HomeMy WebLinkAboutWAT2024-00124 - WAT Application - 3/4/2024 WAT�2. - b01 Z1
MASON COUNTY
COMMUNITY DEVELOPMENT
ov�:r,5�.nurcermor.e„�unr.namnr
415 N 601'Street,Bldg 8,Shelton WA 98584,
Shallow(360)427-9670 ext 400 O Belfair.(360)275A467 ext 400 O Erma:(360)482-5269 ext 400
FAX(3W)427-7787
Application for Determination of Water Adequacy
Instructions
1. Complete Pad 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: Brad & Debbie Buck Date: March 4, 2024
Mailing Address: 3625 70th Ave W, University Pl, VPhone: 253-377-1735
Parcel Number. 22233-51.00114
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more Building penn8 1/ICJ ZLV—'4 - 60�0 1
connections) ❑ Division of land:
0 Individual water source(one connection), #of Parcels? SPL
0 Well ❑ Boundary line adjustment
❑ Springlsudace water ❑ Other(explain)
❑ Other(explain) ❑ Replacement or Remodel pia (please indicate name
ff you have more than one residence connected of water system blow 4 applicable—no
to this well, check the PubliclCommunity 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: Well
Water Facility Inventory(WFI)Number.
(write"none'for two-party)
❑ I 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.
0 I am the manager of this system.This connection will be to upgrade or change the use of an existing
connection on this system(Le.:recreational to full time). Please indicate on the following line the nature
of this change: building horse to connect to.
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 Data March 4, 2024
This form may be scanned and available for public view at www.co.mason.wa.us.
1:\pa Fp \DnMin,Wwn Revised 1125M8
Individual Water Well
Water well report(attached to application). Depth A�5
Well capacity Test(attached to application) .214 gpm 7�D� 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 httoa/gis.w.mason.wa.us/planning 1 , 1q]16[ ]22�
Water use or limitation recorded................................... WA yes F—I
WellDrilled ............................................................... Data n
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 600 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
Pan 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 mdirates requirements of Sanitary Code,Title 6,Chapter 6.66.040-0elemtination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
Unsatisfactory Determination:
Applicanrs water supply does not appear adequate to meet the needs of its intended use for the following
mason(s).
R 1 mees Signatures:
Environ. Health: Date II
n
CSD Director: Date 2.f2
F—:(M,:,
W 09322
WATER WELL REPORT aYAMMLLD.a ACD 961
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(3) PROPOSED USE: N 0. imYaY C x.m.a n (10) WELL LOG or ABANDONMENT PROCEDURE OESCFAPr1ON
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(5) ORENSIONS: m.maraw
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(6) CONSTRUCTION DETAILS:
C.aq btr.a: 6 oYn.bn D Lm 78 a.
❑ ��❑ tl s & gravel with water 67 75
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COLIFORIIA BACTERIA ANALYSIS FORM_,'-z,
Dale Semple Calleded Time Sample Caunry
g i a )aoa3 11 rno5on
b hDa, Y.
Type of Water System(ched leans box)
❑GrwPA ❑GmWS
Gmup Aand 8Syatama-Pmvitle��yG//garnn Facilities lmanhxy(WFI):
ID% c� J7 � T
System Name: L �(�fp l-• nNSr�✓LtKf[i• W
Camegperson: U-ck
Day Phwm:Glsa )3CS-970 CNI PFam:( )
Email: E..Pham:( )
Sad�eaW6 m:IPma Nlwm,�udabmdef r.
Sample colkcmd by(name): o -&�k
Specific location where sample mlo : Spedaleabutlbne ormmmenb:
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"Type of Sample(seWor*kww typauf sample Gan tylres 4N'iwgh 5 below -t•`Nj- -
1.❑Rwdne MIributi nSample(AIP) P.❑ Report Sample(AV) ~
ChWrwbd:Yoa Np Ifian deOimAbn sys+an aMrumrtmNm)
Unsal§fxMy mere lab number
Chmdm Resoud:TdaL_Free_
3.0rwnd Welar Rule Swraa Semple --- — ---
Gneatlstadorymumie mikddale:
S I
Chlumod:Yee No
❑Tdggered(AIP) Chbdre Reddual:TmL_Free_
❑Assessment(AR)
I. Surface or V ftw S me Wamr Sampm(Fnumem5 )
❑E:mfi ❑Fen( ..Yon_% S
5.❑Sample Cnllecmd M Idamulion Onty:
bTUe USE ONLY , DRINIGNG WATERRESU4T8,„ pT
❑Gmatisfaclory Tool Coleoim Presenland SatletaCam
❑E.mllpmsenl ❑Emfiabeed
Several Dainty Romi Toml Coldaml----Jtmd. EmY 110om1.
Feral Calitoml - NOO 1. HPC - Nd.
Repmcament San"Required: ❑TNTC ❑Sample mo old
❑ Semple Yalume ❑Damaged Container ❑ -
lab Relae�Nmyy�O
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