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HomeMy WebLinkAboutWAT2023-00293 - WAT Application - 10/27/2023 WAT a023- 00 MASON COUNTY COMMUNITY DEVELOPMENT _ m C E I V E D m�eawmo�am.n amiemyru�m� G\ 415 N&Street,Bldg 8,Shelton WA 98584, OCT t 12023 11 Shelton:(360)427-9670 eta 400 S Belfalr:(360)275-4467 eta 400 a Elms:(360)4825269 eta 40 FAX(360)427-7787 15 W. Alder Street 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: Applicant/ Parcel Identification Name on Applicant: Joseph Dang and Chinh Nguyen Date: 9/9/23 Mailing Address: 5001 NE 184th St, Lake Forest PiPhone: 206.818.7656 Parcel Number: 320245100027 Type of Water System Reason for Application ic1nation EI Public/Community Water System (2 or more El Building permit � PGwn 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 Sothis well, check the Public/Community,Water signatureq�u�ire ' �PN � e System box. OW y� .Wa Part 2: Water Connection Information f` . ,[ ,C&A Qo r Complete the section appropriate for the Nam"_ gyp ptype of water connection being evaluated: tnH� 'i't'� Public Water System VVfr.Y CIO Name of Water System: DOERSCH EL Water Facility Inventory(WFI)Number: NONE (write"none"for two-party) El I am the manager of this water system.The water system has been approved for 2 services. There are presently 2 connection(s)in use.This will be the 1 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 sect by state and local _regulation. Signature of Water System Manager /�/V� Date 9/9/23 This form may be scanned and available far public view at www.co.mason.wa.us. J.\EB Forms\Dfi cub ware Revved I/25n018 Individual Water Well Water well report(attached to application). Depth0 ft. t� Well capacity Test(attached to application) Vq 4 l 1 apm L 8 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 drew-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,/IQis.co.mason.wa.us/olannina 14f'?^I 5=]16=]220 Water use or limitation recorded................................... N/Al=Yes—E�f Well Drilled ............................................................... Date 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 6.66.040-Detenmina6on of Adequacyfor Building Penmits 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: Environ. Health: iU I �/�'`rW 'br'_' Date (2 (L Z-5 CSD Director: Date 2 U2 ENVIRONMENTAL e2L'gx'?5_oIa5� WATER WELL REPORT 6M TUNT OF Noticeaflmerd No. WE48034 RECEIVE ECOLOGY Unique Ecology W.11 JDTag No. BNH 717 Type ofwork Seat.ofwashwvm. O Cmunuulw Site Well Name(ifmore than one.wip: ❑ Deca:m up.. b origau imia5uoo NOt No. Water Right PermiVCutificsse No. OCTProposed U.: RO Domenic ❑tndomiel ❑Mwiupl Property0moeNmee Aaron Doamchel C ❑r -wrong Cmiguion ❑T.o Well ❑6.Mr Wdl Street Addrus 215E Channel Point Rd et CoN—u $1 Type: M.flow013m, Maas'' e ENew well ❑Aavniw ❑Ddvu ❑]enN RCabk Tool City $heaon Cowry ❑Drepn'dng DO — ❑Dog ®Av R Mud-Romy Tu Pereel No. 32024-51-00027 Dimenuo:n: Dianwur ofbamg 6 n'. 75 R WmavammieeeppmvWfor Wswel17 OYa EINo Dc,:h ercompbW weO TS e. Cone6_umem: wall Ifyq w5in was to variance for? Cooing Elms Diemem Fmm To Tlddneu Suet PVC Welded Tluud ❑a 1 ❑ 6 m ts 71 25 ia. ❑a 1 ❑ ❑ 1 ❑ Locadon(sw moructirns on page 2): ❑O WWM or Wm O 1 ❑ ❑ 1 ❑ V..A. ❑ 1 ❑ SE of N SW e %:Smlion 24 Township 2oN R 0 ovge _ ❑ 1 ❑ — —io. ❑ 1 ❑ ❑ 1 ❑ ❑ 1 ❑ —in. ❑ 1 ❑ ❑ 1 ❑ Wlaude(aample:47.12345) 47.20001 L Vtude(Enampie:-120.12M5) -123.00295 pr,o m. ❑Yo G_No Ty epnromomueed Drilier'sUglConslruellov or Deoumndesioe Pracedun tto.ofpofinetipn_ SbeelP��re!iws_in by_in Fomu!wm Orne by cola,cbemmo,ime ofromon)and atrueemq and de kind and Pmi:ned fiav_a b_a.below grmind saf ewe ofslu meu:ialmueh byupe.UA wine o loon one entry!mead chvngeof Sere o ❑O Yee ❑No W K-Pedal b DI(b 70 t nfa:mnon. Uu Mdhiwul efeelr ifnavmery. M®o0onvo Ne!o Jolmaon Marttial From To type Stainless Sled Model NP, N. 5 in, Slo sve .018 in man 71 a.m 76 g Clay,some sand,Cmwn/hard 0 11 oiemem_ m. slnsde_ mfian Rm a. Cla ,graylhard 11 16 seod/Pmer P.cR:❑Yo ®No Sue ofyd mnmid_m. Cloy,some Una sand ra /hard 16 53 Sand,coarse,sifi,small gravel,grayltiard,win 53 77 Maemek plmed man_R i_a. Sand,silt,marse sand,graytanc,wb Surrme Seal: ©Yrs ❑No To wbn deph118 R. less water 77 79 Mamul used n eed 6entimb Dmnuea Dgmyaneuc.munmeblawueR ❑Yin ON. Tp rfwaml Dgdiofinela MMndnfeul"onneoft Pump:MmoLcwu'e Nome WA Top,. NP,_ Pump rood:.dyuh:_R. Dongoed Raw om:_gpin Wam Lerch:WtlsmGee ele"non eWve me —level a. goa- am,i fwelleomg -1.5 ftabmugreuodnuf ,00l_mkvn 72 Rbebw era o(wdl using tali `WJ 022 A:esen geuuro_Ies.Per fGux mc6 Due Anaim wasm6 wmmlkd by (uP.wlve,eu) WA Tmh: Wnapim�in®mrt peRonn 14 ©No C Y. b bywbm} Yi.,_®m wbh_A.drewdowo efler_line Yialtl_fpm wit_R drawdawn aan_hry Yid4_ppm win_4.drad4 eav_hn Recway d6(Grc=mo whin pump 6 w:-1 aN-rosy I"menwW limn well woo—lmsl) Time Wam level Time W.level Tore Weevlevel Den orpanpigq ran "one'mnnww_amawmwvar_ 7 A oro 1e ®,n wit nem ann 7s n.sr me JF D� N4 Meson Pow_pose Temperewevfwam_°F Wmac6emvlemlyz6 model ❑Yo ®No Start Ate 5lM2022 Completed Oete 5/4/2022 WELL CONSMUCYLON CER'TUNCAMN: I emo"oned n!d/m accept!osponeDility for consvueion ofdos well,and Ate compliance wit ell Waawinsom well corsnmcfion s,me em,s.Materiels used end to infomeeiion reposed drove are Isere t my Iscd ksawledge and belief Oa NM O Tnwne❑PE-Print Name Chds Jones Billing Comin iy Moerke g Sons Pump end Drilling gtppnore _ Addre s 1162 NW State Avenue Llomse No. 2253 C'ry,Stine,Zip Chehalis WA 98532 IFTR a S,ionom'sUcemon No Convactor's Ste'=Sm!dme=Smdure gogoemn,No, MOERKSP0721,15 ph 5f412022 FCY05 l-20(Revll/l8) Ij)vmneedthk dxumem eras nlsermrcformat Pleas sell she Warcr Resources Program ar 360407-6871. Pnmu wlN hearing foa inn cal/lll fares Nrsgron RetayServlce. Po.,ilhalpeechd1mbih'Y— all 8T7-833-6341. ThUrSton County Environmental Health 2000 Lakeridge Dr.SW E Olympia,WA 98502 < . 360 867-2631 THU0.SIOY�Ola COLIFORM BACTERIA ANALYSIS Data Sample Calleded Time SNMW County Coliedled W Cry v ❑ pdi Household Type al Water Syetam(rheckony and box) � ,i bt,6 ❑Group A OGmapB Group Aand Group B Syabms-PmIW1I'm Wmm Fadlities Invanlory(WFl): On -_ - - - SystemWe.: ContaGPonm:C k rl4 KLi ll"ly , (Mj4l, Davpixae:( 'i(l) ) �, L! Cell Phoned ) t Covl!"AA , vl'�fve.Plwrma ) Ernae:Ql\li! il' y b Senor wmia it, n ndd,.17 and rep order a treat adbma) SAMPLE INFORMATION Sample by x Ylrlu Speciau bralim mrsY1,re-1 rrole mlkckd' SpeddinsWcOonsmwrrmonls' Typeo sampb(rmddteckanryonebmoislmmugn"H uuu.h l 1. Routine Dleadbutbn Sampk 2.Repeal Sample letter unamt.routine) Ghbdrursd:Yes—No_ ❑Disblbu600 System ChW.Residual:Told_Free_ Chbdnabd:Yes—No— 3.Raw Ruder SourceSample Chlorine Residual:Teel_,Free_ ❑Fecal-we ,Goutu Mal ^^I U,,Efaclay moundlab number. Fe-d:Yes—No_ _— ❑AssassmenlWrimri Win) Udujsfeclory routine colbol dale: ❑Other __I__I_ S a.❑Sample Collected for Informed.Only lronntpeeee— Canabuedon l Repairs— Other_ LAB USE ONLY DRINKING WATER RESULTS IAIj,USE ONLY ❑Unaalehclory Total Conn Present and Saedactory o (bottled ❑E mli present ❑E.mli absent - Replacement Sample Requi.d: OSempbboold(s30houm) ❑TNTG ❑ Baderlal Density Rewlla:Totel Colifoim_. 1100mi. Ecnd 1100m Fecal Colibrm 110dd Enlemcood 100ml Methdd Code: SM9223B [3SM92220 DawwdTMPMW%d:f t OSM9215a OEnbrolerM �U « � oea.w nmaamtpea: 10 Ir)_ -�j w.mrank. s.�o.xmmnrowweerpwo-naHl tebwe OrM: a B 0 Cj 3-- d��aoa3-o�a� ENVIRONMENTAL 2203452 MASON CO WA HEALTH '1Uj 1)93 RaoaFv�TCE30< 50 P 3 IV�m�IIII�IUII�INIII�I�II��III�I,I go C'4l,/7 N'�uye0 -DECEIVED Lf7kf_ FaQFST /��/L/[ . Goy} JK/ SS OCT 17 2023 W Alder Street Grantor(s):(1) Gramee(s): (1)PUBLIC Legal Description(1) s.axuwram)Pnc*s rn n a r n vu uxruxeo no w�s�)nw,s av+se (Abbrevieted form:I.e.W,, block,plat orsecticn,township,range) Assessor's Tax Parcel: (1) 3 2 0 2 4 _ 5 1 _ 0 0 0 2 7 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: 14 Maximum AnnmllAAverage Gallons Per Day: 950 gallons Dated on this / / day of C 20 Z 3 Signature of Grantor s (1) . (2) 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 gerBry thajQn this 1 day of U ck)bP-r 20 03, Zoe �b n C U h (personally appeared before me,who is known to be signer of the abov4 instrument, Ad acknowledged that he (she) (they)signed it. GIVEN under my hand and official seal the day yaand _year last above written. M,NY,NIIIIII�,g1 !.` ��6��1 tt1 ' W�� Np, LE M w '4 Notary ubiic in and for the State of Washington residing at � r X I � 27�gggy My commission expires: I 2 �sd+1;5 PUBLIC ?� . ..WPS�,NNi Ilyy4ulY0YM Page 2 of 2