HomeMy WebLinkAboutWAT Application - 12/28/2023 WAT�-
MASON COUNTY
COMMUNITY DEVELOPMENT
Pe,m,I Assistance CeN,aWldl ,N.—,
415 N 6"Street, Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 J Belfair(360)275-4467 eat 400 4 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.
0 3. Submit completed application,with any required attachments for review.
t 4. An approved building site plan must accompany this application.
(6 Part 1: Applicant/ Parcel Identification
II Name on Applicant:Zrtp.yy d'r�i1"(A.rt 'J7 Date: laldola3
Mailing Address: II51D F >f Q- -ID(c Phone: �—%O-la33 • 7A6c1
Parcel Number: Ur1(by— UJA Ctb6q9. ,a51!aot30 — .1a-1- 0"0
CS Type of Water System d Reason for Application
J C1 Public/Community Water System(2 or more N Building permit j31C!AA;a — 015145
connections) ❑ Division of land:
.� Individual water source(one connection), #of Parcels? SPL
Well ❑ Boundary line adjustment
❑ Spring/surface water
❑ Other(explain) ❑ ReplacOther ement )
O 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 Public/Community,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.
❑ I 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\EH Fame\Drink,,Water Revisit 1252018
Individual Water Well
Water well report(attached to application). Depth It
Well capacity Test(attached to application) 7-S7— gpm -�8 oo 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.
Cry'Satisfactory bacteriological test(attach to application).
II Water Resource Inventory Area (WRIA)
Development within which WRIA httc://ois.co.mason.wa.us/planning 140 15r 18[=]220
Water use or limitation recorded................................... N/A 7-1 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 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 wth 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 RCW.
❑ Unsatisfactory Determination:
Applicants watersupply does not appear adequate to meet the needs of its intended use forthe following
reason(s).
Reviewer's Signatures: 2 r�
Environ. Health: Date ✓ C/
11
CSD Director: Date 2°f3
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NICHOLSON DRILLING INC.
PUMP TEST
NAME: Emily Stelanko DATE September 21,2021
SITE: XXX E ST RT 105 TIME
Union,WA 98592
1PRGL:22230-23-OODIO
WELL DEPTH F--8-9.-Gl Feet WELL DIAMETER 6 Inches
PUMP MAKE Berkele PUMP MODEL B7P4MSD5221-D2
TANK MAKE TANK MODEL
Time Depth Draw Rate Time Depth Draw Rate Time Depth Draw Rate
moaw To Down gpm to Down gpm to Down gpm
Water Water Water
Stak 64.8 0.0 40 80.9 13.1 720 0.0 �m
1 74.0 0.4 7.5 45 80.8 13.0 7.5 780 0.13
2 78.2 11.4 50 80.9 13.0 840 0.0 f
3 79.4 11.8 7.5 80 80.9 10.1 7.5 900 0.0
4 80.7 12.9 70 0.0 900 0.0
5 80.8 13.0 7.5 80 0.0 960 0.0 .nl�
B 80.9 13.1 90 0.0 1020 0.0 '�1�_ �f`•I
7 80.8 13.0 7.5 100 0.0 1080 0.0 n fD�
8 80.8 13.0 120 0.0. 1140 0.0 Vim'
9 80.8 13.0 7.5 150 0.0 1200 0.0
10 80.9 13.1 180 0.0 12B0 0.0
11 80.8 13.0 7.5 210 0.0 1320 0.0
12 80.8 13.0 24D 0.0 1380 0.0
13 80.9 13.0 7.5 27D 0.0 1440 0.0
14 80.9 13.1 300 0.0 1500 0.0
15 80.9 13.0 7.5 380 0.0 1680 0.0
20 80.8 13.0 420 0.0 1620 0.0
25 80.8 13.0 7.5 480 0.0 1680 0.0
IF30 80.8 13.0 540 0.0 1740 0.0
35 80.8 13.0 7.5 800 0.0 1800 0.0
RECOVERY
Time Depth Draw Time Depth Draw 17ma Depth Draw
to Down to Down to Down
Water Water Water
1 75.9 8.1 11 0.0 45 0.0
2 732 5.4 12 0.0 50 0.0
3 71.8 3.8 13 0.0 60 0.0
4 70.4 2.6 14 0.0 70 0.0
5 69.6 1.8 15 0.0 80 0.0
6 69.1 1.3 20 0.0 90 0.0
7 68.7 0.9 25 0.0 100 0.0
8 68.5 0.7 30 0.0 120 0.0
9 68.21 0.41 35 0.0 150 0.0
10 0.0 40 0.0 180 0.0
SIGNED BY:
Alan Mye0e-Pump Supervisor
412 Lilly Rd NE
Olympia, WA 98506
360-867-2631
COLIFORM BACTERIA ANALYSIS
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SAMPLE INFORMATION
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Chbnnated:Yes_No,> ❑0atr@ution Syelam
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❑Other eclaymutimothaddia,
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4.❑simple CoSacaed for lefomuBon Only
Immtigadve_ Conshuctiony Repaks_ Otlwr
LAB USE ONLY DRINKING WATER RESULTS USE ONLY
❑Unsetlabctmy Total Cobon,Pmse Land smhkc ,Y
❑E.mA'msent ❑Ewbebeed o I'norm danced
Replacement Sample Required:
0Samplebodd(>30houn) ❑TNTC ❑
Bachnial Censily,Resuha:Total Coflblm n00m1. Emb HOGd.
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Return To
BriA.n 54I !, i.. LD 2206137 MASON CO WA
I(SIC E �� Rt- IU(p ei' rN120za 10 5 an None
U ST K0 N19307
e Rec Fee' $300 50 Paees 2
Uniarn L&A �S i� IIIIIIIIIIIIIIIIIIIIIIIIIIMI111111111111I11111111111[1111111111111
Grantor(s): (1) �21J�JSTCF(�v Ka (2)
Grantee(s): (1) PUBLIC _ 1 ' 1 (� t� ,p µn
Legal Description (1) S `)LO S3a 122— IL.r^'"'
(Abbreviated form:i.e.lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1) A -;?, r,A �3 Q- c;L `4 - () d Q a O
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 6.66. These
restrictions and conditions are based on location of property and/or Water Resource
Inventory Area or WRIA.
WRIA: 1�5
Maximum Annual Average Gallons Per Day: C hit gallons
Dated on this 1&LA da of 20��
Signature of G or(s):
(1 (2)
State of Washin on )
County of Mason )
Page 1 of 2
I,the undersigned, a N tary Public in and for the above na County and State, do hereby
certify that on this day of 20
persona appeared before me,who is known to be
signer of the above instrument, and acknowledged that he(she) (they)signed it.
GIVEN under my hand and official seal the day and y last above wdtten.
```so,1ALLMj,1//:,� Notary Public in and fo he State of Washington,
�r,. \swan p•. Q
ry31-2 residing ati"I
O \ 9 O
xir' NOT�V '"imc My commission expires: k 11-M
N m PUBLIC �j=`
Page 2 of 2