HomeMy WebLinkAboutWAT2024-00097 - WAT Application - 2/21/2024 WATp2 ' 4 - 00-77
• / MASON COUNTY
COMMUNITY SERVICES
9uilding,%anninq EmummeMel Hnllh Cammniry NeYM
415 N 61°Street Bldg 8,Shelton WA 98594.
Shelton:(360)427-9670 ext 400 O Betiair.(360)2754467 ext 400 O Elma:(360)4825269 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: Appllcantl Parcel Identification
Name on Applicant: INl0.vt Date: WZi 12l9{
Mailing Address: 430� fbY[jf SQQ4Lr ijY. Phone: 253'3�a?-7�45
Parcel Number. aw-94-000f0
Type of Water System J Reason for Applicatiio/nL
❑ Public/Community Water System(2 or more ill( Building pgnnit OLWL50� 00a9#
connections) ❑ Division of land:
J0 Individual water source(one connection), #of Pamels? SPL
B 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 PublicYCommunity,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:rEi Fmms\Dn>ildvg WMr Revised 125R019
Individual Water Well
Water well report(attached to application). Depth .16 R L.-�
Well capacity Test(attached to application)�pm 7 •G ppd.
(y�The well driller often performs well rapacity 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 rapacity test,
a well capacity test,which provides stabilization of draw-down and recovery data, must be performed
by a licensed contractor.
j atisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htto://gis.co.mason.wa.us/planning 14�]1b�if�220
Water use or limitation recorded................................... N/A /�Z�, yes
Well Drilled ............................................................... Date
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 Daft
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 fieure,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 RCVJ.
❑ Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reason(s). `{'�Q ,{1 ' p, \I
-- �trp Reviewer's Signatures: J(/CJn/ l
Environ. Health: D r • r Date
CSD Director.
Date z uf2
WATER WELL REPORT MDEPARTMENTOF Noticcoflnunt No. WE555B4
ECOLOGY Cnbeue Ecology Well ID Tag No. BP0116
Type of work: State of wasnin jUm
ENC.aramwi Site Well Name(ifmare than one well):
❑ nxummishim d IXlginaliwallmion NDl No. Water Right PermbVCenificm No,
Proposed Use: MDemme ❑mdmnlal ❑Municipal Property Owner Name Rvan Holman
❑Dewuenas ❑Laipption ❑Test Well ❑gher
Well$IrM Address 451 E North Say Rd
Type: Mahal*New well
:
New ❑Attention ❑Dmen ❑lened M Cable Tool Elly AIM County Mason
❑Dane—, ❑them ❑Dag ❑Air- ❑Mud-Rotary Tax Parcel No. 12217d4-00040
Dinarom e: Diam ounbormg 6 in.,to 76 p.
Wes a variance approved for this well? ❑Ya ❑No
t%pN atoomptotd well 76 ft.
Crowns..titanium wall Ifyes,what was the variance fob
Casing Line Dirmeler F. To Thickness Stal PVC Weldd Thmd
1 ❑ 6 in. •1 88 114 on. M 1 ❑ O I ❑ Location(so,instructions m page 2). ❑W WM m❑EWM
❑ 1 ❑ — , ❑ 1 ❑ ❑ Ye s/e❑ SE of Ne SE 'A;Scm ion 17 Township 22N Range 1 W
❑ 1 ❑ — — n. ❑ 1 ❑ ❑ ❑
❑ 1 ❑ — u ❑ 1 ❑ ❑ I ❑ Latitude(Example:47.12345) 47.392340
Longitude(Example:-120.12345) -122.826119
Perforadaas: DYow AN. Typeofperfma-wool
No.ofpermmliom_ Siaofperfmaiom_ioby_in Driller's LolpConstruedon orDaommisaiav Procedure
Ndomld be. fl.m ft,below Foodnflin Formation:Eyetooth,by mind,character,sin northeast and sauctme.and the kind and
name ofthe material in each layer'n'thotd,with to least oar eery for mh clump of
Sear.: MY. ❑No ❑a K.Poker Depth 63 ft. mfamaion Useddition lahnuifnamusy.
Manuf a 's Name Johnston Material From TO
Type stainless Model Na.
Diamner 5 to Slottom 10 or fiew 66 ft,to 76 ft Top Soil 0 2
Diamner_ m. slor sou_ m.fiem_fl.m_e. Light brown sand 8 ravel 2 13
Light brown firm sand 13 15
SmadlDDar .park:❑Y. ❑No Swe ofaek modal_in Whits brawn haN pan 15 27
Materiels placed fiam_ft,m_ft.
Seed and gravel wet 27 80
Marne Seal: 9Yea ❑No To wM1n depth? 18 0. brown mint!Win fi0 78
Materul umdin seal pamonlle
Didanysbmammarri mumblewasm' OYca ON.
Typeofwater1 Depthofprau
Method minshng sera oD
Pump: Mmutacdunt't Name arundfoa Type'. sae
FI.P. 1 PumpirmandhAh,10 a. Designdnewrme: 20 ppm
Waar leveb: lsnd-normeelevmion above man as lerel_ft.
Slink-upofft,im Hormag_ fl.athwewouMsurfa
Amicwmnleval 27.T bbeawmpnfwellaming Dme
Mesienpremre_Ibs per,.,a.heh Date
MemanwaariscmlrolledbY (mp,vmw,ne.)
Well Tma:
Was a pumping tut pmtmmadl 0 No ❑Yes b by whom?
Yield _®m with_a.d—dk—after_ha.
Yield _Rnnwhh n.doommaalier_hrs.
Yield _gym with_ft draw&—after_bre.
Rehovay des(limo-mrc when pump is maned off-outer lent mrmund ban well
aPtowatalenh
Time water Leal Time Water lswl Time W.lerel
Dau of pumping an
9aileram 25 arm with 40 ft dn.down afln1 her
Air ttn _Wmwnh Whim deul_fttA_hn. Dee
Mwim Dow_span
Tempemeuofwear_'F Wmachemictl.elysismde? Dyes ❑No I Sort Dye 3-13-24 Compined Date 3-16-24
WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all Washington well
concoction standards.Materials used and the information reported above are true to my best knowledge and belief.
19 Driller❑Tom.❑PE-Print Name Emil Daubs Drilling Company Davis Drilling
S®ryure p,6i{y Address 340 NE Davis Farm RD
License No. 3142 City Stale ZIP Belfair,WA 98528
IF TRAINEE:Sponsors License No. Contractor's
S,wAwws Sigmwre Reg sbmbm No DAVISDI1100A Date March 2024
ECY 050-1-20(Rev Og119)Ijyw undthisda amemot in an alarrmre format➢lame w11 he Were,Reswrcea Program in 360-407-6872..
Persons with heminglasscancnU 711jm Wmhfngran Relay Servire. Pemom with a speech dmabilfty can m11877-833-6341.
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Sac it SPECTRA Laboratories - Kitsap
P-4b .-WA ...avean soon
98370
(360)TT9-5141 COLIFORM BACTERIA ANALYSIS FORM
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SAMPLE INFORMATION
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2207759 MASON CO WA
02121/2024 12.28 PM NOTCE
DALE HeRT p195203 Rec Fee a303.50 Paees-. 1
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Retum to:
Dale Hart
1571 NE Tahuya Blacksmith RD.
Tahuya, WA 98588
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA)
I(We),the undersigned grantor(s),hereby place this notice on record that the following dermLW real estate situated
in Mason County,State of Washington;to wit,.
OR 1 W 22N 17
Subdivision Division Lot Range Township Section
andhavingthe7sa ParoelNuouberof, 12217 ___44 __00040___
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 VV I
WRIA: 14/l ,, Maximm u Annual Average Callous Per Day: 950
Dated on this 20 day of Fe�709,it .
Sigvatum of(3rantor(a):
Printed name ofCiraNOr(s):
Grantee: Public
State of Washington )
County of Mason )
I,the undersigned,eNotasy Public in and for the above named
r County and State,do hereby certify that on this
a_dny ✓ /of FP w"r4 20�, I(In�n t/G&1a4 personally appeared
before me,who is known" the eigoer of the above inslrssmont,and acffiowledged Bathe(she)(Biry)signed it
Given,under my hand and official wal the day and year last above written.
IJArr/ r//
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pPQ4uni�H�rECFy�o Notary Publi(c���',nnp,,and
�/'�for the State of Washington,
`` I• ra 9.'� 'Residing at LxAr `I V,
• `
��; iO4BC1� _My commission expires: �Ct ll
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