Loading...
HomeMy WebLinkAboutWAT2023-00234 - WAT Application - 9/6/2023 • RECEIVED ,if RONMENTAL HEALTH SEP - 6 2023 WAT a,o 3.5--_-_-_ 9:7) It -,r tree III 415 N.6th Street MASON COUNTY Shelton,WA 98584 Shelton:360- - ,Ext.400 COMMUNITY DEVELOPMENT Belfair:360-275275-44674467,Ext.400 Permit Assistance Center,Building,Planning Elma:360-482-5269,Ext.400 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: FUTURE HOME SERVICES LLC Date: ViC/R0, - Mailing Address: PO BOX 2503 GIG HARBOR, WA 98335 Phone: 360-900-9777 Parcel Number: 22302-41-00010 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more .<Building permit bLO 9O2- —0I0599 connections) ❑ Division of land: IX Individual water source (one connection), #of Parcels? SPL I4 Well ❑ Boundary line adjustment ❑ Spring/surface water 0 Other(explain) 0 Other(explain) 0 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) 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. 0 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:\EH Forms\Drinking Water ke'iscj,; :_'i s 4 ,a Individual Water Well w Water well report(attached to application). Depth (-4(0 5 ft. Well capacity Test(attached to application) gpm (?)1vD 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. IX Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://qis.co.mason.wa.us/planninq 14_1516 22_ Water use or limitation recorded N/A Yes Well Drilled Date ( lI e Individual Spring/Surface Water ❑ WDOE permit (attach to application) O 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). 1� �Rneviewer's Signatures: Environ. Health: Y "' 1 Date (0( 3 )7- 3 This form may be scanned and available for public view at www.co.mason.wa.us. Pace 2of2 amosta „...„_..." ENVIRONMENTAL 8L0,309.b- d Id S(.1 WATER WELL REPORT DEPARTM KEALT1�tice of Intent No. WE48063 C EIVF0 ECOLOGY Unique Ecology Well ID Tag No. BLN192 Type of Work: iligNiall State of Washington CI Construction Site Well Name(if more than one well): SEP - 6 2023 0 Decommission r- , Original installation NOI No. Water Right Permit/Certificate No. ^ Proposed Use: :IC Domestic 0 Industrial ❑Municipal Property Owner Name ANTHONY RAYMOND a ❑Dewatering ❑Irrigation 0 Test Well 0 Other Well Street Address 231 TOONERVILLE Construction Type: Method: A New well ❑Alteration ❑Driven ❑Jetted ❑Cable Tool City BELFAIR County MASON 0 Deepening ❑Other 0 Dug E Air- ❑Mud-Rotary Tax Parcel No. 223024100010 Dimensions: Diameter of boring 6 in.,to 463 ft. Was a variance approved for this well? 0 Yes 0 No Depth of completed well 463 ft. If yes,what was the variance for? Construction Details: Wall - Casing Liner Diameter From To Thickness Steel PVC Welded Thread p I ❑ 6 in. +1 453 .250 in. 0 1 0 E I ❑ Location(see instructions on page 2): 0 WWM or❑EWM 0 I 0 in. in. ❑ I 0 0 1 0 NE '/.-'/of the SE '/;Section 2 Township 23N Range 2 ❑ I ❑ in. in. ❑ I ❑ ❑ 1 ❑ 0 1 ❑ in. in. ❑ I ❑ ❑ 1 ❑ Latitude(Example:47.12345)47.512657 Longitude(Example:-120.12345) -122.889088 _ Perforations: 0 Yes 0 No Type of perforator used No.of perforations Size of perforations in.by in. Drillers Log/Construction or Decommission Procedure Formation:Describe by color,character,size of material and structure,and the kind and Perforated from ft to ft below ground surface nature of the material in each layer penetrated,with at least one entry for each change of Screens: 0 Yes ❑No 0 K-Packer r=> Depth R information, Use additional sheets if necessary. Manufacturer's Name_ Material From To Type STANLESS Model No. GRAVEL BEOWN 0 160 Diameter 6 in. Slot size 10 in. CLAY& from 453 ft.to 463 ft. CLAY&B V 160 168 Diameter in. Slot size in.from ft.to A. CLAY&GRAVEL BROWN 168 452 Sand/Filter pack:❑Yes A No Size of pack material in. GRAVEL H2O BROWN 452 463 Materials placed from ft.to ft. Surface Seal: A Yes 0 No To what depth? 20 ft. Material used in seal BENTONITE Did any strata contain unusable water? ❑Yes A No Type of water? Depth of strata Method of sealing strata off stump: Manufacturer's Name GOULDS Type: SUB H.P. 3 Pump intake depth: Me ft. Designed flow rate: 10 gpm Water Levels: Land-surface elevation above mean sea level ft. Stick-up of top of well casing 1 ft above ground surface Static water level 405 ft.below top of well casing Date 9-13-22 Artesian pressure lbs.per square inch Date Artesian water is controlled by (cap,valve,etc.) Well Tests: Was a pumping test performed? ❑No Cl Yes b by whom? Yield 17 gpm with 1 ft drawdown after 4 hrs. Yield gpm with_ft.drawdown after hrs. Yield gpm with_ft.drawdown after hrs. Recovery data(time—zero when pump is turned off-water level measured from well top to water level) Time Water Level Time Water Level Time Water Level Date of pumping test _ Bailer test gpm with ft.drawdown after_hrs. Air test gpm with stem set at ft.for hrs. - Date Artesian flow gpm _ Temperature of water °F Was a chemical analysis made? ❑Yes I!)No Start Date 8-17-22 Completed Date 9-6-22 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well construction standards.Materials used and the information reported above are true to my best knowledge and belief. 0 Driller 0 T 'nee ■ '-— 'rint Name CLAYTON PITTS Drilling Company COOLWATER DRILLING,INC. Signature Address 10921 NW HOLLY RD I License N.1T 6 City,State,Zip BREMERTON WA 98312 IF TRAINEE:Sponsor's License No. Contractor's Sponsor's Signature Registration No.COOLWDI941QM Date 9-20-22 ECY 050-1-20(Rev 11/18) If you need this document in an alternate format,please call the Water Resources Program at 360-407-6872. Persons with hearing loss can call 711 for Washington Relay Service. Persons with a speech disability can call 877-833-6341. Twelve Trees NW RECEIVED Trees Ln stc.0 SPECTRA Laboratories - Kitsap Poulsbo,WA - - ._.Where experience matters S360)774 5141 COLIFORM BACTERIA ANALYSIS FORM Q - F 2(171 ENVIRONMENTAL Date Sample Collected Time Sample I County a� !/3 1202 z Col'ecte ° aAM HEALTH Math Day Year 3 .©a 0 t 5 Type of Water System(check only one box) ❑Group A ❑Group B 3-Other--- Group A and Group B Systems-Prmrde from Water Fealties Inventory(WFI): ID4 _ System Name: ifj rJ I//C / 4 /)-Y d`T'J t-' Contact Person: c o 0 t.-W ri T C Day Phone:3C 0 is 2 n --"0 o5 Cell Phone: Email: ; Eve.Phone: Send rrx'i!h'to:{Pllntfttn name,address and ip code or email above to:electron copy o1 mutts) ; t Z L: %' mot,.. SAMPLE INFORMATION Sample collected by(name): cod LW' rc.L Specific location where sample coteded: Special instructions or comments: 0 If CV r Type of Sample(check only one box) _ 1.r]Routine Distribution Sample(ARP) T 2.❑Repeat Sample(AIR) Chlorinated:Yes 0 No❑ (from dsr1utton system after usat.routine) Unsatisfactory routine lab number. Chlorine Residual:Total Free__ 3.Ground Water Rule Source Sample ——- •- ——— — S ( I I Unsatisfactory routine collect date: Chlorinated:Yes__No ❑Triggered (A/P) Chlorine Residual Total -Free___-_ ❑Assessment(AiP) 4.Surface or GWI Raw Source Water Sample(Enumeration) ISI 0 E.coN ❑Fecal Meted Yee uv _ 5.0 Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS VE ONLY ❑Unsatisfactory Total Califon Present and tisfactory ❑Eco&present 0 Ecofi absent Bacterial Density Results:Total Califon mpN100ml.Scoff mpn/100ml. Fecal Cotform chil100m1. HPC _cfu/1ml. Replacement Sample Required: ❑TNTC 0 Sample too old ❑ Sample Volume ❑Damaged Container ❑ _- atrieM 2 'h7`i`04 Receipt Temp C: Method Code:SM92230/QT-COUNT/SM9222D Ttb recap I.erodaoldt fir rr u.dolio perm a wsc�e b Dalear ...aoyr+odr anra..aeea. DattP 1 4 2022 SEp 5512E.. a , .dzi .errede(s) b/w DOH Lab—Sample 88 Them[� ° enoorN,enFenOe,. / V (^/�r m ale Mebarly r.n urfd endtMP by to iebaaM TW mat that not b. �d•�r O�O• l/�— . ...ad..-_ ^AO.r*o.t Paa"4,,"""El re"wawa bi spars uto-aote. oanl Fans a331319 Oren Oanl) 2202979 MASON CO WA 10/04/2023 10.45 AM NOTCE RAYMOND #191422 Rec Fee $204 50 Pages 2 Return To I IUI U II UI III I II IIINII IUNI IUI NU 1111 INII IIIII I III II it I III UN 11 LISA GRICE&ANTHONY RAYMOND 1701 NE TOONERVILLE DR BELFAIR,WA 98525 Grantor(s): (1) LISA GRICE , (2) ANTHONY RAYMOND Grantee(s): (1) PUBLIC ,C -(' 2 Legal Description (1) TR 1 OF SE V 0(9, f ��J Ip,+� (Abbreviated form:i.e. lot, block, plat or section, township, range) Assessor's Tax Parcel: (1)2_ 2 3 0 2 - a 1 _ 0 0 0 1 0 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: 15 Maximum Annual Average Gallonst Per Day: 950 gallons Dotod on ;i is_ day U'` S Y j , 20 al. Signatu of Grantor(s): (1) (2) Stat ashington County of Mason i • Page 1 of 2 0 A • I, the undersigned, a Notary Public in and for the above named County and State, do hereby certify that on this day of c`Y J(j12/- , 2Ck 2 , Lisu Gtv c-e 4 FrrtN�mi V'uymyvj 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. Notary Pubic in and for the State of Washington, Notary Public residing at _�lam} State of Washington s My commission expires: 075- r1- 0.9077 DEZIRAE BATES COMM.#207434 MY COMM.EXP.03/17/2027 ' Page 2 of 2