HomeMy WebLinkAboutWAT2023-00239 - WAT Application - 7/26/2024 i
WAT Q7.3 - OD�.3q
415 N.6-St
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES ReMir:360-2754467,Ext.400
salt..:36042sa46?,Ext.400
.v. ,1a.—.E[ —m '..Ikk « lH..im Elms: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 approved building site p Ian must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: f*cnr, 1504e fqu1l Date: 7y26/Z3
Mailing Address: Gb-o SE fn..r.J Q4adj Phone: y75" SIIY• 5gm
Parcel Number: ,7ZCA - 7S- Gc) IV 0
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more W Building permit BLD 1,W13-0107U
connections) ❑ Division of land:
gr Individual water source(one connection), #of Parcels? SPL
af 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 9 applicable-no
to this weft,check the PubliclCommunify 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)
❑ I 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.
J-,WH Poems\Drinking Water Revised 4/4/3018
Individual Water Well
Water well report(attached to application). Depth I Z8 ft
Well rapacity Test(attached to application)----d'D Qpd.
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.
Iv Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA hnp'//eis co mason wit us/planning 14?c15_16_22_
Water use or limitation recorded................................... N/A_yes9
WellDrilled ............................................................... Date 7
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 W DOE 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:
Applicants water supply does not appear adequate to meet the needs of its Intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: `� r" f Date
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of2
WATER WELL REPORT OIDEPARTMENTOF NdineofIntnMNo. M34744
ECOLOGY Urr wEoImWflMTag No. BM078
ryp<nr wo.b sate ofwasnkgru
Q Cme:wdon Site Wdl Name(ifmom than ant wall):
❑Ds®®imC Uig4ul i:eb&rion NOlNo. WaWRight PemiU ifiWcNO.
Pmanitu- 090.w 0wnn,6l 0muoicipel K-nnMNnnw NllenrVBawman
DR dnvq; O4ripism ❑Ten,Wdl ❑p&r
Wdl 5ha[Addrem B80 Fheweatl We
Gm npifl yp: MWad:
o Nw wA ❑Ahembn ppiveu ❑le&d ❑GbbToel CRY shWOn CauMy Mea9lr
O Dmp®w ❑UM ODm RAie ❑Mud nin, Tax Perin Na 3OM75OD100
Dlmeado:^,. olhamp6 Iv,b 170 t WmavndmunppmvM fa thin wdl7 Ely. [INo
Dephdvn,lebdwell 1M L
G®rmr4e oaefh: win Vym,xlut xssthc wrienccfM
C®, lies Diwmra F. To lhid:mn Sbd PVC W Wed Thr
0 1 O e in. H 1Tt— .25U in. o f ❑ m 10 1.eutial(auhmbrrcaomonpege2y. UWWM or❑sw
I 0 _in. 0 I 0 0 I 0 SW Pi-Kofthe SE K:Smlion 26 Tawmhi 20N 3W
— n ❑ I ❑ ❑ 1 0 P—RmBe_
0 1 0 —'n' — n 0 1 D 0 1 0 Wimde(O pin:47.12345) 47.1898148
Imgimde(Eadnple:-120.12345) -123.0148809
Pill i DYm MNo T3wofpumnrmmed DrI11er4Log/Comtructba orpeconndulon Pruednrc
N:.ofWbetims_ Steefprbnrim_66y_m Fmurin:Umibe by wlw,chuub,eiu ofoxM1riYerdemolme..od rMDied
PuRnrrdfim_!N_L&Io..pmMenrRce vm..Nrbvrahl in nchlanrpemoared,whh nlanvmemy Fmewh cheap of
3ereens my. ❑No MK-Fn'ker b Deplh 1T2 L lebor�Uee eddidonvl ehub ifnecevmy.
M®ur rare Ne®AIIovM ML Wwkn Mannial Fran To
Typo Slolletl M Na
Uemeb: 5_ SLreiv012 ioaem IM &01ia t RIVNTr 1aV81 firla SarM,tl 0 7
ITavear_ skReim_ufivm tm_t Beam fine Sandy prav ,silt ba ,dim 7 14
BNGe 9.v.Ity 9.yc0 dq 14 23
saM�lnr pech:DYm ONe 5'brefptl rmmiel_u Black rim sand rgyd MM,a 23 41
Malwls\JCM t b_L GM
SwN"Snl: wy,s ONo TowMdvo to t aB day.6011 41 ]6
Mem —d Neel BerdonlN Chios Black revsil Ind to fmdlun Bend N silt 78
Did any so-so comoinunumbN wnefl DYu ON. Ga d
Typecfwwn? ""innm Giea ,atN[tl BB 105
h iifYedim..ff Black ONM 9MW,sift bound UIK dry im lie
MUIB nod ow" a QMY sold wet 118 129
Pemp: M®vtamei eNuw Tape: Blom AM tIgM sand,wet 129 1 135
N.P._ Pnpinnkcdegh:_R Dedpd dow ma:_®m Gmy medium sand,heavi ,water 135 169
Wear Wrb:f.vo-uvi ebrwia above m. mbwl et R tletlhxn black sand,dean water,heaving 169 We
Sritop ofepafwdlmi:p 1 fl.ebaw gouodman
abdc nnnnnn e_5 6.&bwrunninihl mivp tha][L](1,a 1�9
Ararhnpiv¢me_Rr.pa9w imh Dde
ANruowelmu cmoBMbY (W.relw,m.)
We11Tmm
Wmapvepiogbnpn& M ONv OYa b bywFnm4
Yi ni_W:nwirh_9.dnwdmm n&r_M
ypld_pNnwirh_RGnwd�reefler hm
Yetl_Wmwirh_fi,kewdawne&r_M.
Remary Am(time uro wMn Pnmpu Nmrd aR'-xeraleel mu+uel fivm Mdl •
r. knh
T W.level Ti— Werer4w1 T'vrc WrwrleN
Debofpmp�trat
BdbrdN_apmwYR_fl.dnwdameBe_hm
wbrr 30 ®mwiONmmm 120 fl.far 1 nm Deb]/11FL019
Tempaa^a.+ofmm 51 •P wmerhminleWwleesm9 ❑Yee oNo Stm Dam ll1 D201B annpininniNt. ]I112019
WELL CON81'RUCTION CRRTIPIGTION: I ulwmcud ardhxacaplrmpauiNliry Gruoraudimo[Mu x<II,and itlampliaec with dl Wedrirrpmi xdl
eamhrxlim aandmdR tfelaidr used end tlm itdormatbn repWled about era lrummYbW kmwiWgevrd hdief.
Ellhil or dnmOPs- NemyRNew FIrMan Drilling Comm Arcefs Dr Ing In,
g nanant Addnnn PO BM 1790
U.M.2053 / City SM1te Zip Shelton.WA 98584
V TRAR�� Spomore LiumaNa. CpnSmbr'a
Sponsor.S'9abee Regidmdnn No.ARCADDI09SK1 pate 7/1 Mile
ECY050.1-20(Rm09/19) HMrenmdar4 daaumenl in an nlwmul rm(Plraa murk Wanr Remurcu Program al360-IOJ-IfBJl.
Perrzw wlrh hemi�lmaran mll731jor WpaMrrgron&lay Sendu. Perraa wLlrarpeech dimMliO'can mllBJJ-033�6341.
Thurston County Environmental Health
2000 Lakeridge Dr.SW •Olympia,WA 98502
360 867-2631
T
COLIFORM BACTERIA ANALYSIS
Date Sample C.1ladel T.Sampk County
colkolerl
Mao on a
Type of Wake Syatem(d..A only one box) ❑ PPmateeHH.o�useho�ld
❑Group A ❑Group B au 0,•nL7!/rYaYs
Group A ad Group 0 Systems-ProWde from Water Facilities Inventory(WFQ:
ID# _ — - -
SyNem No.:
OrvnW passe:
Oay Phone:( ) Cell PFa—:
E-mail: E..Ph.
SeM.b h(Pont lul mare,edmae a,l dp oede a emen adbeec)
SAMPLE INFORMATION
Sample mI
or d 6 kew Spedal in.*hu onsarm m mmb:
9_c i
Type of sample(must check only one bon of Al"Ir M4likled below)
1.0 Roudne Dleblbulbn sample y.Repeat Sample(after mrsat mullets)
ChlommmJ:Yea_No_,K- - ❑Distrbulbn System
Chrome Residual:Total_Free_ Chlorinated:Yea_No
3.Raw WaWsource Saamle Chbmre Residual:Total_Frea_
❑E.rod-GWR(AIP)
❑Fecal-%nee,mi.vraa Oeraelml Unsatlsbckory routine lab member.
FaaaGYa_No_ _
❑Omer ��_
s
A.❑Sample Collected for Information Only
Instigative_ Comsbooticn l Repairs_ Other_
LAB USE ONLY DRINKING WATER RESULTS LABUSEONLY
❑Urmmn(aetery Total Cditmm Pmwntand szBaeactory
❑E.ad present ❑E.md absent
Replacamem SemPle PeauUed:
❑Sample tiw net Q30 house) [I TN
❑
Backtal Deoslly Resale:Total CojR n_-M00m. E.cad /10dN.
Fecal Colilor, I1WM Enterococtl n9D ml.
Mdmd Code: 9TL3B ❑SM9222D ern Time Roorl d
❑SM 92168 ❑EnterolaW } Z3
OeMaq Tyne MMynd "?"Z WlePepmed 1)
emq.xwca Noxnmeagamaddel lab Use OW
D BD31 -
t ooxrmlpnlsa11Z9 m �� 3a51
2201852 MASON CO WA
09/00/2023 10.31 PM NOTCE
BFTEMRN #190590 Rec Fee: S204.50 Pases: 2
zgv�
To IIIIIIIIIIIII1IIIIIIIIIIIIIIIII1IIIIIIIIIIIIIIIIIIIIINIIIIIIIIII
Grantor(s): (1) �PNVI.I T B0. eman , (2)
Grantee(s): (1) PUBLIC Sj�T�-�j
Legal Description (1)TR ID OF C QuE�/ 4�)l '
(Abbreviated form:i.e. lot block,plat orsection, township, range)
Assessor's Tax Parcel: (1)3-A-Q 9—-(P--Z5--QQ1.-Q---(I- -
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 properly and/or Water Resource
Inventory Area or WRIA.
WRIA: �4 (�G/'t
Maximum Annual Average Gallons Per Day: ( J50 gallons
*ofa
O day of �P {�� 20 2.l
�-
(1)
(2)
gtonn )
Page 1 of 2
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
fy that on this day of SeilkmkYev , 20,�,
certi
rnYi �{ 21 JP v 0Q n 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 above written.
�. n� Notary Public in and for the State of Washington,
6 z
ga .. residing at
My commission expires: L(�29f�Z6
PUBLIC C
Op
Page 2 of 2