HomeMy WebLinkAboutWAT2023-00336 - WAT Application - 10/19/2023 ENVIRONMENTAL
HEALTH wwT - �o331n
415 N.Bh Street
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICE E C E IV E D Shelton:360-427-9670,Ext.400
Belfnir:360-2754467,Ext.400
\ M,itdnry Ming Emi,mmenuI H4th.Comm I, HMIM NOV 21 2023 Elms:360-482-5269,Ext.400
Application for Determination,/ogldW& Adlaquacy
Instructions
1. Complete Part 1. No determination can be made until Part 1 is fully completed.
. Complete only the portion of Part 2 applying to the type of water connection utilized.
. Submit completed application, with any required attachments for review.
. An approved building site plan must accompany this application.
Part 1: Applicant/ P rcel Identif/ir/a/lion
NameonApplicant: Wadew alp* frtol D..a�tt1ee�: ID /� .Z p
Mailing Address: Q I-ft C htfn 6 ' 1 B
Parcel Number: Q O /
Type of Water System Reason for Application t'
❑ Public/Community Water System (2 or more Building permit Of,12R02 3
connections) ❑ Division of land:
Individual water source(one connection), #of Parcels? SPL
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 Public1community 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.
1'.\EB Fomu\Drinking Waw Revised 4/4/2018
Individual Water Well
Water well report(attached to application). Depth O� I ft. y�
,Well rapacity Test(attached to application) 1-0 gpm pd.
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://ais.ca.mason.wa.uslplanning 14*5_16_22_
Water use or limitation recorded................................... N/A_Yes ILI
WellDrilled ............................................................... .'Date A
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 3: Mason County Community Services Evaluation (staff use only)
atisfactory 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 Pernits 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).
Reviewer's Signatures: -7
Environ. Health: t • I Date
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
WATER WELL REPORT DEPARTMENT OP Nod..flnkMNo, WE54784
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Si a Addmu PO Box 1790
Ucmme No.2874 �� Cit,,Sum,tip SheBon,WA 88584
IF IRARVEE:Sromar's Liu o. CmhacWr'S
Spon50i s Sipature Repjshtllon No ARCADDOMIK1 Dam 11924
1C 050.1-20(Rc09/18) (/paP used rhfgda:Pmem loan alkrrNkfammE pteate mil the Waur RstomttS Pmgtamu36a197d312.
PerSom with hearfrgfon inn rn11711 for Wa+hilMmn Rcby SeMce. Perzov wiNa5lzech dSaNttrycan oil S77-033L3If.
v anguara 4.amramry
2635 Parkmont Lane SW, Suite A
Olympia WA 98502
a Lj1,LaD 360-967-7010 Lj kLA
COLIFORM BACTERIA ANALYSIS FORM
Dab Semple DollecleA Tim Semple County
callede0 02/13/2024 ' ' ow MASON
NwN De Yu —•—�RI
Type of Wamr Syslem(died only one boa)
❑GmapA 0Gmup6 ®DNer
Group Aand Group 8 Syeleim—Provide ham Wakr Faciliam hiwnbry(VFI):
Do
sPhan New: BRUCE CHITESTER
Contact Peron:Arcadia DNlling,Inc
Dry Phaw:(360 )426-3395
Emil Ew.Phac( )
9ed heei4b:lAid Nll neap,manusad eptose memi)
Ybp®suEle6iq.[an ANO NM�waIMNI W.mm
SAMPLE INFORMATION
Sample oNklecl by(name):AI DEN
spedlicl°mlionwhemaawlewlkcheE: Spadeliwbmaoro noammenb'.
BPF115 7530 SE Lynch Rd,Shaltpn
Type of Semple(sekctmy one type of sample ham types 1 through 5 below)
1.O Routine Dls Po i$in Sample(AIP) 2.O Repeat Sample(W)
Chbmated:Yes_No (man duel.erelan"a a a make)
Umalbleckry roatrre at,number
Chbrae ftwkml:Tpml_Free_ '
3.Omund Water Rule Souma Sample
UieallelacNry routine mlbG dale:
S I
Cherh W:Yes_No_
0TNgemd(A1P) ChWne Randal:Total_Fme_
❑Assessment (AIP)
4. SuHace orGW7 taw8ourwWwrSangta lEnumaretlon)
8
❑E rot ❑Fecal seine Y._w_
5.®sapb Coleaed w lahamelw Dnly:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Umawlft q Total Cdiram Present and .®Satsihcmry
❑E.cah Deem ❑E.meal,enl
Bacterial Density Results:Tmal Wftn I100ml. Ems H0Nt
Fecal Colifam I100M. HPC 11 rN.
Replecemem Sample Requimd: ❑TNTC ❑Sample bo act
❑ Sample Volime ❑Damaged Owlsiner
tea ReYaw Nanaer
Daeflhm Rxb : /53 V -1
f+s«q Tamo C. abehoa Cade:
22
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DOH Le Sanplell
285-
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2204784 MASON CO WA
11121/2023 01 49 PM NOTCE
BRUCE CHITESTER #192802 Rec Fee $204 50 Pa=_es 2
I11111111111111 JI 1111111111111IN 11111111111ll ll1111111111111111111111
3m To
i'�, '+-eite�RECEIVED
2O G NOV 21 2023
rr �1 h �is6�d iENViRONMENTAL
615 W. Alder Stree HEALTH
Grantor(s):(1) �✓r-L'e r1jj.rfktek- ,(2)�OKEAfC—Gl1 i�TNd$�FJ'1�rj�r�A"2
Grantae(s): (1)PUBLIC
Legal Description(1) LOT 2 OF SP#3030 AF#1922454 PTN SE NW
(Abbroweledt'orm:ie. lot, bock plat or section,township, range)
Assessor's Tax Parcel: (1) 2 2 0 3 2 2 4 _ 9 0 0 2 0
S3z.- Tz0-fz2,
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA MM)
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 <?/ day of /tea"+^ i-- 2023
Sign ra or(s):
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 day of')Jhnle Yn6"— , 20—1,
�•n. h i )c. �i 14.- personally appeared before me,who is known to be
signer of the abovd instrume It, id acknowledged that he(she)(they)signed it.
GIVEN under my hand and official seal the day and year last above written.
N„ VA J5�
Notary Public in and for the State of Washington,
g9to" F#q�•.11T'��i�
°aNOTARY 9'",�e ' residing at
21009497 = My commission expires: 03D ZLYL
Nam; PUBLIC
s9�.orrepadLS S'�a
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