 min 75.5'
10 min 74.4'
30 min 72'
1 hr 70.6'
2 hr 70.6'
1 1786 SE Mile Hill Dr.
Port Orchard,WA 98366
J SPECTRA Laboratories - Kitsap (360)443-7845
...Where experience matters
IOC TEST PANEL
. Complete or Selected Inorganics
' System ID No: System Group Type: Private
Sample Number: 225 41902 System Name: Lincoln
j Sample Location: Wellhead County: Mason
Sampler:
Source Number(s): Sampler Phone No:
Sample Purpose: Investigative Date Collected: 12/26/2019
i Sample Composition: Single Source Date Received: 12/27/2019
Sample Type: DW:Untreated Date Reported: 1/15/2020
Send Report to: Bill to:
Davis Drilling Davis Drilling
340 NE Davis Farm Road 340 NE Davis Farm Road
Belfair,WA 98528 Belfair,WA 98528
' DOH# Analyte I Results Qual. Units SDRL Trigger MCL Exceeds Method Analyst Analysis
MCL Date
0008 Iron ND mg/L 0.1 — 0.3' EPA200.7 010 1/2/20201
! 0010 Manganese 0.050 mg/L 0.01 — 0.05' EPA200.7 010 1/2/2020
Tannin I ND 1 mg/L 0.1 — — SM 5550 B 010 1A/2020
NOTES: Sample_Number: 111419-02
'Confirmation Include the original lab number,sample number,and collection date of onginal sample in either lab or sampler comments section.
SDRL: (State Detection Reporting Limit)The minimum reportable detection of an analyte as established by the department..
Trigger Level: DOH drinking water response level.Systems with compounds detected at concentrations in excess of this level may be required to take
additional samples or monitor more frequently.Please contact your DOH drinking water regional office for further information.
MCL: (Maximum Contam:nant Level)If the contaminant amount exceeds the MCL,please contact your regional DOH office to determine follow-up actions.
NA: (Not Analyzed)In the results column,indicates this compound was not included in the current analysis.
ND: (Not Detected)In the results column,indicates this compound was analyzed and not detected at a level greater than or equal to the SDRL.
<(O.00x): The compound was not detected in the sample at or above the concentration indicated(usually the lab method reporting limit).
mglL: milligrams per liter or parts per million.
NTU: nephelometric turbidity units(a measure of water clarity).
Nmhoslcm: Micro ohms per centimeter(a measure of the ability of the water to conduct electricity).One micro ohm per centimeter is equivalent to one micro
siemen per centimeter(uS/cm).
—: No existing trigger or MCL value.
1: Secondary MCL(Established for aesthetic purposes,not health based).
Lab Qualifiers Comments:
010: Analysis performed by Spectra Laboratories-Kitsap,LLC Lab-Sample#:010-7520I.
Approved By
Jessica Miller
Laboratory Supervisor
111419-02 Page 1
Thurston County Environmental Health
• 2000 Lakeridge Dr. SW Olympia,WA 98502
360 867-2631
,
D j L �0�3 _ °O0\>7 COLIFORM BACTERIA ANALYSIS
L�L, Date Sample Collected Time Sample County
Collected
1 1,1 D 5- / / Q°° I p Mandl Day Year
Type of Water System(check only one box) ❑ Private Household
0 Group A 0 Group B Igr Other_$ � (
Group A and Group B Systems-Provide from Water Facilities Inventory,+CFI):
ID# ---
System Name:
Contact Person: `""Trik._
Day Phone:Lido)get -$ 5 3Z Cell Phone:(34,0)f s0/ 2
E-mail: + j i,,,4 giP 4 put l)�CI: A Eve.Phone:( )
Send results to:(Print full name,addreafki zip code or email address)
• - 3 DLO :r- 1.0A- 98Ss8
SAMPLE INFORMATION
Sample collected by(name): r� L 1 h,k
Specific location or addr s ere sample collected: Special instructions or comments:
y7ouE I-141erC'eeK-
LAws- . ete
Type of Sample(must check only one box of#1 through#4 listed below)
1.14Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes No X ❑Distribution System
Chlorine Residual:Total—Free_ Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total_Free
❑E.coil-GWR(A/P)
❑Fecal-surface,owl spivs(numerafon) Unsatisfactory routine lab number:
Filtered:Yes No
❑Assessment Monitoring(AIP) Unsatisfactory routine collect date:
❑Other / 1
S
4.0 Sample Collected for Information Only
Investigative Construction 1 Repairs Other
LAB USE ONLY DRINKING WATER RESULTS ,�LA/B USE ONLY
El Unsatisfactory Total Cordon Present and l Qt 4tisfactory
❑E.coli present 0 E.coli absent
`io Coliform detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑ _.--
Bacterial Density Results:Total Colifom' 1100m1. E.coli /100m1.
Fecal Coliform 1100m1 Enterococci 1100 ml.
Method Codet4M 92238 ❑SM 9222D Date and Time Received
❑SM 9215B 0 Enterolert® tC .t 1p 13 115s
Date and Time Analyzed: rev• I Z3 Dale Reporte.•let1,334
Sample Number(DOH number plus digits) Lab Use Only:
0 8 0 c ZLt
tLt•319 revgedQlrlo0 7
Return To ' 2200999 MASON CO WA
08/21/2023 09:21 AM NOTCE
1 1117 L111 CC1I ! LINCOLN #189929 Rec Fee: $204.50 Pages: 2
der i ca1 ie52h
Grantor(s): (1) i W( L✓I I'1C.vI ►) , (2)
Grantee(s): (1) PUBLIC
Legal Description (1) le- I (1 11C I ll,C.; i (" 4-1 Cat 6.71}r V ')-S'')
(Abbreviated form:i.e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1) 1 9 L1 5 - rI 5- 0 0 0 1 O_
S O A
TITLE NOTIFICATION OF ER 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'7
Maximum Annual Average Gallons Per Day: i 'ci gallons
s� 1
Dated on this 2- t day of , 1 V `\ , 20 Z
Signature of Grantor(s):
(1) , (2)
State of Washington
County of Mason )
Page 1 of 2
I, the undersigned, a Notary Public in and for the above na d County and State, do hereby
certify that on this 21 day of A"1.)90 5 k , 20
Ira°-NAL.tv\co kA 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 abo e written.
GASI4Rl a'gc�, i,�� Notary Public in and for the State of Washington,
sok
•• y residing at kVIN S U v\ U..}✓1±
sOTARy
111.•.4 ; = My commission expires: 1 i 12cl l
PUBLIC
• •
•
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