HomeMy WebLinkAboutWAT2023-00077 - WAT Application - 4/19/2023 WAT 2a23 -alGb-��
MASON COUNTY
COMMUNITY SERVICES
Building PWmm EmimnmmulNwxh Community Hnitl,
415 N 61h Street,Bldg 8,Shelton WA 98594,
Shelton:(360)427-9670 ext 400 J Belfair:(360)275-4467 ex1400 vt Elme:(360)4825269 ex1400
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. Ana roved buildin site Ian must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: JULIE MANLEY Date:
Mailing Address: 143 MI.Washington Dr.Hoodsport,WA 985M Phone: 360-877-2750
Parcel Number: 22020-75-90090
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more Building permit- 1d2b23.OD4 3
connections) ❑ Division of land:
l� Individual water source(one connection), #of Parcels? SPL
)K Well ❑ Boundary line adjustment
❑ Spring/surface water. ❑ 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)
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)
❑ 1 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.
❑ 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)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.
JBEH F.A Drinking water Recited 1/25/201 g
Individual Water Well
Water well report(attached to application). Depth 1 —ft.
Well capacity Test(attached to application) r%� apm 7?)OOgpd.
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 MID//gis.co.mason.wa.usJpIannincl 14)�15_16_22_
1 Water use or limitation recorded................................... NIA_Yes
1 Well Drilled ............................................................... Date co y �23
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.
rl Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reasons).
qq p Reviewer's Signatures:
Environ. Health: P'C.JP Date , _
CSD Director.
Date 2.f2
[IN RECEIVED cbWROa3 -ooya�
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Lewis County Environmental Health Laboratory Q?Ll
360 NW North Street, Chehalis,WA 98532
(360)740-1237 R�r-��� r=DO—D
IRONMENTAL Nitrate
HEALTH _ Report of Analysis DEC 29 2023
Date Collated: (MM/DDNY) / / 2_1 Time:3oo en_ System Gr . ,( . ee B 6� e
Waters stem ID Number: System Name: -t" s. „e I •-1
Lab Number/Sam le Number. 091/ rC'1 &7 County: f/'1 wSV h
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❑ RC—Routine/Compliance(sausfia mmitwing mqube u) Date Received: (MMNDNY)
❑ C—Conftmatim(confimstinnefcbemiWmulO' Z..
❑ I—IavesRgative(does not satisfy monitoring requirement) Date Analyzed: ,dal l L
VO—Other(specify—dins not satisfy mmpodng requbemrts)
_Date orted>—tun D/YY)-
CO 'ITS:
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S—Single Source ❑ Post-treament(Finished)
❑ B—Blended Dist source numbers in'So .Number Ocid) ❑ Unknown or Other
❑ C—Composite Olttsomce numbers in'Source Number held)
Sample Cp
❑ D—Distribution SamplCollected by:(antic) �
Phone Number: 3Pu
Send Report m• Sperm al Instructions or Comments.
tzwi / k f--
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ANALYTICAL RESULTS
EXCEEDS
DOH DATA ANALYST
N ANALYSE QUALIFIER RESULTS SDRL TRIGGER MCL UNITS (X yes) METHOD INITIALS
Hach
0020 Nitrate-N /^ Jl 0.5 5.0 10.0 mg/L 10206
_ _ ._NOTES: ._
*Confirmation: Include the original lab number,sample mother,and collection date aforismal sample in comment section.
DATA QUALIFIER:A symbol or letter to denote additional information about ire result
EXCEEDS MCL(Maximum Cantamimant Level): Mar d if the comaminmt amount exceeds the MCL under chapters 246-290 and 246-291 WAC.
Please contact the depatment's drinking water regional office in your ma to determine follow-up actions.
tng/L: milligmesperlirermpmtspamillico. -
SDRL(Suite Direction Reporting Limh): The minimum ,portable dee,c ion of an uoelyte a established by the deparment
TRIGGER The deprment's drinking wmrreepome lad. Systems with containment detected at concentrations in excess of this level may be required
takein additional pl .=am frequently Phas,comact the department's drinking water regional office in your area for further inhommon.
INTERPRETING NITRATE SAMPLE RESULTS FOR NON-PUBLIC WATER SYSTEMS
Las than 0.5 mg/L(<0.5 mg/L): Water does not contain significant amounts of nitrates.
0.5-3.0 mg/L: Water in this category should be monitored regularly to determine if nitrate concentrations are increasing. We recommend yearly
testing.
3.1-9.9 mg/L: This water should be monitored at least yearly. Surface land use should be evaluated to determine if there are nitrate sources that can
be minimised or eliminated in order to prevent further(mtamination.
Greater than 10.0 mg/L(,10 mg/L): Some people,particularly infants and pregnant women are considered to be at risk if they drink this water.
Additional information from the Washington State Department of Health is included.
More information is available at the following Washington State Department of Health websites:
I f h P 'I 11) meni,Pub.,331-14.ndf
1111, uwn.d,h,u.eot norms I D:wvm.ius nuns 331 49.nd1
3f.D;Z093 -004a3
Return To 2199718 MASON CO WA
0711912023 01 14 PM NOTU
NRNLEY Y199905 Rec Fee. $204 50 Pages 2
t+tW,.qoa+ RECEIVED
JUL 19 2023
615 W. Alder Street
Grantor(s):(1) ,rnaG M MgNIkY, (0.us2r.E , (2)
Grantse(s):(1) PUBLIC
Legal Description (1) 1 tas 5 `VI9 - S 4Yleii5
(Abbreviated form:i.e.lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1)�
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: 1,4
Maximum Annual Average Gallons Per Day: CIS gallons
Dated on this 30'day of .k7fYG , 20 2�.
Signature of Granlor(s):
(1) M. , (2)
State of Washington )
County of Mason )
Page 1 of 2
I, the undersigned, a Notary Publi in and for the above named County and State, do hereby
ce ' rat on this 30 day of , 20 12
eared before me, who is known to be
signer of the above instrum t,and acknowledged that he(she) (they) signed it.
GIVEN under my hand and official seal the day and year last above written.n
Rene Minard Not '�ublic in and for the State of Washington,
Notary Public
State of Washington residing at 1.lt�
My Appointment Expire) 6/112026 My commission expires:
Commission Number 220 2r6
Page 2 of 2