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HomeMy WebLinkAboutWAT2023-00366 - WAT Application - 12/20/2023 WAT _- 415 N.6m Sttcet MASON COUNTY Sh lmn,WA 985" COMMUNITY SERVICES Shellue:360-275 9 7,Ext.4W 13Eim:3N482-546/,ExL 400 6.uuns�raks r,,.`anmeaix.iMram,„,,,;y� Elms:360-082-5269,ExL 400 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:-:�>0, ,-x ,)v'4Z2R N�`% D,att� Mailing Address: PO �" r S?POc9 �ayPKlone: �tpr1-'7 xtZ'fS3k1 Parcel Number: LA0n_���c_5'A - S��t Type of Water System Reason for Application ❑ PubliclCommunity Water System(2 or more Cf Buildingpermit connections) ❑ Division of land: ❑ Individual w ter 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 to this well, check the Public/Communily 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(W FI)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 connections)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. 1:\EH Pains\Dunking Wata Rcvtsc i 442018 individual Water Well f6iWater well report(attached to application). Depth 7 ft. pp / Well capacity Test(attached to application) gpm pd. 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 http fiois.co.mason.wa.us/plaffi'ffl 14 Y-h5 /16_22_ Water use or limitation recorded................................... N/A_Yes n WellDrilled ............................................................... Date ?- Individual Spring/Surface Water ❑ WDOE permit(attach to application) Cl 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 with all applicable WDOE water resource regulations. Recommended approval Indicates requirements of sanitary Cade,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: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). � �nnReeviewees Signatures: t� Environ. Health: q,�-" ' �V Date "Ut(ram i This form may be scanned and available for public view at twww to mason.wa us. Pap 2 of 2 WATERWELLREPORT 10 DEPARTMENT OF Notice ofmterd No. M49M ECOLOGY Unigm&obg Well IDTag No. BNM47 Trmofwnh: 9a¢d WnhIvnn sire Wdl Name(ifmar than one wdp. OO C nrn ❑ Dgmi,pilr O,WNl iuWblioo NOl Na Water Rigor Pem:itlCMifk9e No, PvapmNtw: ®Dee:mric ❑Id:wevl ❑M:miripd Properry Owner Name T,* WRer ^ ❑Oewerminp n Irn'- ❑Tea Well nDrM Well Senn Address 121 WIAIVIA Rd Crlanedw type: Mdmd: city SheaOn Cowh Mail nAn,.- ❑Dnvm MOM nLlbk Tm ❑Dw mi ❑Odwr. ❑thin ill n Md-Rmry Tan pmml Nn. 41903-34-50031 DIo1imm: Die:rcm afbor'u:a¢_m im ro 78 n. Wmawceappmvedforthiawdl? OYa ONa Degnefcompkn4"178 n. If en, WWI l'ea.went waz the MarinefW1 (I ug Liner Demmer Fmm To Thin:ee. 81a1 PVC WAdW 1Ned h@ 1 ❑ e to 73 .025 in M 1 ❑ 111 1 ❑ [,,neNrn(sceillsow4.onpV2): ©WWMm❑gWM ❑ 1 ❑ in, n. ❑ 1 ❑ ❑ 1 ❑ SE %Y.of rhe�Y.;Smum 3 T'OwtN:ry ION Rmpa 4W ❑ 1 ❑ _ u. ❑ 1 ❑ ❑ 1 ❑ ❑ ❑ 1 ❑ ❑ 1 ❑ TBtinuk D+aamPle:6112?0.5) 47.157838 ❑ I _ _ — e. L,Aigjhdr(P .pIc-120.12MS) -123,174608 Pnrontlum: OYm SIN. Type of pernmanud Dr10er'a Lag/f astruction or Decommlmloe Procedure NaofpM'om_ Siu of nom_ie by F._..ONe..ny aalm.vFvromm,give afmlemlend suunwe.and Ne Mid eW Per6Md6om_&b_n.Nflr, ound� rtoflM1e mumiW ioencM1L:yermnmld.wilM1 Vlkml meewyfttmcncM1mpeef &veem: ❑Tee 0No ❑K-Pnnhm O Deph_A infm:Wiart Urdditio Wiftenifo¢esu:y. Mmnl&mmaNwe -_._ Materiel F. To Type Model No. I'troAn silty eaM mM hA*l 0 12 Uemekr_ Sbtnm_infim: _fl.n_@ Diemewr_ SW eim nfimo _@m_6 Gray ty aarldaM 9raVe1 12 Cm a silty day 49 8 &odlFilbpxk❑Yn 0No SireofpaJ:v:Ymkl_io. (a°r 81ir C with Flitting 5R 58 Munels qxd fine_n.:o_a. Muftw1anx!growl,hroan Morlium M MOM BB &nDmSed: OYea ON. TowMUeprh? 20 @ send,I.,Welef 78 MelmallediueeN Sankrift Chl Ditl any.malecavain uMeWkwek(! nYr 0No Typaofwuef' Dwhofunm M<IIW ofualioB Mlso11 Pump: MmufummlNnex TNe, HP Pumpinla4e hptl::_fl. DeeiwM aaw mn:_Wm Wanrlsrele: LUWaufelevwiaoabrc me uelevel 190 n. $SldcheuwpW of:nkPa oNf wa ui..1 5 aM ow1 uPflofNd 8mmns:d a:eDI 4 B1222 pn vgnert lrcDin,h D Nk6..1 h,eun:mlld b) trip.v0lw,uc.) WW Tmb: Wya puoginp W FmMn::d? Ill ❑Ym U by whim'v Tkld_ppm wnh_n Mwdowu seer_M. ywd_pPm wim_n.dm:.mwn.wr_hw. .it_®mwi1M1_ft dnwdown aRu_kx Rewv<rytlwa(nme-mm wkn Pumrk PmwdoD-xuu kwl aimWad hum wd T,n,e Tim.xablewD Weaelevel Timor war"..1 Times Wakrlevd Dwenfp::miramm aeikrlee_8 wi&_@ baedwe&r_hm Air nu .{0 0em wi16uem emu BO n.nb1 M. [Mk Bf2/22 Meekn 9ory_ppn T<mpenurt afw.w 50 °I wmarhmiW mNyxkmde? eves ONo jswminjM�2 Comphvtl Dam B1222 WEU CONSTRUCTION CERTIPICATION: I rmsmlme6 eoNm aecept resgnuimlih rm conmuctim ofihis well,and its Immplisllce wilhall Wsshinglm well constmdion MAnnWs,,math used and the infmmmim reported above em 1.tD MY best ImowlMge eM belief M Driller❑Trainer❑PE-Print Name J h Knepp Milli Coh,uh,Arcadia DIII&V I.. siont. Address PO Bo%17M Li.--N 2874 �TT City Stan,Zip Shellon WA 98584 IFIFI WEF-S 'e I.meOee FM Ctwnfte i5 Spc^m'ecsignrd re R 'slmtim No,ARCAD01098KI DeR 8022 ECY050-1-20(RerMIS) UYou nred Mls d.1renlln an AlmrmMformot.please will the Woler Remurees Pmsmmet 36IN4074877. Persmu with Monng bu mn cell Al(rWmhingmn Helay Service. Perzom wnhaspeech dlmhili7 cw m71817-033b341. Thurston County Environmental Hearth412 Lilly Rd NE Olympia,WA 96506 300-867-2631 �oau� COLIFORM BACTERIA ANALYSIS Deb San*CONdetl Tare is Camp y I 0 I Zy y �y, /Hasb>7 D T1TeaWebr SYMem(d«kmNam Eo4 dvaY Haueehok 00m A ❑oewB ❑Derr Gimp Amtl GmaPBSyebm-PmrM M1amW�rFaAba MenbrytwF9: IC/ _ _ _ — - - �I{ CanNri Pamn: yae Ll 4 Dey Plane:(Tub) 4L-4 S`L c.0 PSare:( --l— Emed: ean(..L \,p Eva.Pkre:l 1 SedmWY b:IPdmus eameae and rode , N•-� SAMPLE INFORMATION - S-*ee abd by(naa): M I Speeffik fionaasHvess 's .pleaWtYd: SPaIe FWUGorcaWnYrenk . IZI W t V AI loq0LJi} Typea Pb{mrMchecka9yane boxa9l tlrrNghM loved[stew) t. RoaWe Obblbalan 9aiple/ 2Rapea Sample leReruren routlne) Ch49�abd:Yea_No_ ❑DsUte iSystem Ch "Res a TaM 3mp Sangle _Fem_ Chbmabd:Yes ._N _..__ o_ B.Rewyeaa5oume e Chb.Res".ToYe�Free_ ❑E.ayl-GWR(AN) ❑Fete-sem.ca.psivearines�1 Unetlebtlnrypabal®reaher. FMed:Yu_No_ ❑Aaee�anentMmibrtglAR) UnaeasdpymuewcoYaadMe: 8 { 4.I] ColbcWd is o .Omy hweskso'e— ConebumbOH"`e ✓ Otlw__ LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY i ❑UawtlebabryTael ColAam Revd bM 'w°... o lab7 .. ❑EmypressM ❑EaW aSaent RrPh4Piea Sempb RequM: ❑s"w tea eM(,x harm) ❑TNTG O I BeNerbl DenaNRemla Tm Coltim n00m1. Eom'__/f00m1. Fete C*.M I100W Enbmmc _ 1100 m1. i M*WCade: SIA=18 ❑SM92Y20 DebaNlha Rrsivm'. SM92158 ❑EftwAft Dft"Teee N$vR -7.. 0ae 1 s pirN rartrpe dO InEII�OPf 0 1 1 IN -- Thurston County Environmental Health A�a 412 Lilly Rd. NE S Olympia,WA 48506 360 867-2631 THURS NITRATE TEST PANEL Report of Analysis Date Collected: (MMNWYY) / Lp_! Sysem Gmmp Typa:,mkmel A B Other Water System ID Number. _ _ — — — System Name: Lab d-Sam It 6: 090 -- _n--,— Cuan Semple Location: (Z► Numbet(s): (liewun<s i(deMd orrnmpnaned—_. — s : k W Date Received:IMMiDDIVY) 1 l RC-Rou0nelCompliance(naificcmnilodng rtyubmMnlal Date Analyzed-(MM/DD!YY) _1 l C-CnnDmnalion fronflm4lon afdlemiul mxwo• Date Reported: tMMItIDMYI �1 / 2 ❑ I-Investigative lams nm.m4n mmaoRng mgviremenn! Sumpter Comments: ❑ O-Other(sytcify d,e n,sw6uylrnadlodnamauimmela,l c Tr ( tick Pm-treatmenttUntreated(Raw) rls�c- S ❑ Post-trca0nenl(Finished) Side nme:,i f b,ek mrlmd•e Mxource B- Blended tun.wlum in'bw n f umbeuW Fuld) ❑ Unknown or other ❑ C- Composite(ils sour¢,in•Soorcc Numts,00'feld) Sample CollecWby:(name) 1nw�s 0421GK ❑ D- Distrlbnion sample Phone Namben 71-0 - 71L-¢164 Send to(mniling or a-m address): BDI Lo: (d u$ <100 �t<ii,� LL�s\ L•3 K EPA REGULATED AND STATE REGULATED OR REQUIRED DOB ANALYTE I DATA RESULT'S 11Nl'IS MRL SDAL TRIGGER MCL EXCEEDS META IF QUALIFIER (x Rre+) AN(kRO Nnmla-N mg.L O.S 0.4 SA 'uo SMaSOONWDt FE NITRATE LEVEL IN YOUR WATER SYSTEM IS: In compliance- -10 mgrL is the maximum em mminm,level allowed. Out of Compliance -CoMrmlllfon:IrclW'IM on,umILA mlmbrr.ample number.uM a Wxw dwe rf iPxu vmpc in daax 4bms+,lm axnrmms ratim. DATA QUALIFIER: A sYmM or knanpderem additiolW inbumFli,m atiwnhe rcsull. Iop(L: milliarmmper lile means tcx millhm. MRL(MMbudWpm,by Lkm,l: The Wwes19uamlfaMeamcemnikw of an aroiyte. SDILISDm Deastbn Repor,ing Liudt, The mitdmum uaurNe Me --ofan¢Wye a,,vudis by the dclwma-1 TRI(A:F:R! fN1H dnnkinK wmexmpme le•el. SYsxms wish xonpwlats Ma'Ied m xmwmmunm in excess ut'tltis level may ti rcauied W uke addidrmm samples m �m WAC.a mamas uendy. EXCF,ED1i MlT.(oaxanum xonDmivnvl k,dY. Malked ifthe eonwnina m 0e ammm exred. MC'/.ulWereWyaem 2lM1-39oar+12aG:91 Plmueomacl lne depanmeni s t skin¢v,w r uni.,mice in}roar araa W Mcmlirc Wild v-up anions. Lob Cusuamas: 2206918 MASON CO WA M O :LNeDPr#g50N CBDDIGETT194516 Rec Fee $304 50 Pages 2 IIII ill III Ii IIIIIII III IIII IIII IIIII IIIII IIIIIII III IIIII III IIII IIII Return To T �� S�\\On 1.)A S2SSa Grantor(s):(1)�� A1QW/id1Jf . (2) 9m ell CA Grantee(s):(1) PUBLIC/ Legal Description(1) S 4z/-O I A:a p 7 re(Abbviated(orm:i.e.lot, bkxk,plat or section, township, range) Assessor's Tx Parcel:y((1)_tL 5 Or' axTITLE NO I IC TIONN 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 viater 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 andlor Water Rescurce Inventory Area or WRIA. WRIA: 14 nn C Maximum Annual Average Gallons Per Day: " 0 gallons Dated on this i A day of Jd�. 2014. Signature of Grardor(s): (2) a'mlk&Zudl�kov State of Washington ) County of Mason ) Page 1 of 2 I " I, the undersigned, a Notary Public in and for the above named County and State,do hereby certify that on this g2O` day of /.Ua.�ofrou� personally appeared before me,wFo 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 year last above /w itidtten. / Notary Publi n and i A e State of Washington, r y �ACKSO so '•ti '% residing at :�.� i,g'�0. 2ij�.,•. 's My commission expires: 7 Page 2 of 2