HomeMy WebLinkAboutWAT2024-00060 - WAT Application MASON COUNTY LWAT - 0MLgo
COMMUNITY DEVELOPMENT
velmrc Nu me W auildiry Nanninr,
415 N V Street,Bldg 8,Shelton WA 98584,
Shelton: (360)427-9670 ext 400 d Beffair:(360)275-4467 ext 400 8 Elmo:(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: Kristofer and Elizabeth Pearson Date:
Mailing Address: P.O. Box 2201 Shelton, 98584 Phone: 360-870-6706
Parcel Number: 22131-40-01010
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more p Building permit LZi.l�o�r�2�'-OQ/J'r
connections) ❑ Division of land:
O Individual water source (one connection), #of Parcels? SPL
O 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 it applicable-no
to this weil, check the PublWr-ommunify 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.
❑ 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 v w .co.mason.wa.us.
Jr1Ea Paine\Drinking Water R. d1,25M18
Individual Water Well
Water well report(attached to application). Depth LA G( ft.
Well capacity Test(attached to application) ks 9pm 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.
Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http'//ois.co.mason.wa-us/`l)lanniing 14�b�ifs 220
Water use or limitation recorded................................... WAS(
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 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.
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: �.1�C0 ' I Date
CSD Director: Date 2.f2
i
WATER WELL REPORT '7 DEPARTMENT OF Notice aflntnt No.WE43291
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WELL CONSTRUCTION CERTIFICATION: I conslructd iouPoraccept tespundbility for conslmetien of Nis well,and ils<mop5aocewithall Ws9lR gtoa x II
ranaauction aWdenly Materials tlad and Ne information sapond above arc tole to FAY best knowledge eM belkL
lilDrilles inc M-PontN.ROBERT LAYMDN Union Co.,,ADVANCED DRILLING
Si t� yyYY'" Ad3en11530 SCHOOL LAND RD SW
Liemae No.25R8 CRY,saN.Zip ROCHESTER WA 98679
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Thurston County Environmental Health
412 Lilly Rd NE
Olympia, WA 98506
360-867-2631
TxURa-mN mtrarx
COLIFORM BACTERIA ANALYSIS
Oft Simple Collected rime son* county
11231 1 � Mason
iknM De,Type of Warr System toheck only one box) Pdwle Househokl
❑Group A ❑Group B ❑Other
GmW A aW Group R SysRire-Provide hem Welm Facilities Inventory(WA):
IDN _
System Name
ConW Penn' v( Q O
Day Phone: 1 70-1002. Call Phore: )
E—it Me Ew.Phorm:( I
draeuas m Ndname,Wd2u anc. ooda ala Sen '(Pn 1 (teeq
a a L n_- - kum-�
b 0dc 2 Z Q _ _ __ ma�wct
SAMPLE INFORMATION
$ample wllecrd by enamel hi lvc0.J soki
Specific location w address saint wllecled: SpeddinsWctims or conwooft:
Isol E *n lee WO
Type of sample(mad cheG onty one M of ht through sb lend below)
1.❑Roam Distribution Sample 2.Reped Sample(aPom onset mud")
Chlonnated:Yes_No ❑Detrtonon Syerrn
Chlonne Residual:Totel_Frea_ Chbrinald:Yes_No_
3.11aw Waler Soume Sample Chian Readual:Tail—Free—
❑E coN-GWR(AT)
❑Fecal-roam.uv4. hn ) Unsatidadory mdlm lab rmmLen
Filmed:Ym—rto_
❑Aseeament trnhall9(Aa') 1.0.6*eact"roukmecolenaem:
❑otimr
B
a Sample Collecrdfor lntomutlon Onty
Inves4gahw_ ComWctionl Repass Odma_
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Tone Conn Present arm ry
❑E.wlipresent ❑E.colabsmt dercled
Replacement Sample Repuimd:
❑Sam*w old( 30 hours) (:I TNTC ❑
Bacterial Dmsiy Results:Told Co#fon )100n1. Ecdi MCML
Feat Wen. AMIN Entoccocd 110Bm1.
Ma mo Cade: SM92238 ❑W9222D D.1.1017 iiqw
❑SM 9215E ❑EnrrordD G al'WI
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2207078 MASON CO WA
... 01/3112020 03:14 PN NOTCE
EL IZA,ETH PEARSON 9190600 Rec Fee' $300.50 Pages. 2
I IIIIIII IIIIII III IIII IIIIIII IIIIII IIII IIII IIIII IIIII IIIIIII III IIIII IIIII IIII IIII
Return To
YI l fcjlx+k QCct (S�r
Oi IPyDv� Tz-0I
Rk o,l 0Y)J WA
Grantor(s):(1) C 1i t-Laloe l ?ecu Say1 . (2) K-\lS -cAy Ve CLYSb y
Grantee(s): (1)PUBLIC ,
Legal Description (1) 'Fi 112 N 11� SE
(Abbreviated form:i.e.lot block Plat or section,township, range)
Assessor's Tax Parcel•
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: I q
Maximum Annual Average Gallons Per Day: 'V 15 v gallons
Dated on this_Z;�day of (j" I)fA/(M.20_�L.
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 rjanjed County and State, do hereby
ce that on this day of 20
rt fy Y
��na�'ti RA.�i K✓14 )t¢✓�persona ly 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 year last above written.
EMT TERESA L WAY Notary Public in a d for the Sta o ashington,
Notary Public
State of Washington residing at e
License Number 135501
Commission Expires My commission expires: `L
Me 15,2024
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