HomeMy WebLinkAboutWAT2023-00367 - WAT Application - 12/20/2023 DU 3(p
MASON COUNTY WAT'& -
COMMUNITY SERVICES
Builtling.Pl mug,E,rvimircNal Hrellh Cwnnunity HealM
415 N 6-Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 eat 400 0 Selieir.(360)275-4467 ext 400 O Elma:(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 1A1r1 R,Vyci0 Date:
Mailing Address: I Phone::: 3U6 • driD-133oo
Parcel Number: J4— 66wo
Type of Water System Reason for Application
)Public/Community Water System (2 or more Building permit Pleua?� -615at5
wnnections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water
❑ Other(explain) ❑ ReplacOther ement )
❑ 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.
Part 2: Water Connection Information
Complete the section appropriate forthe type of water connection being evaluated:
1 tPublic Water'System
Name of Water System: IIE6t) -r l6bA6 I.I 611AuJilk-le Wl_
Water Facility Inventory(WFI)Number. n6y1E
(write"none"for two-party)
I am the manager of thi water system.The water system has been approved for a services.
There are presently connection(s)in use.This will be the Z connection.
Cl I 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 forth may be scanned and available for public view at www.co.mason.wa.us.
J:�Fa Ddnb,Warn aev 1/252018
Individual Water Well
Water well report(attached to application). Depthft.
Well capacity 'J
Test(attached to application) '— v gpm -7"b�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.
l¢' Satisfactory bacteriological test(attach to application).
/' Water Resource Inventory Area (W WA)
Development within which WRIA htto:/lais.co.mason.wa.us/olanning 14[Zj 15[;�16=22[[]-
Water use or limitation recorded................................... N/AQ 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)
atisfactory Determination:
This determination tices not address adequacy of the disbibution 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-Deternination 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: 0. tl 1 -\I" Date I ��
CSD Director: T Date 2of2
i
E�CEIVED
WATER WELL REPORT CURRENT NOV 17 2017
a11i+ Odgi-I&P<pr-Reolep,Pa co,,-ovMar emPY-drl@e Nodceof IMcmt Nm WR29361 INA
nt
KOLOGY ConstrpeRon/Dwommission("r"in circle) Unique Fmbgy Well m Teg No.ALD 606 M F�..I,..... ,m,.,RO)
IN Cow"cdon We.Ripda Perdu N.
'
❑ Decommission ORIGINAL MSTALLATTON Pmpety Owne Nsene Jennifer Chavis
�}f1 Nodron Infenf Number
PROPOSED W. 0monk ❑ IMunkl O musneml Well Sbeed Addreas Kissing Tree Lane
O Dewev ❑ Idmtbn O Ted wo O over City Tahava County Mason
TYPROTWORR: Dwner'a mmberofxll(ifnwrt Non me)� (g1,.etionbW/4-1/4.�w1/ASw Tid Twn23 R3 EWM ❑
0 New well ❑ RetvMbbmd Med Id 0 Des C1 Re:ed 0 Wwn❑ Deepn is,1 r Still REQUIRED) Or
ee 0 CaMe El
DIMENSIONS: Du..fwd16 Teem,filled J„4]_n. La0ldeg
of<mm k4ewepxM a LUDeg _ Lu min/Sec
COMSTRUCOON DETAILS Leng Deg_ Long MiNSec_
cw, 0 Welded 6 Dian,ndm +l a,a 249 n.IM.Ike: ❑ 3 e =' Dim.fis _n.
Tx mel No.(Requred)32134-2/-000M
❑ m Dem Fenm-1
m_n
Perlaratlau: xm No CONSTRUCTION OR DECOMMISSION PROCEDURE
Type ofpmfmuoruud Fdsmalim'.Dmcaba by cobs.cberaelw,sae ofineterial add nmcmrc,
C D2Eorwrra_in.bY_in..N m.efperh_rm,: n.m 0, laud
N an e Line d n^ :etu of themMcrud in mcb I..penetrated,wilb
Serwm: ❑ vm ❑ No ■ E-P.< L«adon 246 laud rt des,®hy fen mch chenille i ofiemmation. (USE ADDITIONAL
SHEETS O NECESSARY.
MmfenueeI N..Alby Maehlne woe" MATERIAL FROM TO
Tn. Minims Model No,
Oiant L—M..aew somxw Rw. ft NI 0 5
men SIcu,S fmm a m ft Redish brown RO 5 45
ti GnwVPWrpmaeN 0 Yn E No Sw ofrev"Un^e_ peat 45 40
Mm:i.e phmd rmm a m rt Cemented sand&novel with water 40 95
smem Swl: ■ rm ❑ No Towtwdcpn?IS n. Radish brown till 95 100
!O M.teriel m<d inenl aneam Light brown till 100 200
Did any Nnmwnein uneble.0, ❑ Yen ON. Sand&Revel with water 200 254
TxpeefwakVt DePN ofnnn
^' MCNoeofwli .eau oR
i PUMP: M—fimlum'a Name Gendds
YL� Type:epb. Np. 1.5
WATERLEVELS: IeMawfm elewlionabow elan wkaTl�A
C SWmk,elm ftne wpofwll Use,
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�w Am.knwaurnmdmlle4b wl ew.
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wtmpw ww=f..;l ime —
lid Tuen w..level T w.:er tewl nme waMlJwl
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a� Adman now_W.m D.0
�Va Te eom ofwum_Wmaciemicd.-",4:mde? DY. ■ Ne Sba DMd0/9/17 Cm:pMed Date 1113117
WELL CONSTRUCTION CERTIFICATION: I constmttW and/or euep«sponsibiliy for cooawuidn of this well,end in I-Wdisves with 8I1 Wasbinglon well
conmundionanndeds. Melma6m and Mcinfommionreponedabowmetmelomyb tlmowlWvg dbdief.
Driller❑E ' r TrtiMe Nome Emi Edwin, Dell' R Comp Davis DPDDnR
Drill /En ' ? S' Addrea 340 NE Davis Farm Rd.
Drillermeainee License No.3142 r Ciy,Sude,L Relfair WA 90520
IF TRAINEE:Drillds Ucedw No: Cdnl kv 3
Qt Ddlln's S'maauc Reldtefm No DAVISDIIIOOA pace Nov.2011
G ECT05&1-20(Rev02-MI0) TereeaeMADA a<awrnpda6tn lndWpngmawiatr iw a/wmMJpr We daadly impdM,uO AroloO WaferRmonmO Pregnn
et36&I874172. PerrenswMiarydndlwMMoR m WwhiMW.Rdo&e edlll. Pmanswfmwtchmmm'Y'mrycdl MotdYld33-63d1.
Davis Drilling
340 NE Davis Farm Rd
Beljair, WA 98528
275-5367
Test pump for: Jennifer Chavis
Well Tag k ALH 686
Pump: lyih.p. sub
Well Depth: 254'
Static Level: 200.6'
Date, 11/05/2017
Draw Down
Time Water Level Flaw GPM
0 min 200.6' 0
5 min 206' 20
10 min 2D6' 20
15 min 206' 20 -
30 min 206' 20
1 hr 206' 20
2 hr 206' 20
Recovery
Time Water Level
0 min 206'
1 min 204.6'
2 min 202.8'
3 min 202.6'
4 min 202.5'
5 min 202.4'
10 min 201.5'
15 min 201'
30 min 200.6'
1 hr 200.6'
Printed From Mason County DMS
Printed from Mason County DMS
Thurston County W a 01n 11.W Health
30001ANnrltlge Or.SW r OITrrOIG.WA 98603
360 867-2631
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Thurston County Environmental Health
2000 Lakeridge Dr. SW • Olympia, WA 98502
360867-2631
THURSTON COUNTY
® NITRATE TEST PANEL
Report of Analysis
Date Collected: (XIM/DtLYYt _LQ/— System Group Type:(dmle one) A B Other:
Water System ID Number: — — — — System Name:
Lab#-Sample#: OSO -- — — _ Count : M on
Samto ple LN 'vocation: Lt ft. f�S` LJA 4Q$gg Source Number(s): (liumumesifdendedormmpmued__. _
' n L✓, --
Sawle Pu '( cheek mummeriate,box) Dare Received:IMMMMY) / I O /
❑ RC-Routine/Compliance(mtisfiesmmitodngrtuirements) Date Analyzed:(MMMD/YY7 /
❑ C-COnrirntaliOn(cmfinnation of<M1emi®I remh)• Date Reported: (MMMMYYI ��/�_/ Z
❑ 1-Investigative(dmaaa;atisry mm�itudng reyuiremenm) Sampler Comments:
❑ O-Other(speeify-does nd sntisfymentoring".iremenls)
Sample Compositim r heck bo ) $ to_1 T . t h k e) ❑ Pre-treatment/Untremed(Raw)
® S -Single Source ❑ Post-trealment(Finished)
❑ B- Blended(jig saumesin'S..Nmnberml'field) ❑ Unknown
or other q
❑ C- Composite(limsoumesin'Soume Number(s)'field) Sample Collected by: (name) 5AM qaG .Jpet 66a �Gnllin'IW4e��
❑ D- Distribution sample Phone Number: (7e9) aSO 830 S
Send Report to(mailing ore-mailaddress): Bill to: (client name)
� Il:n . oa-Mmoll tt7l nn.:l .Cowl L II' A ,�11
310 N E le tssle, Tree A1r S. .l ,y uA 4Ysn
EPA REGULATED AND STATE REGULATED OR REQUIRED
DOH ANALYTE DATA RESULTS UNITS MRL SDRL TRIGGER MCL EXCEEDS METHOD/
# QUALIFIER MCL? ANALYST
(X If yes)
0020 Nitrate-N s5 my/L I 0.5 OS 5.0 10.0 SM4.500 NOW`ayle,
THE NITRATE LEVEL IN YOUR WATER SYSTEM IS:
M In Compliance* "10 mg/L is the maximum contaminant level allowed.
❑ Oul of Complianm
NOTES:
•CoMrmatbn:Include the origmal lab number.sample number,and collection date of miglnal ample in ether lab or umplereamntenm section.
DATA QUALIFIER: A symbel or Idterta demur additional infmmmioa about be remi1.
mg/L: milligrams per liter or pans per million.
MRL(Mdhod Reporting Limio: The lnwen quantifiable cnmemmtion of an eaal)ne.
SDRL(Sndelsmatioa Reporting Limit): The minimum reponeble detmion efan analyse as established by the deponmem.
TRIGGER: DOH drinking wrier response level. Systems with compounds detwed at omeentradons in excess of this level may be occulted mmke additional struges or
mania more frequently.
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depamnent's dunking watd regional ol0a in your area la ddemsine follw-up onions.
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2206031 MASON CO WA
12128IM23 02afi PM NOTOE
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Return(,t)1 To
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Grantor(s):(1)
Grantee(s): (1)PUBLIC
Legal Description(t) c,uw ,2cnk) 5 3H Ta3 R 3
( re.W bb*plat or section,township,range)
Assessor's Tax Parcel: (1) ntx�.
TITLE NOTIFI ON7ATER RESOURCE INVENTORY AREA(WRIA)
I (We),the undersi ra ,hereby place this notice on record that the described mat
estate sduated in on C ty,State of Washington is subject to water use restrictions and
conditions set State Senate Bill 6091 and Mason County Code 6.68. These
restrictions 40 c ns are based on location of property andfor Water Resource
nventory
nual Average Gallons Per Day: Gyn gallons
this day of CE1")h,1✓' 202-3—.
ature of Grantor(s):
(1) (2)
State of Washington 7
�� County of Mason )
Page 1 of 2
I,the undersigned,a Notary Public in and for the above named Cc State,do hereby
certify that on this Z`a day of�Pc . 20 23,
�k 1 n (L. O�+SS� t\_p�onally appeared bo is known to he
signer of the above instrument, and acknowledged thjhe :tkheY3ned it.
GIVEN under my hand and official seat the day and ywritten.
+++++��11101", Notary r the Staten Wash gton,
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Page 2 of 2
2206031 Page 2 of 2 12/28/2023 02:46:32 PM Mason County, WA