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HomeMy WebLinkAboutWAT2023-00272 - WAT Application - 10/4/2023 WAT 2oA3 - O6,-7a 415 N.6°Stm MASON COUNTY Sbeltmy WA 98584 COMMUNITY SERVICES ShdW 360-427-9670,ExC400 Belfair.360-275497,Ext.400 �/ anmy,vw,nyr,xa,nKm�xwm x�bxwn Elm,:360482-5269,Ext.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 ap2roved building site plan must accompany this application. Part 1: Applicant/ Parcel Identificatiop Name on Applicant: Date: Mailing Address: C 20U5 Phone: 31AO• ?-&A •C31 I10 Parcel Number. Fief fwA- Wd 9es?$ - MbA9 - M - 0=0 Type of Water System Reason for Application ❑ PubliciCommunity Water System(2 or more Building permR ��d�2.3• i_iti connections) ❑ Division of land: individual L al/water source(one connection), #of Parcels? SP /g Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) ❑ Other(explain) ❑ Replacement or Remodel(please indicate name ff you have more than one residence connected of water system below if applicable—no to this well, check the PubficXommunily 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. Print Name of Water System Manager Phone Signature of Water System Manager Date This form may be scanned and available for public view at www.00.mason.wa.us. l:U,+FIFome\Um6'og W&c Reviudd(Mnl Individual Water Well Water well report(attached to application). Depth r (-1 - ft. rQ�Well capacity Test(attached to application) �1i0 apm �g 0 u opd. 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 rapacity 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 IA) Development within which WRIA htto://gis.w.mason.wa.us/olannind 14_15 16_22_ Water use or limitation recorded................................... N/A 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 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 Date2412/2" This form may be scanned and available for public view at www.co.mason.wa us. Page 2 af2 WATER WELL REPORT _ DEPARTMENT OF Noticeoflntent No. WE53729 ECOLOGY Unique Emlogy Well ID Tag No, BPO 120 Type of Work: State o1 Washington 19 Cnnmm,ion Site Well Name(if more lhan awe well)'. ❑ Derarnmemoa b Onared lmemmlm NOl NO Water Right PeemidCertifieae,No, Proposed Use: N Domestic ❑Wwemal ❑Mmkipal Property Owner Name Holl'e MWUIIIM ❑Dewuedng ❑legation ❑TM Well ❑Oder Well Street Address 750 NE Foster DR *New 11 Type: 0Imad: OO New well ❑Altermion ❑Uiwn ❑letld RI Cobb Tnol CIIY B8Ra1r (,'orally MaBpn ❑Deepening ❑Odur ❑Dag ❑Air- ❑Mad4tohay Tax Parcel No. 1232913000M Diaemions: Diameterofboring 6 m.,to 143 ft. Was a varisnee approved for this well? ❑Yes ❑No Deph wf.cmplod-11143 ft. Contraction Demlk: WWI If yes,what was the variance for?. Geeing Liner Diameter From To Thiekn-n Steel PVC WeMN Thnad ❑a 1 ❑ 6 in, et 131 114 Pa. ❑O 1 ❑ ❑a 1 ❑ Location(am insaucdons an page 2): ❑W WM or❑EWM ❑ ❑ _ie. _ _ _in ❑ ❑ ❑ ❑ SW '/.-%efthe NE '/.;Smion 29 Township 23N Range 1W ❑ ❑ _in. in. ❑ 1 ❑ ❑ 1 ❑ Lmimde,(Example:47.12345)47.455326 Longimde(Exampla-120.12345) -122.832566 Perkntimom ❑Ym ON. TypeofpMonroruad No.ofpcomoims— Sao oflxrtotuiau_in.by_w, Driller'.Logr,c m to mmofr DecommissionR fie lei ndmd Peromed from_0,to—ft below growd surface Form,oft1: mmoreby each averaa-morr,f cods in to od e,worm,melee lookco �eonlm.male k cash rarer Peae mmd wim ri le.n wne easy for each aange or Sareos: pYes ❑No NK-Packer b Door 123 ft. inf.niatwer. Use d:fitiomldwerr Ifweensnry. Marefac.nYa Name common Material From To Type smi idoor Mead No Dwrwwr5 n. Measime into. 128 fi.ro133 ft. Topsoil 0 20 Farmer io. Shashi in ftom 133 ato 143 fl. Peat 20 23 G silts sand and gravel 23 50 s.wFute.prick:❑Yev ❑xo ss ofPuk mumal_in. Brown sand and silts 50 104 Materials Placed flu._A.m_fl. Brown fine sand Wb 104 143 6ureaa Snl: N Ym ❑No To whri dep h?18 ft. Mrieal used in sal b ndershe Dld oey evu croomm n.mable rvid.0 ❑Yes ❑No Typeofwmm" Dembofawam Method of s alioe r mara oR Pomp: Manumcmrer'a Name corks Type:ad, H P. 1/2 P.npiatakede dr:30 ft. De.ignad now ran: 10 Win Water : ISM-surfaceelevation aria mono keel_fl. Slick-upofmpofwalliceine_ fl.eaova gourd..rice Smic weer lecel saws ftMow tap ofwell using Date InQ24 Aneaim pmrmor— ba.pn(team imh Dome "as.wrieris controlled by (cap,wlw,etc) Well Tmn: War atamping ma performed? ❑No ❑Yee by whem1 Yield _on.wim_ft dnwdown mRer_hn. Yield_Ran with_ft dnwdmm after_M. ynid_Rom with_ft dowdown aner_hi. sorrows,date(time-ame when pump is hared off-wrier lewl measured from well top to wamr lece0 Time Wrier Lewd Time Wrier Uwrl Time Water Lewl Dme of Pamping Ira Brooks.M gpm wimZ ft.Mwdown chat M.� Air ten _Opm m whhrtextm_fl.fm_bn. Due Aaoim flow_gross Tempand—fwmo_-F Wasememkalannlysismade? ❑Yea ❑Nw Start feme 1119124 Completed Do. 1/24/24 WELL CONSTRUCTION CERTIFICATION: 1 constmaed and/or accept responsibility for construction of Nis well,and its compliance wish all Washington well coastnmtion standard.Materials used and she infoonation reported above are true to my best knowledge and belief S Driller❑Trainee❑P -Print Name Emll Davis m 11' g Company Davis DDIIin9 Sgp Address 340 NE Davis Farm RD License No.3142 city,Smce Zip BeHair,WA W528 IF TRAINEE'Soon is License No Cowpaver's Spaslsi S'gtmmre Registration . eR yfnNo DAVIS011100A Dace JAN 2024 ECY 050-1.20(Rev 08119)Ijyoa need this document in an alternaseformal.Please call the Wafer Resoarres Program at 3 60 40 7-6 8 72. popsw with Marini lass ran call 711 Jor Washington Relay&,ohm. Persona with a speech disabiGN con mll877.8334341. !6206 Twelve frees Ln NW Sm.c I! SPECTRA Laboratories- Kit_ap PoWsba.WA _...».... —_ 993/0 360 n9-slal COLIFORM BACTERIA ANALYSIS FORM Dab Sample Cdlepe6 Tore Sempb Canty r412Ll Cdlecbtl � 3 'mow wan We rsx "Ype d Wabr Synm(akd ady aro bm) ❑GmupA ❑Cap B ONm uap A and GmW B Sys6ms-Pswbe tam Web FadWm haw"IN* V _ _ Ystem Name: 164 :anted Pollan: � K•U(lA.e{�iMs/ by F-- Do3 Cm Phma: :mat Eve.R. eN mats b:yeat" a,,ounaa mwsrneentuwnienk«nanxMl kE INFORMATION - :enpleralMeEby(nxre: QaJa$ gadfic locetlon ramm semg6aldetl: SpKW osbudivmv ammmk: ,m of Sompk IMectanh cola bns) .❑Refine DlHdbulbn 9ampk(AN) 2.❑Repud Semple(ANI Cblvimbd:ym ❑ WD pmxaHamnermnH amx.mahel Chleme Residual:Tnml_From_ Iksa5sb"y mule lob camber .Ground Wabt Rule Source Sample ——— ----- T*eaI _ I I ' UmeEaleclay ralealpdelx ChblhMk:Yas_Np_ ❑Assess ent(A Dtlube ResidAt TdBL_Fm_ ❑Assesammt(A?) Sudaca par Owl Sax Same water Smimk(EnumveNon) ❑ E ror ❑Feral fans rs._w_ B q.cdlmwmhmmxka aid: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY 7 UnuMtmwry TdH Cogan Present and Soeshcbry ❑Ea pm ❑Ec alent Modal DonalNR uts:TOW Cabnn_mMMODnt Ewa "WIDOMI. Feral Colilam cW/00M. WC cdlml. eplacemenl8ampk Regulmd: ❑TNTC ❑Sample t.old ❑ Sample Vdums ❑Dammged CdnWrme ❑ plan»2: 23�3,4I D L nplTenpc:�e�.J ���� MxkdCod.: an:tae, Ttownste® onr..muaaawwn 2202974 MASON CO WA II��1GW4y�U���ILaryLIBIgqN3W�I�IN0rry1W1a�II'''E'I %�1l9IIII CC] FecI'' FeMle y��g3I2II06 pp5�u10'' Pages Y Return To IIIIIII IIII IIIgIlllll NNI t 1I111N111111I81P�1111 H� ul I L2.n4X "oWe, I�O.I�x1z ;NU a 3f Ifn Lie Lb A g9528 Grantor(s): (1) e MCQ( j'`\\CGn , (2) e©U;1\CAY) Grantee(s): (1) PUBLIC Legal Description (1)�I LL 2oF BI.� 1N ZZ df+l 202'1311 l�Tll of F SW nE (Abbreviated form:i.e. lot, block,plat or section, townshp, range) Assessor's Tax Parcel: (1) I _rIl. a a 9 - 1 3 -6 0 0 0 6 saq - -ra3 - 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: 15 Maximum Annual Average Gallons Per Day: —I5O gallons Dated on this_ day of IY-4U6Y 20Q0- Signature of Grantor(s): yy� (1)44060i MwU' (2) 111 State of Washington ) County of Mason ) Page 1 of 2 I, the undersigned, a tary Public in qnq for the above named County and State,do hereby cqrtify t at on this day of , 20�, e llt V� personally 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 a�en. "`�OAFI Ap unrn.. .`` ..u.... , Notary Public in and for the State of Washington, `:• m�EN�••• ig residing at MasonOn �..+✓�4� NOq�•. '� B • My commission expires: 11L 7.0 3 ,p py�PUB LIG y j 7A•"'MIYAYS�I.•'•• Page 2 of 2