HomeMy WebLinkAboutWAT2024-00110 - WAT Application - 3/19/2024 MASON COUNTY
COMMUNITY DEVELOPMENT
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415 N 6-Street,Bldg 8.Shelton WA 88584,
Shelton:(360)427-9670 ex14DD 4 Belfalr:1360)276-4467 ex14DD 4 Elme.(360)482-5269 ex14 '
FAX(360)427-7787 r
Application for Determination of Water Adequacy 1f4R 19 `
Instructions
1. Complete Part 1. No determination can be made until Part 1 is fully completed. FD
2. Complete only the portion or 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 Applicarit: Chris Van Ackeren Date: 2-29-24
Mailing Address: 3810 SE Lynch Rd. Phone: 541-913-0950
Parcel Number: 31902-43-90021
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more El Building permit p iitt"�"51
connections) ❑ Division of land:
❑ Individual water source(one connection), If of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
Cl 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/Community Water signature required)
System box. J'WD T"\(*J WeI( V jy4Ai J—
Part2: Water Connection Information wet[ 7Z ,ZA-MCI13 Tlrn
Complete the section appropriate for the type of water connection being evaluated.
Public Water System
Name of water System: Chris Van Ackeren
Water Facility Inventory(WFI)Number: None
(write"none'for two-party)
(y I am the manager of this water system.The water system has been apprrNed for 7_services.
There are presently I connection(s)in use.This will be the_L_connectlon.
❑ 1 am the manager of this system.This connection will be to upgrade or change the use or an existing
connection on this system(te.: recreational to full lime). Please indicate on the following line the nature
of this change.
This water system is able and willing to provide er to 1 rail se onnaction(s)withoul exceeding
the limits of the water system or any limits at tat n li I r �ulation.
Signature of Water System Manager Data 2-29-24
This form may be scanned and available for public view at www.co,mason.wa.us.
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rmaa`.Itrinking\Vnlcr saknl IliA1n IR
� l'vfda..h ®sly..,. .,_ ,u
Individual Water Well
V Water well report(attached to application). Depth M ft.
'C Well capacity Test(attached to application) ZO apm 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). /yILQLY
Water Resource Inventory Area (WRIA)
Development within which WRIA htto://ais.m.mason.wa.us/planning 14['Z15[=16=]22=
Water use or limitation recorded.................. ..... N/A_[_L1,Ves_QL[AFp:2=AIr
Well Drilled ............................................................... Date .�, �
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 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 6 040-Determination of
Adequacy for Building permits are satisfied. Additional Growth Management require nPay apply. Chapter
36.70A RCW. Rip
i:I Unsatisfactory Determination: C
Applicant's water supply does not appear adequate to meet the needs of its intended use f�rlbe following
reason(s). At,. HHhh'' )91�?4
Reviewer's Signatures: NV IRO
Environ. Health: —J% - Date 11
CSD Director: Date 2 of2
I
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Arcadia Drilling Inc.
P.O.Box 1790
Shelton,WA.98584
Customer: Christopher Van Ackeren Well Tag M: ALN049
Phone: 541-913-0950 Depth; 96'
Well Site Address: 381 SE Lynch Rd., Shelton Pump Set: 95,
Date of Test: 12/13/2021 Static: 4D.7
TIME GPM LEVEL RECOVERY
1 Min 2 41.6 TIME LEVEL
2 Min 2 42.5 1 Min 50
3 Min 8 45 2 Min 46.5
4 Min 8 47.2 3 Min 45
5 Min 8 48.6 4 Min 43.7
6 Min 8 49.1 5 Min 43.1
7 Min a 49.5 6 Min 42.7
8 Min 8 49.7 7 Min 42.5
9 Min 8 49.9 8 Min 42.2
10 Min I 8 1 9 Min 42.1
15 MIn 8 50.3 iD Min 42A
20 Min 8 50.7
25 Min 8 60.9
30 Min 13 51.6
35 Min 13 56.5
40 Min 13 57
45 Min 13 57.2
Vanguard Laboratory
2635 Parkmont lane SW
Olympia,WA 99502
360.967.7010
VANOUAMID Report of Laboratory Analysis
LABORATORY
Collected by:
Chns Van Ackerca Matru Drinking Water
541-913-0950 L.bor.tory to: V240301-10
Sampling Adeheon D.I.Sampled: VM413:45
60 SE Sells Dr Dam Received; 3/124 16:00
Shelton,WA 99584 Date Reported: 3/4/2024
Sample ID: 60 SE Sells Dr
Analysis Result SDRL MCL Units DF Date Analysed
Toml Coliform&E.call by SM 9223B(IDEXX) Batch IDN240301-10 Analyse VJ
Coliform,Total Negative 1 1 MPN/100mL 1 31M416:40
E.cob Negative 1 1 MPMI00mL 1 3/ln416.40
Noten:
b1PN:Man Probable Number
ppm:Wm per million
od:nan.delwl Reviewed by Robert Smalling,Chemist on 03/042024
Wand applicable
SORL:SlmeN eclbn Reporting Limit Approved by Ton Johnson,Operations Manager on 03I04R024
OF:Dilation Factor I9aW.2av
MCL:Muimum Cgoamimnt Lauel Page l oft
Samples reecho!in acceptable ceaition The n5ah(s)in this neon Nme ody to the pomw of0a Sample(s)eened.All amlyses was performed wmiflan
with an Quon,Anonew protean,ofvanb nod Lab wary.Plena wnmm the lab xwory ifyw,Muld have eoyqucnimn above We eando,
2635 Parkmont Ln SW,Suite,A,Olympia WA 985021 Office:360.967.70101 testing@vanguaidlaboramry.com I
www.vanguardlabomtory.com
} 2208105 MASON CO WA
CNRISTOPMEROWW nCKERENOt195453 Rec Fee $304.50 Geyes l
11111111111111111111111 mill IIII11 K Iliflill 1 IIP 1i III III
Grantor(s): (1) hr� rhA�e" ��ej{rvitfwt/ -
Grantee(s): (1) PUBLIC Tj Q
Legal Description (1)1-01-1 O��J' r > IqDZ.gq p FT�)W l 456
(Abbreviated form:i.e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1)� ( �,O �- `i 3 - '1 O O 2 �
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—
Maximum Annual Average Gallons Per Day: `"I y0 gallons
Dated on this day of , 2012�.
Signature of nto
State of Washington )
County of Mason )
Page 1 of 2
I, the undersigned, ry Publics nd for the above named County and State,do hereby
rtify that on this day of V' V .v 20 ,
personal 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 d and ye r last above written.
A LL 1WII .4 ti
a
y�C .�f61..... O No i ry Public in and fo State of Washington,
Q'ro6�,•3[-1d�A /yG residing at
=.ti v N•.
_My commission expires:
�Ntm9 PUBLIC wry;
5 a•.m Z�
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