Loading...
HomeMy WebLinkAboutWAT2024-00160 - WAT Application - 3/13/2024 MASON COUNTY WAT COMMUNITY DEVELOPMENT Pormn Pulcbnce UMa aulw1w Plamlry 415 N 60 Street, Bldg 8,Shelton WA 98584, Shelton:(360)427-9670 ext 400 4 Belfair:(360)275-4467 ext 400 O Elms: (360)482-5269 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: Applicant/ Parcel Identification Name on Applicant: 14t"2KYJA Date: t 3-i3 -.1A4 Mailing Address: II ..11 Phone: k�1� •�'14}aa' �1aJ 1.r7J Parcel Number: WA qB6115�qo ► - 5a• aioro Type of Water 4stem Reason for Application ddppy-1 ❑ Public/Community Water System(2 or more Building permit -OQ`3V ' connections) ❑ Division of land: ` Individual water source(one connection), #of Parcels? SPL )i Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) ❑ Other(explain) ❑ Replacement or Remodel(please indicate name #you have more than one residence connected of water system below if applicable-no to this well, check the Public/Commun#y 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) ❑ 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. ❑ 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. J TH Forms\Dunking Wak Rc,,,cd 125/2018 Individual Water Well Water well report(attached to application). Depth_ 1 _ft. Well capacity Test(attached to application) - pm�,O gpd. The well dnller 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 r� by a licensed contractor. Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA httn:/igis.co.mason.we.us/plannina 146015 116022= Water use or limitation recorded................ N/A r-1 Yes`i�l Well Drilled ............................................................... Date 7/ 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) Satlsfactory 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-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: (,1 Environ. Health: Date rsh CSD Director: Date 2°f 2 WATER WELL REPORT DEPARTMENT OF Nmiee MLaem No. M50174 ECOLOGY Unigte Ecdogy Well TO Tag No BN1f25B Ty,9 Work: smtt M Wdshhigtm O Cvahmrmt She Well Name(ifmam Man m<wit) 0 D[wmtw.a Qi®rcllmmReaoo N0l Nr Wuer Right PelmiUCmifi<eN No. Prrpevl Ure 09 Umnane ❑teaPatma ❑Mmacgw Property pwlwr Name Joey Mammon O Oeauairy oboiwkru ❑Ter Well ❑Omar cemratlw type: Merv: Well Street Adtlrm 51 W Lost lake View Dr. O New"1 O AMtim ❑1to— O hmed O C[bb Twl City Sll¢Ilpl County Mow ❑Deepmor,g ❑Other ❑Or, 0 Ab- ❑Mud Ramy Tart No. 5l Wl-52-01010 mmeapaa: Uemraeaofborita 6 tn.m TO A Waevuw,ceepprovetl fm tNa mallP OYm [ENo Degl:ofwmpkmd xell BB ft, Caabaaw Demb: well Ifyee.MmtVw the ,.namcew m Cwg limy Onmebr From To Tbiceam Seat PVC W[Idai Threat N ❑ a in. 6 gy_ .025 to at 1 ❑ a I O Loetemn(re interactions on PAR,2): ©WWM or O EWM ❑ ❑ _ _ _n. 0 1 ❑ ❑ O NE A-5orthe SE k:Redlm 1 Towndtip ION Rage 5W ❑ O _ _ in, ❑ 1 ❑ ❑ 1 ❑ latitttle(ExamPle 47.12345) 47.185558 Iangilttle(Exemple:-120.12345) -123.2A835B PerronX®: ❑Yn WIN. Typeafpvb:pad Na.arpvrwtiom_ Ssorpv6wmme_nby_in. Dr01<r•a La4Coaatra<Nonoa DemmmlWea PronXart W6mW fiom_flto_ehebw Rmatlanr6ee P.MrIIta.cby-hlata, rwcomfto mereleN arrarq WlM Yutla6 Sena: ❑Yea ONo 0K- eXmofOe Usaielmmoh6yesmaewkQ xitba Wameaay faex8oba8vof PrLr d Degh_R. iof un Dw edditiooelrbeeb ifrcmamry. Maufi[veiaNeme Type MWd Na. Metatd From To Drmemr stm.w_u.bvm R.m_R. BOWO silty oentl antl ravel 0 28 urabr_ Smlam b.fiom _X.m_0. Brown silty Rand and aravel WIN day bkltla n 32 Brpvn safM aM revel 32 45 SaMMlrawdfi OYn M. siaoftmr+mufel_ Gr gRbouM ean6 antl reve Fight 45 0Maenala Plned 6om_R,m_R Stance Sera: Oya ONo Towla MpIM 18 R. anal Naek mototel,mama black Sam 53 MWnalu: mtwrd ElammoTta ChEra I.,Water flg Orlaro ear.inamebbwraell OYm ❑Nu Blelesil Berdasd naval 0 TO TYR Methof Deah ofwm od.or.w ceiling mud aM Pomp: Mmobemmia Name Type: H.P.— qunP wmk[degb:_R. DcppWX>w.:_,m Waea Leaeb:laMrmrue ekntion above meutwbvel 510 R. Srbaormpafwell—.g 1 fl.[Ww pamd auN[e Stati[wmabM 28 Rmlow tcporwell miry 0.b Blflf22 MeaW:mnoao—Iw.pb NtaoiM I1m Amtim uPoNroIW Ey (mp,Ww,Nc) We11 Tar: .. , makeperromutl90No OyeaI byxhoM Tiid_8pmwitn_R.eawaownana_I,n yield_gpmwia:_n.dra d—arow—ke YIN_Wm Wllh_n.dnwdoxn.n.a_M. Raot—r,1-1mp ssm when WnpbOvm1 oa-wYn IerN meuuW bom xea map la weer,lewp Time WWlewl Tice Waal lawt Time Wale Lewl - DeuarPmpiaw Am,.o _ra imh_R.Mwdoxe eRar M Aiate[t DO gaa with mnara BU R.fort In D.m Rr8R2 Andaien Ibw_®m Temaraue orwna 50 •p wmeraneleraemlyab medeR ❑Ya ENO Smn Oete gl&22 Completed Dale 918122 WELL CONSTRUCTION CERTIFICATION: ImnslmnM atM/araocept mpor tlttyfor conswctim ofthis mall,end ib complertcewiit all Washington mall cpnstrvnim mnamm.Materials uletl eN the information repoNed eborc awlve to my best kmwledge end bclicf E.Driller O Tmitta O PE-Prin Josh Koepp Drilling Company Arratlis DXRing Inc. al Si ine /' d% 9 Ad6ren PO Box 11811 I—nor No.2874 { _ �1 - City,State,Zip Stallion,WA MU IF TRAINEE.Sponv'a L'kmfe Np. 1 Commdlor's '.. Sponsa'e Stputure Regtstmtmo No.ARCAODIMK1 Dab WW2 ECY050-1-20(R<v00/18) IIfpumNd this Meumem In arr,abemmej n,Phase mlrthe Water Remmrvs Program at360J01-6SR Penom with Aaring bssmn wll]Ilfpr Washirrgmn Reby Service. Person wiMasyenh Ambilirymn wlf Rlz833-611/. bLDaoa>�- 00367 Thurston County Environmental Health 412 Lilly Rd NE RECEIVED Olympia,WA 98506 360-867-2631 MAY 10 M4 rxuRTrow CO1aS[Y COLIFORM BACTERIA ANALYSIS 615 W. Alder Street Dab Sample CuleoW Time 1=1e CUnty - 3 1e iao2y �Ileted ^ ENVIRONMENTAL eeb Dw ne 01-:PA0. M450Al HEALTH Type of Water System(tlnds only om boa) ❑ POste Hmmhod ❑GmtmA ❑Group s CgOSerSsss�ead fear Watt Group A anal Group B Systems-Pmatle from Waer Faolites Immo,(WFI): IDe System No. epbam Perron: 104V MAJ t MAd Dav Pbo^a l3eo1 1- 9ei 9S cdPem.:(34e)9yx• Ese.Pham:( S&h aebresma b:IP comma.aamss eM Wmde aemelatldee) a 41Me1 AN _ SI eat Last LnK4 Ut>EW DA• _ _9xja'I SAMPLE INFORMATION Samoemlkcbtl by(nama): Ger<e MAamAj SpecifbbratbnortlmmwMm wmple mlleged: Specialkueuc crmrnmeft $ k wcsf Sos? Ln1t4 ULcaa2 DkA.a�• 'I Sg Typeof Sample(ometrheckmlyonaboaofe1 rhmuphp4 flA babe) 1.0 RouUssftodbutlm Semple 2.Repeat Semple(aMrunaeL reuem) Chbnnewo:Yea_No_ ❑Disbibutbn System Chlaim Residual:Total_Free_ Chbnnamc Yes_No 3.1taw Water Soures Sample Chbnm Resdual:Total Free_ ❑E.poll-GWR(AIP) ❑Fecal-s:no.Gvn.roses(meeerml Umammcbry raNne lab number: FME:Yac_No_ ❑Anesament MoRbrrg Wle) UreaSalarbryroutine mlbtltlele: ❑omm /� S A.❑Semple Collected tar n Only Imesapawe CmsWxtlon Repeima_ Other_ LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Umadsfactery Total Wiform Pmeseot ale SaWbcbry ❑E.carpment ❑E.mgabW aCOMam tlekGetl Replacemeb Sample Re9ulred: ❑Sampk ko o8(>30 hovel ❑TNTC ❑ Backnal0malty Remlla:Tornl DPRam 1100m1. E.ttMi It00aU. Fecal Wibm /1DOml Enteromad 1100m1. MetlroCCode: SM9223B ❑W9222D Cmednmen'v''m m� SM9215B ❑EUlemler* pee.Time emyme. MMFgIM: amroa xw.enl�mnunxrµn LaO Um Only. 2208874 MASON CO WA earnrzar< es:rI M WTM Return To Jot v tine-WW Grantor(s):(1) , (2) Gra tee(s): (1) PUBLIC Legal Description (1) L Ah}" L"- vial —I Bi K: I LJ+ )t) (Abbreviated form:i.e. lot, block,plat or section, township, range) Assessoes Tax Parcel: (1)a51 �t n�L- -L—L.SL1 g 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:H Maximum Annual Average Gallons Per Day: gallons Dated on this day of.m�, 204. Signature of Grantor(s): (1)�... -w� . (2) State of Washington ) County of Mason ) Page 1 of 2 I, the undersigned, a Notary Public in for thq_above named County and State, do hereby cert that on this_1,�day of L( .• 20 personally appeared before me,who is known to be signer oft the above instrument, and acknowledged that he(she) (they)signv it. GIVEN under my hand and official seal the day year at above wri �.��.ggrSIR ,�, �'��•. N ry ublic 1 afjcTfor St a of Washington, �o'NOTARY QN; i residing at i 23c38426 [ 6 N PUBLIC ? My commission expires: _ � Page 2 of 2