HomeMy WebLinkAboutWAT2023-00163 - WAT Application - 7/10/2023 :1L
`�' WAT �_- Mlla3
L12023
415 N.6'^Street
Shelton,WA 98584
M Shelton:360-427-9670,Ext.400
COMMUNITY SERVICES Bellffhi,:360A82-5 67,Ext.400
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Application for Determination of Water Adequacy
Instructions
1. Complete Part t. No det:rmltlt,on can be made until Pan 1 is fully completed.
2. Complete only the portio 2 applyingto the type of water connection utilized.
3. Submit completed applicwth any required attachments for review.
4. Ana roved buildin sitmust accompany this ap lication.
Part 1: Applicant/ Parcel Identification Pr i' l 20 z 3
Name on Applicant: MA ' \' �� y Date:
Mailing Address: 2`y^���8 y�
Phone:
Parcel Number:
azo tsocook7— Reason for App 'Application
Type of Water System
2bZ3 -00�`E
PubliclCommunity Water System(2 or more Building permit-ADU�
❑ Division of land:
connections) SPL
#of Parcels?
Well ❑ Boundary line adjustment
❑ Spring/surface water Cl Other(explain)
❑ Other(explain) ❑ Replacement or Remodel (please indicate name
of water system below if applicable-no
If you have more than one residence connected signature required)
to this well, check the Public/Community Water signature
�
'OpOO
system box. ,- e- 'Z
Part 2: Water Connection Information V
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Wa[er System: I
FI Number: Y16rlF (write"none"for two-party)
Water Facility Inventory(W )
roved for?. services.There
�am the manager of this water system.The water system has bee approved
foon.
are presently connection(s)in use.This will be the
❑ 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:
limits This water
tthe system
is able and or any ling to provide
state end local(these)connection(s)will
exceeding e
tem
Phone
Print Name of Water System Manager
Date
Signature of Water System Manager
Fyn wa-us.
This form may be scanned and available for public view at Ras* wp—pint
1:\EII Forms\Drmklne W-W
Individual Water Well
II///'I,, poi} aW11?5tf
t"lIA O Water well report (attached to application). Depth ft.Well capacity Test(attached to application) r S gpm ..Z �'Y�d�n
O 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 rapacity test,which provides stabilization of dmw-dmn and recovery data, must be performed
by a licensed contractor.
yy Satisfactory bacteriological test(attach to application). �i�OZ3
Water Resource Inventory Area (WRIA)
EDev(lopment within which WRIA httg:Bgis co mason wa us/planning 144 15_ 16_An22_
r use or limitation recorded................................... NIA_
Y.�e X f.-ZIQQJ24
Drilled ............................................................... Date !�t/i Q(/dl 1u�7�
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 Court Communit 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 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
C Unsatisfactory Determination: d
Applicant's water supply does not appear adequate to meet the needs of its intended use fNtf�lfr r�i pO
mason(s).
Reviewer's Signatures: N titl 4 4P3
Environ. Health: 49 fDatej7//, 0 Mf
This form may be scanned and available for public view at www co mason wa us. 8r4Z rN
Page 2 of
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA.98584
Customer: Mark Potvin Well Tag M: N/A
Phone: 206-890-4615 Depth: 143.5'
Well Site Address: 1161 SE Somers Drive, Shelton Pump Set: 13F
Date of Test: 12/21/2022 Static 115.8'
TIME GPM LEVEL RECOVERY
1 Min 5.0 120.0 TIME LEVEL
2 Min S.0 120.5 1 Min 119.9
3 Min 7.5 121.2 E4Min
119.4
4 Min 7.5 121.5 119.0
5 Min 7.5 121.5 118.66 Min 12.0 121.6 118.4
7 Min 12.0 123.3 6 Min 118.2
8 Min 12.0 723.fi 7 Min 118.0
9 Min 12.0 123.8 8 Min 117.8
10 Min 16.5 123.8 9 Min 117.6
15 Min 16.5 124.5 10 Min 117A
20 Min 16.5 124.5
25 Min 16.5 124.5
30 Min 1 16.5 124.5
35 Min 16.5 124.5
40 Min 16S 124.5
45 Min 16.5 124.5
50 Min 16.5 124.5
55 Min 16.5 124.5
1 Hr 16.5 124.5
Printed From Mason County DMS
Printed from Mason County DMS
Thurston Count.Environmental Health
2000 Lakeridge Dr.SW 6 Olympia,WA9g502 r�
360 867-2631 G V rtn tl
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COLIFORM BACTERIA ANALYSIS APR 1 b 2023s .CtOu rm RECEIVED
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Retum To 2199326 MASON CO WA
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JUL 111013
q P RECENEp
Grantor(s): (1) ��WF'�L S • `b'N�rJ (2) us �o-cvl
Grantee(s): (1) PUBLIC
Legal Description (1) �aMCA$horlS'F}1212``-T1*X 2�Et • 1p5ti1�6f ,tint m�lah52fa
(Abbreviated loan:i.e. lot, block, plat orsectlon, township,range)
Assessor's Tax Parcel: (1) 2 2 C>_3 1 - ';- O - O O 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 6.68. 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: ql5o gallons
Dated on t day of � �'`( , 20 2-3.
Sign u ra torts): (�
State of W s gton )
County oNAHSon
Page 1 of 2
I, the undersigned, a NoNry Publir..e and for the above named County and State, do hereby
certi that on this day of J ONE . 209.S .
�� k �TC'rOT� 1I4 personally appeared before me, who is known to be
signer of the abo;k, C ment, and acknowledged that he(she) (they) signed it.
GIVEN undetaA�� gJ(icial seal the day an r ast above written.
O ��Tb Ot ARY MM S i
j5yy4 £ z Notary Public in and for the State of Washington,
u r 0 �,�7��
i a ' p0By 1`'FzV_ residing at !"'r« r
ry4r9TF Q;W`p�`Vz
My commission expires:
Page 2 of 2