HomeMy WebLinkAboutWAT2023-00363 - WAT Application - 1/23/2024 WAT - 00 a_6_3
415 N.6ih Street
MASON COUNTY Shelton,WA 98584
4) COMMUNITY SERVICES Shelton:360427-9670,Ext.400
110fatr:360-275-4467,Ext.400
a,ra,y,pw�..arn..wn.wixwu.< nary xwe, Elms:360482-5269,Em.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: Ag..✓I 441)ns c� Date: 1123�
MailingAddress: F. t1dj4-ev TY S6o/dn.Phone: `R021�y,0Is
Parcel Number: Q]o I ')11 Sp2�}n
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more IBA Building Permit 111 �Z"D�c 6
connections) ❑ Division of land:
0 Individual water 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 9 applicable—no 1
to this well, check the Public/Community Water signature required)
System box.
2 3 2a
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 y .co.mason.wa.us.
h EH Fo=\Drinkiv8 Wata Revised 4142018
Individual Water Well
JV�Water well report(attached to application). Depth Hat tt.
ll� Well capacity Test(attached to application) 2.t f gpm 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 htto7/qis co mason wa us/olanning 14,X15_16_22_
Water use or limitation recorded................................... NIA_Yes_G
WellDrilled ............................................................... 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)
atisfactory Determination:
This determination does not address adequacy"a distribution system,guarantee an adequate supply of
water indefinitely in the future,or guarantee compliance with all applicable W DOE water resoume 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
35.7OA RCW.
❑ Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reasari
Reviewer's Signatures: r �f
Environ. Health: ",,,' r ' Date ` 3
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
RECEIVED 1311PR 3'6{50�
JAN 23 2024
WATER WELL REPORT EWOp erYStr Unique
Fcolent Well
S
��!hl Ll7 Unryuc Ecology W.II ID Tag No.8PN048
'I ype xr u�nF:
❑ cm¢waixn tide N'dl Nnm'lif murc lNan one xclll:
Cl Ovvvmmwwn O UnIP^m maulta:iw.vul No. Waler Right it ce ilictm No.
Pr.p•wd Uv: • wnn'.li, fW 'p l Muniehnl Propeny Oxr(N.KEVIN AND JO HOLM44ANSEN
Ll M..' =In,. = faa\YA =ONvr
N'dl Slnq Addnv 360 E WAITER SWTT 0_RNE_-_ —
C••au1
N.x xcR _.Umm4`n C'iry SHELTON _ _ Cpml1Y MASON
' ',Ikcpning I lA D" p am. MW.Rdop tan Panes Nn.220I3-I I-50240
Wrmbm: uuma'raflm:ing6 n .u,161 a Wnsava(i.e.Mn d4xlhisucIV 7Ya QNo
Ikmu nn,.n:PlmJ xeu lm IL
('ae cline MUNw WLI Ilyes.xlul xas lh[vanance foY! __
(S.inN Linm Umnvr to IhNka l Seel M we" IhmW
tit 1 ❑ e a3 156 2 . ❑• 1 ZI IP 17 � Lovouonl einslmai Page2R A%'W orO EWM
1 1 :1 in. _ln. 1.1 I -I .J I NE 6.'Loflhe NE rzticctim 13 Township 2ON Range 2
_
Z) I ❑ _in. _e. ❑ 1 7 7 1 .7
7 I _hl. _in. ❑ I 7 7 1 7 Imnude lP.xample:4'.1'1451 47.22558
Imghuk lli•ample:-I in.CJJ31-122.86553__ __
Yaamme: Yea aNn IYP:nrpaann,mw
w..apat eun._ sin ntre,.aim. i..q_ Dr10eesnCanslrunbam Demtn9u•lon Prm'Mam
PMi¢alW rn.x_fl.n _:I.heF�N�mxnW unGrt Ymnonnn'Gx""u6e M-,ukt.,iwy-ler..vc arrnn'rml mlauwtm.uW nnki:W UW
ve..rllr iman,l ina'h byar Peoew J.vdh N kart nm em:y fnr exh.M1any'ul
Seram: •\l'v IFu 'uK-PxFvblhyN tSJ fl. N(rnmmn. l'v rFlnmml.Im,Rm'ravary.
Material From To
im STAINLESS MxA'1 No
ummx.e ;n. Mw.vat5 1•.fmm '56 f_w is, n. SANDY CLAY LOAM 0 4
ni.memr_ m. sex.�n_ �n.5.�m_n .110 CLAY SAND BROWN 0 v
s••nrvlxr pae=n+ aNx sue."luck mnmw_u GRAVEL SAND CLAY 27 40
Malcwh plxw lrvm_Rm_IL SAND CLAY BROWN 40 BO
Rurr cegnl: �Ycx ❑Ni. L�xlm wmn•16 II GRAVEL SAND CLAY N 140
Mmmel rd m,cal 3R BENTONITE CHIP CLAY BROWN 1d0 150
mJ any xmaamkm muvnle x.m: ^_Y" 9 sn CLAY GRAY SAND 150 155
type ofxay+` IJ.Ixn nl,:mm GRAVEL SAND WS I 161
Nedud of realin4onanR
Yu�p: M:um(xnorch Name Tmc:
IIY._ 1`unN iuub a.T�ar_a. 4aiyu.l llev nm.�pm: "
Watr Lea,: la:d.w.m.'e hvmenivMnem am lenR_e.
slmF-Wnny:,.rxell.mmp 2
smu vales level 125 R6ehw wpnf wollevi:R: UaR 1VIS4023
Anvsun Pnum:e_1M1+mr W:um i:u-M1 wy
Anvkian x'vv narnml4J FY Icap.val,c.,.cl
Well Tme:
Wn.urylMvy Nl R.bm r.9 Nx :J Yv, Fy rMn:'
Yedd_Imn`.0_h.duxd Ae,_M1n.
Y.ekl_(pm xi:h_ft d—l-n allot_M1n.
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. lu uew kw)
T.. %.Il "d Ti.. Wam anal Tn¢ ewc,Laacl
INikrlm ppm xdM1_u.nmxAmnall,. m. l
2_n A gpmxnn sNm+n:u f61 Alix2 nn. Fwrc lvte2e2]
msi:n M._mm
Ieopmnm nrway+ 'F wasacMmwal•my.¢md.^ Crc, [6 N.` Slm Dple121136=3 C,mnldrnl Dare 12/IMM _
HELL CONSTRUCTION CERTIFICATION: I cunvwcnvl mW ur vnupl naPw bisp f n nmzlrvuirn nllhiz xcli.aM its cumplimrcc xith all N'vhingmn nett
canmmalm.tandmda.Mmenalx unW aW the information rep acd ahnve an tme to my hest km dealy ami mlief
iU"mil ulee❑PE-prim Name LAYMON Tnillin C ,, nt ADVANCED DRILLING LLC
SiYnmun Addre-11530 SCHOOL LAND RD SW
❑tense N..25M p C'i,Smte,zip ROCHESTER WA 0579
IT INAINI It.W.. b.se N.. ('anmamin
Sponsors Sigaumm R 'o h.No ADVANDL6040L Dalu0IMM024
ELY 091-1•20 1 Itev M 19111:a 'ol(hia,h...nu+uO tmullmwer l,rmw, /......dll01.II'uxv Ravmrcrn Program yr Jdngq'.Af11.
Ibanwa mifh hYr¢irrg Mu rnn mll J/I/w R¢ehhy;trm Rr/m Sr.nm. A'rmm,vi(Au apardn/i+nbilin.mr null A'"-s.i)b.Nl.
Thurston County Environmental Health
412 Lilly Rd NE•Olympia,WA 98506
360 867-2631
TnuaesoN couNn
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Tbne Sample Ceunty
Collided
1 23 12 e} - M�d17
Kra on
10 , 301-
rw —
Type of Water System(oback only orebox) Private Household
❑GmupA ❑GmupB ❑Wren
Group A real Group B Syaems-PeoNde from Water Facilities Inventory(WFl):
IW
System Now:
Cantactprw,: KevM [jow- 114rLSm
Dry Phore:( : ) 34 2 / I oriphoo 021349 3 /
Email: l'y;I rcl h QS0 al ,, ,Cam I Ere.phona:( )
SSA aeubIm'.(Print MI name,allow,and ap rode same
IZ, 1phi 'Ji} .l
SAMPLE INFORMATION
Sample coltected by(name): VE ..
boom or addrasa allow sample ockesse: Specialinalmctionsoroomnaxde
ShC�ro� U)A
Typo of Semple(must check on"no hox of al through 641leted below)
1. RouUm Ol4Mbudon Sample 2.Repast Sample(efisr.neat.mutters)
Chlorin d:Yes_No_ ❑Dierbution System
Chbnrre Residual Total Fine_ Chbnnansi:Yes_No_
3.Raw Water Seem Sample Chlorine Residual:Total—Free
❑E.ccb-GWR(Alp)
❑Fecal-smaa.owl,snw ,mars.) Unsatisfactory mutine lab number.
Afte ed:Yee No
❑Assessment 14mibmN(AIP) Umnlielxmry motie collect date:
❑Omer ��
S
4.❑Sample Collected for inbmwlbn Only
Imesligma_ Construction/Repairs— OUIa_
LAB USE ONLY DRINKING WATER RESULTS USE ONLY•
❑Unsatisfactory Total ColHorre Present and leolory
❑Ecaepsrnt ❑E.m9absml No Caf/omrtleteoted
Roplacemeet Sample Required:
❑Sample mold 00 hours) ❑TNTC ❑
Bacterial Density Results:Total Cofdoren It00ni. E.mW /10bM.
Fecal Colibnn /t00m1 EMemwad N mi.
Metlad Code: SM 9223E ❑SM92220
❑SM 9215P Enbrolm*
OalewA Tire Anmyud: Wa
awarewwaamoNwwwece!<!» taeueeavy.
0 8 0 (�
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ENVIRONMENTAL
HEALTH 2205554 MASON CO WA
Return To NOL16Hareis3 11 99
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MI IIIIII1IIIII!IIIIIIIII1IIII ill IIIIIIIII!IIIIIIIIIIII1114IIIIUI
!EhJlr" fl CEIVED
DEC 15 2M
5 K Alder Street
Grantor(s): (1) 1•fi ,r1 DIm- Ha.ncrr, , (2) Jo 4olrv, - I-( @ncrn
Grardeels): (1) PUBLIC
Legal Description (1) O-2'� r 11S 3drtl5O35O6 -S W/40 -12
(Abbreviated form:i.e.lot dock,Plat or section, toanstop, range)
Assessor's Tax Parcel: (1) &.1 a Q�.�-L J_-aZ Q 2_Al
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA)
I (We), the undersigned gramor(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: Ir' _
Maximum Annual Average Gallons Per Day: 'q50 gallons
Dated on this /Syi day of )QfI,Mh&— 20l3 .
Signal
bra of Grrranilo/r/(s): �//]
-" . (2)
State of Washington )
County of Mason )
Page 1 of 2
I, the undersigned, a Notary Public in and for the above named County and State, do hereby
certify that on this _tlay of 20
Alm N µdlM_4cn en-3, )fUIM-liars onally 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.
�0Q�!+"s5sion'••.!V . Notary Pub& in a r Me State of Washington,
Q P0A7-yof+u;;S�•
`~•moo NO7gq�B v Z' residing at �1
ice. UPUP BL' _ My commission expires: I I POUVi
' 4i�9AF°?Numbat�G�\
i,�iOrWASH0�o``�
Papa 2 of 2