HomeMy WebLinkAboutWAT2023-00276 - WAT Application - 10/4/2023 • _ WATX0(2,3 - Oo27&
�1 MASON COUNTY
r-N4,lR�'o'i 4�ENTAI. .' . COMMUNITY DEVELOPMENT
-CEIVED
HL A LT H Permit Assistance Center,Building,Planning
`1[_
415 N 69'Street, Bldg 8, Shelton WA 98584, ^323
Shelton: (360)427-9670 ext 400 •: Belfair: (360)275-4467 ext 400 Elma: (360)482-5269 ext 400
FAX(360)427-7787 -? \.Y.!. Alder Street
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: Ac7 \p--• Date: �,+. 4 762-3
Mailing Address: \\63Th St, 01 cdc. i 0I c\ one: zc3 3 \O S
Parcel Number:
r2\v-1.325o \ 00 wNi85.1
Type of Water System Reason for Application
01 Public/Community Water System (2 or more Building permit 0L0,RU -O 1/?
connections) ❑ Division of land:
..IR Individual water source (one connection), #of Parcels? SPL
a Well 0 Boundary line adjustment
0 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.
yq-c
Part 2: Water Connection Information J vv- pa
�J
Complete the section appropriate for the type of water connection being evaluated: �� Ido2S---
Public Water System
Name of Water System: E� �C Si �
Water Facility Inventory (WFI) Number: ()�f_______
(write"none"for two-party)
I am the manager of this wat em. The water system has been appr ved for (J./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'\Elt Forms\Drinking Water Revised 125/2015
Individual Water Well
7,, Water well report (attached to application). Depth �"11 1 ft.
Well capacity Test (attached to application) gpmO 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 14i15i 116n 2211
Water use or limitation recorded N/A = Yes
Well Drilled Date (.0
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)
rkw
Satisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
ater 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:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
�Re/viienwer's Signatures:
V Environ. Health: " �W GO AA v t Date (LI �) �-
CSD Director: Date 2 of
I al WATER WELL REPORT CURRENT
Orfalut a I copy-LeaeeQ.s"w a�-.w..r,are asap-drpeer Notice of latent No. WE237tN0
awrr.at v
ECOLLOOGY Copstrtietioo/Deeommtssioo("x"In etrck) Unique Ewit>gy Well ID Tao No.
Construction Water Right Permit No.
❑ Decommission ORIGINAL INSTALLATION Ply Nadu Skawa s� de
3 Wake of Intent Number
moment%XEa ■ bathe 0 l.daw aI 0 Maniacal Well street Address Grapeview Loop Rd,
WI 0 DsWoer 0 Inleel* 0 Tar Well 0 Ober _.. .__.. City('j�llpevltCw County Mason
or ItroRt: Ow..era osier dwell Venom�••aa3 Location 5$/4414(l/4 Sec Z Twin 21 R 1 &WM 0
0 New
0 Rtto.diiaed Method:❑❑ Cobb:
❑ carry 0 Barad Di Debora
lamed (a.I.r Still REQUIRED) WPM
W M ■ '
DIhtENSiON ta S: Dictcr.f wcu 6 inches,drilled 147 L Lot/Long
oag •
C Doti d sq.ptoeed eau_ft. Eat peg Lai M eC
Q CONSTRucnotl DETAILS (png Deg MidSee
Cages ■welded j_:' Dims doe +3 A.tr AL Ter peed No.(Roquirod)1j1Q�325ri300 .
i.et a ❑anal interne - Die.here a so__A.
0 Ileaded - D .Dion A e it
Me Terbatieme II Yes ■No CONSTRUCTION OR DECOMMISSION 14OCLDURC
Type d prhrsw and Formatioe:Describe by color,chwruar,size of rmnrial;and structure.
C ) and the kind and nature of the material In each stratum pim ente&with at
_SIZE d orb_ .ja by i..rd roe of_petts toe L e_ _ft.erla least one entry lb(a ch change of information. (USEEFIAL AL
saea., • Yet ❑ No 0 K-Poe D,aerde.
'" kinish aae't is. Machine Alloy Works SHEETS ff NBC MA TO
Type stainless Model No. 2
o tin 21s Slot ti hoe ea L to "I ti $atucatati Dime' 2 55
Dhm Slot sac ere e.to s.
O wtrar pWet bane tits& St3 127
rev. cbodi 0 Toe ■ No Sim or greysai d Jr gravel /;27 147
re Materiels placed ban It to ft. i
BSnv�ea Sob U Yee 0 No To e.Yat depth? is E.
a ►.canal.d:real
Did eery aorta muftis aa.a.bk wee 0 Yet ■ No l
Type dense Depth of fates
it Method of Daiwa wow oil
PUMP: Mwf otwor'r Name Ggidds
44. Type.gob H.P. 3/4 .
alas
CWATER Lead-wrG"alevrioa.bow won tee level IL
SY Static E.blow top of war Doe
IC Arwhn paaeae
be.per squire Tact Dec .
eCi W wee:it oonuoud by taaw..M,ate.)
WELL TIETM De.wdowa le moms want level is lowered*Awes mein Impel ;
Was►poop OW wok?0 Yes No ['yet.by whom?
Yolk t•Uei.with__Jt.thavelma after---ors.
o Y- idk, plho.with a dal allow.a ____ t. RE EIVED Z ' V- isit t#�LL with e f t ieawdowo atb hne.
nbswwry foe rows+earn m rna M.prep ewwd Mwc(level eemra/f ow
i ,
rime
Wsoerrow.eve) — P 2 32415
Taae waver Level Tbae wren Level Trine Mary Leal
. WA Sea a Dap'e eM
t _ .._-____. ___ _ ......_ of EG•IOWl _
Dee aces! �
15 Bailer we 15 Walk wit!70 0.etrawdow.after I In.
6 U `I A,4aat ' oil/oils.with ease se at ft.for In-
15 Arenas bow tp.a Doe
rTaspatature d war Was a chemical a.alysis ntadet 0 Tel ■ Na Start Dud/MS Completed Date 2n Ui 6
1 •WELL CONSTRUCT7ON CERTIFICATION: 1 oositivesod and/or accept responsibilky for construction of thb well,and its complMee with all Wauseon well
co naBuctioa standards. Materials used and the information Tepoded above we true to my beg knowledge and bdisf
r Dnita❑Engineer°Trains Name Emit Daub Drilling Cam Dula DIRK t
Driller/Engineer/Tram trainee
Lie No.S9psalors Addles C NI Davis Fs Rd
Driller or trainee License No.3142 City,State,Zip Bee*,WA 9852E
IF TRAINEE:Dikes License No: Cootactor's
Driller's Signature. qt/� Registration No. DAVISD11100A Data Feb 2414
}Fewer' WY esduae(ten o7-1011)L 11 r►.prdr air ararrfi it sienna*far Ike dealt brerdnl .cal Beek,Wares Remrmt Preform
e 30 4S1-r72. Penmen calla bemired haft mg calf Relnittaliiptas RBI Service et 711. Persons with speech arabld&may call 177 a1 t77 33-[141.
Printed From Mason Uounty ®MEN:
Printed from Mason County DMS
Davis Drilling
340 NE Davis Farm Rd
Belfair, WA 98528 L:
fin
DEC 0 12023
Test Pump for: Estrada 2-party
Address:361 E McClane Cove RECEIVED
Grapeview, WA
Well depth: 147'
Well tag: BIH 075
Pump size: 3/4 hp
Static water level: 47
TIME WATER LEVEL GPM
30m 88' 15
1 h 88' 15
2h 88' 15
24h 88' 15
RECOVERY
30m 48'
1hr 47'
26276 T e1ve r '...
Trees Lee NW r'
Ste.0 1.1 SPECTRA Laboratories - Kitaap
Poulsbo,WA
...W1rtre tape rescs maxim/
98370 COLIFORM BACTERIA ANALYSIS FORM
Date
Sample Colected Time(360)77 S e Sample 1 County
N l 2 S 1 2 j Collected 61 ow
Mon* tie 1_1"4-rC
Type of Water System(check only one brink)
0 Group A 0 Group B ArOdief- /t
—
' Group A end Group B Systems-Provide from Water Facilities Inventory()WI):
104
System Name: 367
Contact Person: �ivi,4 1'41}rt.1
Day Phone Call Phone( 3(a) P o/ -4/3 IS
Em Eve.Phone: ---- —
Sand resit b:plot Ail con..adtrw.r4 fro code a.autt they.tor embark copy of mulls)
pt,s.r/►-,ir;,,9' f.ati .i.
SAMPLE INFORMATION
Sample collected by(name):
Speak locaaon where sample collected: Special instructions of moments:
i
e 14 /4c..11
Type of Semis(cftedc only one box)
I.❑Routine Distribution Sample(AlP) 2 ❑Repeat Sample(AlP)
Chlonnated:Yes ❑ No❑ (freer.d'sviettbn system aner a sat routine)
Unsatisfactory routine lab number
Chlorine Residual Total__ _Free
3.Ground Water Rule Source Sample ——— —— " ——
( I 1 Unsatisfactory routine collect date:
Chlonnated Yes No__-
❑Triggered (Air')
Chiome Residual Total__Free -
❑Assessment(IMP)
4.Surface or GWl Raw Source Water Sample(Enumeration) IS 1 l
❑ E.cot ❑Fecal Fired Cos__No
S.earn*Coleciee rx information Dory:
LAB USE ONLY DRINKING WATER RESULTS • Lit USE ONLY
❑Unsatisfactory Total Coifortn Present and 1 tr•�17
0 E.cot present 0 E.coi abseil ( '�
Bacterial Density Results:Total Coliform mpN100m1.E.coi mpn/100m1
Fecal Cotiform _cfu/l00mi. IiPC dullmt.
Replacement Sample Required: ❑TNTC 0 Sample too old
❑ Sample Volume 0 Damaged Container 0
0 ms R Lab Retires Number
)1.1 (:,3 01 -02_
Receipt Temp C': i4WJwd Code: -40 •T-COUNT/Ssttil2D
1w noon r 4.uM tr a...dire prear et wrq le
N/2.54 DUt. Am pw.Mrtl On/tr.4/Ma Wru.aaSYa►,a
3 dears rape..ur..aa.r rd tre.vr.e be report~
Era,pion roYr Is wear haill*rr 310775.5141 nE
OW tab-s.r�ws °"°'•• iejsipej
1A.a wrle rw ny a N.r far ee4 rep rrrVq.)a
010-_3rn Q , -_-- ..r.w►rrrter...v.Twsorteaiaitomonxr.rerorp"
�(�G�.0 rLL idlinOno mw.,Ai spore Df 51Icra Ut Moir
oQtF'wo aftwwwween)
Printed From Mason County DMS .
Printed from Mason County DMS
2203008 MASON CO WA
10/04/2023 03:43 PM NOTCE
CRRLOS ESTRAOE #191448 Rec Fee. 204 50 Pages: 2
111111111IIII111Oil111111fillI{fl'14111111111!1111111UI11111 fill
ReCEs\Ne IE�
1k -3 9 Se W=A. OCT - 4 2023
Erv'JIR.r �ENTAL %N. Alder Street
HEALTH
Grantor(s):(1) CaS , (2)
Grantee(s): (1) PUBLIC
Legal Description (1) LOT 1 OF LLS #10-02 AF # 1998830 PTN OF NW SW
(Abbreviated form:i.e. lot, block, plat or section, township, range)
Assessor's Tax Parcel: (1) 1 2 1 0 7 _ 3 2 _ 5 0 1 0 0
As o-9-
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: 14
Maximum Annual Average Gallons Per Day: 950 gallons
Dated on this `f day of OC, p , 20111.
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
cstrtify that on this 4 day of( �' IQd, , 20 as,
1bS i�S)rtrC, 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.
t•1E M111111,4,, Notary Public in and for the State of Washington,
�\55,oi;•FQ�cs Sh0_ uJ
Oo NOTAR residing at i
F. yr.
21009497 My commission expires: Q(l6 �ZlJ2�
.�,�,:, PUBLIC :off;=
OF WA ,�SN\ �'`,
Page 2 of 2