HomeMy WebLinkAboutWAT2024-00091 - WAT Application - 2/1/2024 WAT
MASON COUNTY
COMMUNITY DEVELOPMENT
E%`VIRONMENT ,.awla,.,Pl.n"tv _ IVFD
415 N 6r Street Bldg 8,Shelton WA 98584, F
HE, 350>427-9670 ex 400 ? Belfair (360)275-4467 ext 400 4 Elma:(360)482-5269 ext 400 a 0� 2n?S
FAX(360)427-7787 4 V
Application for Determination of Water Adequacy der Streot
Instructions
1. Complete Part 1. No determination can be made until Part 1 is fully comoleted.
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 buildingsite Ian must accom an this a lication.
Part 1: Applicand Parcel Identification Ii
Name on Applicant: Date: 1,
Mailing Address: / . Phone: t" e2n 4 �D�
P y L I Z - 'y$ ' ,�
Parcel Number: L17(
Type of Water System Reason for Application n��f
❑ Public/Community Water System(2 or more ■ Building permit 0W96aq—00 04
connections) ❑ Division of land:
6 Individual water source(one connection), #of Parcels?_ SPL
j9 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 connections) 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)connections)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 v--ly co easua iwa,us.
J'.�EB F. Drinking W--
Individual Water Well
Water well report(attached to application). Depth y� `� R. (�
Well capacity Test(attached to application) l gpm pit.
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 9 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 htto//qis.co.mason.wa us/olanning 14[—_]15[--]1220
Water use or limitation recorded......... ....... .. .. . ...... N/AL)f—Yeses
Well Drilled ...............................................
Date Z 2" —I
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ 1 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 : Mason County Community Services Evaluation (staff use only)
Satisfactory Determination:
This detertninatron 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.
Recanmentle0 approval indicates requirements of Sanitary Code,TNe 6,Chapter 6.68.O40-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).
Reviewer's Signatures:
_
Environ. Health: _ � --1 Date
2 of2
CSD Director: Date
L-L) ►�j1d 20'l -bo2o�
q �MM�ARe�14 2024
id
WATER WELL REPOT 6fvAiliaR@M1°` Notice of Went No. VJE55225 �qR
ECOLOGY Uniquo clog Well W Tag No. BPF166 6
Type Ufw"L state of Nohingten Site wall Name then oam well):
'� co�,wmoa
❑ pecommimlan o Pi®,ulixmlkoonn NOl No. WGkr Right Perinil/Cim Tote No.
p.opmad Uac pNomeatic ❑ladmhial ❑Mmcipl PrOPMyG Namo --- -"r
❑OcwUakg Olnimerion ❑Te+Wtli ❑Ubr Well Sae,,Address l IEWeDS Hill
cUkxm.Trp: City Urdon Cowry Mason
O N=ZU ❑Allmetioo �� 9 ❑°mhdLaeY T.Parcel No. 42124-439 "
❑IXaPmdom ❑Pb
umemiom: pno+mofbodq 8 Ina..-278 6 Wasavxixrcsappfwdfurdhi' lIP ❑Yes ❑c No
DePAof,,,u,,wea 278 A. Wyp wM1elwv Ne rvircefmT
C�Vmtle Debt: Wig
iw lI ❑ it m l
2� knmen sm+ PYc WPBrd 7hemd
.25 im O 1 ❑ 01 ❑ (.oration(ax tnmucuwson page 2): �WWMd❑EWM
❑ 1 ❑ _m _ia ❑ 1 ❑ ❑ 1 ❑ SW '/«%id dha $E 24 Towuhip 21N Range 4W
❑ 1 ❑ _m. _ _m. ❑ I ❑ ❑ 1 ❑ latitude(EUnple:47.12345) 47.2s73B
❑ 1 ❑ _w _ _ _is. ❑ ❑ ❑ ❑
Longitde(ExemPle:-120.12345) -123.12g55
PeeMeee: ❑Ym ONo Type e(pm6a+m vd ihmles l..Wic.et—doP or DeromeWioe Prxedmm
No fpmfbraxr_ Simdpm6ss�xlN_x FmmeliaO:IXmah by mbr,cherenv,as of:xu:islydmucaU..d We keeled
Pxb:md Lom_flm_LWb Foeidr+Lm sme0(We imaeaial io mch kyerpmuxmd wiNtllem�om may lnshebmge of
gores: ❑Ya ONo ❑K-M1rla d DMh-�fl i°romau°o Ux Wdluo MuriMatist el ir:wmmuv
From To
Mmu6cnNaNme ° 5
Type MokINo. R. ravel,mR and to it
Dimmlar_ Sbtux_n am ft.
GMIlmaitthasM ravel. Lis 5 14
amaam_ sw® k.eom _Lm_ floe to medium send aM revel U 38
Se::dlFamr perb O Yx ■Ne 9rte afOxe m+++l�m BIOwn fiM to medium amid 8M mull 38 5B
Mawnak died 5om_am_R. Br floe to medium send and revel,wee a 80 84
BmWrn fire to medium Ord and revel 64 11]
sortm sml: �vm ❑No Towh+mM719 6 117
M.msalxad in and BeMonite Ud Brown finese mld5cdored floe tD medium
Didr:ryemb coobio:vwaehk wue/1 OYm ON.oi read,some stage
mSe 135
Type Orwaen IlapNdahW Fire to medium meM,nnMFedored read, 130
Md:d ofoolws scoff Bot".Wet 13
Tap: Brown fine welandsand, 135 in
PUP: Msfacnam'a Naze Sow:U_@m 130 152
x.P._ Pump kwe myk._R. akaipad Fmoto medium eau ,a,,,.=W,- omd oa M 152
W+erteMr: ImM:c4ce eleMion shove mmn+m keel 3�a fl Brown fine to nxUum seM,muRi-CaIORd ravel, 181
Still-a:pofuoofwellcxiog 2 Aebove B:omW nvLae am",w 784 187
S:atie wxmlevel_R.bebw apafwea urion D 2/23124 Brown fire sand,wet 187 175
nnmkapewme_mx am wxn:ah D+' Brownfine ravdafldsand
gnmimwmmkwmmuedM lraxNe. ) Brown fine sand.mufti-cdared 5lse W medium 175
210
w+ITm@ revel,moist 210 257
WmeVwipieB ttp prlbamedR EN- ❑Ym C' q'aak®9 Brpyar 5ria tO madm118aM aM raMl 257 280
YieN_@m wiN_R.duM:mnanm�hm. Gra %rid aide
Yuld�@mwN,_ftdnwdown anm_ka Brpym eras l0 medium saM am
Net 280 28g
YWd— hm 28B 272
pmovmydW(dme=mmwbnpmq kau:md all-wabM mmneed Rem wetl G. Brlem mend e M ravel d me 272
gpmv+mkM) BfOND flrle to meta mea arq revel. 278
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Aalerivo Row__@'°
N um Date 222124 Ct)"od Dde 21=4
hmp:+mc0rwemr 52 of Wmarl+mixlwalyak m+kl ❑Ym � o S.
WELL CONSTRUCTION CER'TIFICA'f1ON: 1 cwalta:dd adla ececptrxppNLiliry fd comwction of tM1is Nell,and ib wmplim:ce with ell Wuhimglon wall
cwsrructian standerda.Materieb:asd and Ne informMiw reported eEove U Wew my 5m^krws dge Arcade
Dml lac.
am
o Driller❑Tavae❑PE—printN D Addres PD Bo coss ss--
Ci Sue Zi StxeU,WA 88584
L aw:N 2053 Cwomlor's
W TRABBEE:S 's Liprec N . gagisaMbn Na.ARCADDIU98K1 DU 22329
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ECY050-1-20(Ra,N/18) I/3rouoaoddilsdavmenl N an oha.efo ,,Flowr mllaha Water Resources Program as 3R0.401-6g72.
Pe:um+wuh hearlrg lax*can cdl7lll rWashirgron RabY Servin. Parsons wish aspeech dnblllVo, :mII877-8334341.
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA. 98584
Customer: Jacqualine Case 8 Jack Dalton Wall Tag#: BPF166
Site Address: 11 E Webb Hill, Union Depth: 278'
Date of Test: 3/7/2024 Static: 203.8'
Pum Set: 260'
TIME GPM LEVEL RECOVERY
1 Min 5 214.6 TIME LEVEL
2 Min 5 204.6 1 Min 203.
3 Min 5 204.6 2 Min 203.8
4 Min 5 204.6
5 Min 5 204.6
6 Min 5 204.6
7 Min 5 204.6
8 Min 5 204.6
9 Min 5 204.1
10 Min 10 204.7
15 Min 10 205.6
20 Min 10 205.6
25 Min 10 205.6
30 Min 10 205.6
35 Min 10 205.6
40 Min 10 205.6
45 Min 10 205.6
50 Min 10 205.7
55 Min 10 205.7
1 Hr 10 205.7
1 Hr 10 Min 10 1 205.7
• Vanguard Laboratory
2635 Parkmont Lane SW,Suite A
Olympia WA 98502
oA488AF® 360-967-7010
COLIFORM BACTERIA ANALYSIS FORM
Dabttwple CCBxded Tea,Samb Cmay '
03/07/2024 pat . aoat Mason
win IMt rae — —am
Typed Waa Syeban(droll allyane bos)
❑Gm A 0Gmup8 ■DBror
GmpA as Gmup B$}stalls-Plmide hen Water Fatlitlee bWnssy(WHY
IDS - - —
SystanNane JACQUALINE CASE
Called Prim:Arc"a Drilling.Inc
Day Plmne:(3a0 )e2"395 CM PSme:l 1
Erase:
Smd rp W a K(RiM M sere.Me ee jess eN zb woe a email
MMa®vuEuYJergran M^®rmEleblllmgmm
SAMPLE INFORMATION
Sanph Wleded by(name).SHAD
Specific%atim v .sampb wiefti: Speial betrm5msaammetb:
BPF166-11 E WEBB HILL,UNION
Typepf Semple(aWdmy we We of sarpk has was 1 Mtwo 5 bebw)
1.0 Router DistilbNbn SaMle(A(P) 2.0 Repeat SearPle(AP)
Cbtonnatacl Yes No (I.akelbubon 11.a arumd m0*
Unsatisfactory mobs¢lat,number.
Cbbnne Raedua'.Tabl_Fina_
3.Gra�ual Wa e�WRut� Soum�e San,PN Unse mbafedory ecallectdab:
LS f
chwraw:Yw_No_
❑TNBgamd(w) Cblonw Res"Tdel_Frte_
❑Aesewmat(A )
q. Sudecem GWl Rae Sourw Wax Sample(EnumaaDml l e l
❑E cal ❑Feral
5.■3aroleDda.%b d bmmaim ary.
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Uraahhdory Total Cdifam Ptwwt aid �Sa6aedory
❑Emfvesent ❑E.royebeent
Becbda Dwahy RwuBe'.Tebl Catdam I10anl. EaY 1100m1.
Fecal Cdifom 11ODm1. MPG neat
Raplawmwt Semple Raqukad: ❑TNTC ❑Sawlabonld
❑ Sample Vdume 000magw mbiner ❑
i' �12.4U `�
Terp bbane 0,Ka'.
Oab ReP-b DOH Iab Om Odr
WH 1 .10ae
285-
na.,� , , am_.atieaew.e....a. amr,a„n
2207116 MASON CO WA
H IV
E D 02/01/2024 12 46 PO NOTCE
�r C JRC11146E CRSE F190fi91 Fec Fee E304.50 P.Bes. 2
ENVI- DNMENTAL IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII1IIIIIII
FEBdd rS J�L10,QVR {-wRc)4
HEALTH
49
fur To
_�ider Street
u
t
Grantor(s): (1) P / (2)
Grantee(s): (1)PUBLICPTN SW SE, WILY OF R/W EX PARCEL 2 OF BLA#94-64
Legal Description(1) TR 3 OF SP#2573 AF#605143 S S 53/216
(AbbreWated form:Le.lot bkck Plat or sewon, township,range)
Assessor's Tax Parcel: (1) 4 1 2 4 _ 4 3 _ 9 0 0 1 3
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: 16
Maximum Annual Average Gallons Per Day: 5,000 gallons
Dated on this day of, . 2024.
Sig t o G nt r(s):
(1) (2)
State o hington )
County o Mason )
m'UC /2'
.Oze�sP!v'y
t- = Page 1 of 2
nM :�C>C
IA`+Nd`�•
nnoo
I,the undersigned, a Notary Public in and for the above named County and State,do hereby
certify that on this day of , 202a—,
��o.c.r n llne A. Cx a peraon IN appeared before me,who Is known to be
signer of the above instrument, and acknowledged that he(she)(they)psigned i/t.
GIVEN under my hand and official seal the day an ear la bove wr �
" E.PUC/Oi�i.f i Notary Public in and for the Stale of Washington,
�e? slon �
o�ry3t27B�'iaTJ"- residing at S �U A
•U NpTAHY t c My wmmission expires: �-r3ll'J3 L iG PUBUG yy4T�'2c
1111110
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