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HomeMy WebLinkAboutWAT2023-00224 - WAT Application - 8/18/2023 WAT2.0292 - c aa - _4. , MASON COUNTY L COMMUNITY DEVELOPMENT I. Permit Assistance Center,Building,Planning 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: David Mullen Date: 8/18/2023 Mailing Address: PO Box 303 Grapeview, WA Phone: 253-255-2990 Parcel Number: 12108-43-00020 Type of Water System Reason for Application Public/Community Wa r System (2 Qr more ❑ Building permit 0,2 9)- 0061 10 connections) „=rkfit- t IA26, �11�&isf.Q, ❑ Division of land: 0 Individual water source (one connection), #of Parcels? SPL O Well ❑ Boundary line adjustment O 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. Z�7c t. o�-7 vim-' Part 2: Water Connection Information y_— Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: Mullen Water System Water Facility Inventory (WFI) Number: none (write"none"for two-party) O I am the manager of this water system. The water system has been approved for 2 services. There are presently 1 connection(s) in use. This will be the 2nd connection. O 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 stat nd local re ulation. Signature of Water System Manager Hate 8/18/2023 This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Revised 1/25/2018 Individual Water Well I] Water well report(attached to application). Depth 218 ft. El Well capacity Test (attached to application) 14 gpm 20160 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. O Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planninq 144 15n 16n 22n Water use or limitation recorded N/A=_Yes I 244 Well Drilled Date Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection O 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. i Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). Re/viiewer's Signatures: Environ. Healt �v_ Date((2 7 (2� CSD Director: Date 2°' Davis Drilling, Inc. 340 NE Davis Farm Rd Belfair, WA 98528 275-5367 Test pump for: 490 E Stretch Island Rd Grapeview, Wa July 30, 2019 Well Depth: 218' Pump: 3/4 hp Sub Static Level: 66' Well Tag: NA Draw Down Time Water Flow GPM level 0 min 66.5' 0 5 min 80.8' 12.5 10 min 80.8' 12.5 15 min 80.8' 12.5 30 min 80.8' 12.5 1 hr 80.8' 12.5 2 hr 80.8' 12.5 3 hr 4hr Recovery Time Water Level 0 min 80.8' 1 min 74.5' 2 min 71.3' 3 min 69.2' 4 min 68' 5 min 67.3' 10 min 66.5' 26276 Twelve Trees Ln NW • .. • ` •. ste.c SPECTRA Laboratories-Kitsap Poulsbo,WA • 98370 • :Afters expericitccrsotte►s (360)779-5141 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County I !! 2! 23 Collected :emir /11//1/',�(�', a'7 None Day Year ` : l . ❑PM t Type of Water System(check only one box) ❑Group A ❑Group B Other Group A and Group B Systems-Provide from Water F s Inventory(WFI): ID# 1 D System Name: till J f 1 eVt W i er S,) sl 144 Contact Person: �a v e M J Ile ,^ Day Phone: Cell Phone: ?5 3—�55 Z1k Email:d �U 11,24 [3 fs. e_4,4 Eve.Phone: Send reams to:(Fria kltneele,eddrem end zip code or entail above rot electronic copy or results) Pt) n .u"3 /.r:otpe V1rt s.S , L A- '85 lr SAMPLE INFORMATION Sample ooCected by(name): Dt.J e l P Specific location where sample collected:Y� Special instructions or comments: Type of Sample(check only one box) 1.© ine Distribution-Sammplee((AIP) 2.❑•Repeat Sample(A/P) Chlorinated:l ❑ No L� (lron distribution system atter unsat.routine) Unsatisfactory routine lab number. Chlorine Residual:Total Free_ 3.Ground Water Rule Source Sample Unsatisfactory routine colect date: S I I I Chlorinated:Yes No ❑Triggered(A/P) Chlorine Residual:Total Free_ ❑Assessment(A/P) 4.Surface or GWI Raw Source Water Sample(Enumeration) IS I I ❑ E co/i ❑Fecal Filtered Yes_No 511 Collected for Information Only: LAB USE ONLY .DRINKING.WATER RESULTS- LAB USE ONLY : .. ❑Unsatisfactory Total Coliform Present and • • Satisfactory '- ❑E.co!present ❑E.coli absent Bacterial Density Results:Total Colifomi mpn/100m1.E.coff mpnl100rr Fecal Colitorm cfu/100m1. HPC cfu/1m1. Replacement Sample Required: ❑TNTC ❑Sample too dd ❑ Sample Volume ❑Damaged Container ❑ -_ D 3 /V 3 lab Reference Number Z3 �� L�ot Receipt Temp C': Method {1�1 (� SM9223B T-COUNT/SM9222D 2023 Mt' V3 3 Ties writ to hts>uW Arry use, madttperson aoaetn. by F�V� 02 etende beefs. femme.accrin2 et II ..e oua1e intended recpsnl o ranuna¢sd.r sou bra...eft typal� ante pass node ere sender krtede et 3 6 0-7 7941 41 ad chewn>u.eeou Pron.. DOH Lab-Sample# �( h mete one In M ikons s esamyla 010 r.oavedb7l1s tbaeby.TrspOn shell xst be reyroGuoeun ewers n le,wfat Cnor Wets erten emcee te Spate Lebornorim, DOH Far,flr.319 Weave 96'17) .. 2201026 MASON CO WA 08/21/2023 02:14 PM NOTCE DRVID MULLEN #189954 Rec Fee: $204.50 Pages: 2 1111111111131111111�III III 1 I IIIII I III DIIIII III II I IIIII Ell Return To vi-it,Iii MO ill't ) 7 1-W1f il.6, P1(A - AUG 24 2023 61 r(f€.ViLi.u. LLJA 1 6-h RECEIVED Grantor(s): (1) .I PrV/(1 ,Mul(Ln , (2) Grantee(s): (1) PUBLIC Legal Description (1)1 E. A••C• t .14.),I- Lcr t . T r-1 x ItK-4 I 3 t47/ c ( 12 l (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessor's Tax Parcel: (1) I , 1 v - 41. 3 - 0 L' ! ? (' 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: Maximum Annual Average Gallons Per Day: gallons Dated on this 2[ day of A 050-s , 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 named County and State, do hereby certify that on this l day of gv,,5 , 20 2 , 'O<nvt c tA0\ t,v 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 written. oittlitistoit, ...--------8 ����```Ge•• P••4'i'���� Notary Public in and for the State of Washington, '; s residing at (,� ov (d✓�+`'' : ARY I. S 4..•-‘11 : = My commission expires: 11 12-1 1 Zo 2-6 PUtm.‘G 0: •:bl _ Page 2 of 2