HomeMy WebLinkAboutWAT2024-00194 - WAT Application - 3/20/2024 wnTl�- 0b I
415 N.6'^StrCcr
Aft MASON COUNTY Sndmr.WA 98584
COMMUNITY DEVELOPMENT shdwn 360-4z5-9670.4467,Esl.400
00
Belem 360-Z15-4469.ExL 400
MF v—m 1,111 eeem".liAl, ,4lenoing Elnu 360-482-5269.Fm 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 Skf�-���:L 06riy Iijc`- Date. 3 /z C2;c 7
Mailing Address: G'. 3,�/ &V11,(, (,J r1$3Ph ne: 3(� SSA 7$ 3S
Parcel Number: `2-3,b- 24 - co-1 /
Type of Water System Reason for Application /Y'� /�-,
❑ Public/Community Water System(2 or more .Building permit l�L'-r�C; {—X410,
connections) ❑ Division of land:
:bl--Individual water source(one connection), #of Parcels? SPL
,S_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 if applicable—no
to this well, check the Public/Community 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.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
]9ElI FormsV Dnnkme N'umr Revised 4/4"018
Individual Water
Well
,(
Water well report(attached to application). Depth I�H.
Well capacity Test(attached to application) 2(- gpm (�1.0 ad.
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 hthp//gis.cc mason wa.us/planning 14_ 15—Z 16_22_
Water use or limitation recorded..__......._...__.._......... N/A))Yes
Well Drilled ......_ _........ ._..........._.._._ Date 30tLq b
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 6.68.040-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: KtIxA� _ Date
r_
This form may be scanned and available for public view at www.co.mason.wa.us.
raps 2 or
File 0"Onal ant Flnl CUDY Wpm ADVllamm. No
)aD.d Cap of Eamayy WATER WELL REPORT 914-2
Third c,C,ory— n:i:Co°Dr
pr are•I7s OF weetimrrvroN _ )'<rreR Na
(1) OWNER• rarv'z "etcte Add— ^.. lox. ^91_.'_el£air -lash.- 09422
O. (2) LOCATION OF WELL: eowey. .Yason '3E t: . ''"-'I. t.see16 T.23 N. a_1-1.W N.
ee.rme end ,manes bore eeaue. ca_ar sa lei an r
(1) PROPOSED USE: DomesticM 'mdubina ❑ sho elpal❑ (10) WELL LOG:
3 fmipnon ❑ T. Well ❑ Ober 0Foema°n neranbe by enioa now-Ter HS<or male>al and+trueeurq ant
ways'ypstoon narrated. [b ar Yam•par entry )T ewhleM sn, at 1.
In eu=n
np. br dof..e.
N (4) TYPE OF WORK: o.n..e aumxr ar wal _ - . _ _
.- (rf men thbn one)._. ...._....._._._. MATERIAL IRON TO
y Nev sell h. studied'. D. ❑ hoped ❑
DseDeaee ❑ Gb1eJyT Ddeen ❑ B.z Vn. Clay 0_- �9
Recanemanee❑ aa.rr❑ dm.e O Gray Gandy Clay _
C Dry �03Y_j and _— _.__.._—)__55 0-.r5
O (5) DIMENSIONS: nl.menrel .en ... 5 mane arown_Sand- !Vat Qr.-Bearing_ _. } -95-}11-3
Dolled 1� . . ..n. D.Drh Df .oreyl.ted We. 126._....n ggddi ch Prown Sand..Gravell_�1.1_l_3
(8) CONSTRUCTION DETAILS: Cla —_—_ _----T. 20
i 4 n Sand A. Gravel ',lat.er 2G.t 12$
w Casing installed 6 .- 1. pram 0 ft.. lo8._n $eddish Frowns d Gravel_&
G Throbbed❑ " D ano from _ n b 1. _.. n r.1 a� - 159.
Weld l°m m ed)(] •• O fro - n to --n.
N
+�+ Perforations: vas Noxx -- -- - -
�' Type of yenoe.be libel
0 SIZE or yerlontmm m by -. di. _ _
C _ ortarobta o erean _ n. m
__
..... Derloralbw frnn .
fa N r 'r7e11 Total 12 ft. 2 in. _
fa - °`�`°`b"OO. 1OT - `�-` --�- n. To to of Facker i� ftft. n.
Off Screens: Yenta No❑ Riser i e 2 ft. 1 in. _
st.naf.mu Name _Johnson __......... ---- ,02o- 51ot screen ft. in
T,,Sttainless__S.tesl . Nadel N -- Blank 7 ft. Ii in.
i Dwn. .6 "al from 108 f bll}... n. _— _ ..
T Dbm. 6. sll �re.018 Barn 120 am12$.-. n. .Ol Slot screen 5 ft. . 1
Tailpi Pe 4 1_14 —_
�y Gravel packed yen❑ Nora size f gonell Screen overall 20 ft. 41 in,
cr..a pi-ed frap, __ ..... _ nm... ....n Six in. easing 107 ft. 11
Surface seal. Yea® N.❑ To .net depin) 18 _. n Static -Head 95 ft _.__ _
arm do f te a_. Bentomte. . ...___ 10 CY6 __I
Nee � £t
O Old spy •lrz. ....b lie ble selen Ye•❑ mou 20_ pM_ —45 ft
Z Try. of Wa ) __. DtDrb of.'in. _....... _ _._._ _
N Melbod of .l p t bon
p (7) PUMP: Nan r [unu Non..-
L Type.
(8) WATER LEVELS eov° i u.o —_ UN- � —
o a5 b ll t 29Apr42 _
O wn v are lbe a square I h Do...
_ -aA&IdAF2�0:.ifQLGY _ __ -
lL a ,— W.bTis eenwlled br fc'o.a.be etn _c_g�y3'FSI_kirll0`1>QL.`f 1CF �--
O
DnWda 1. .
a-r (9) WELL TESTS: fowene below Wane la=l µ 3 5pr 11 r<2 eomDl=nd 30_.1 Lr11w=2.
C W.a pomp urt mmn Yes ❑ Nu® It r®. by
Ctp hem: m. nth n. dnwn.Wa Amer ore- WELL DRILLER'S STATEMENT:
G - _ This well was drilled under my 7urisficlion and lhls report is
------ - .. - true to the best of my kpawlydae and belief.
6 N=raverr aau a1me l.Ren u pure snm Damp turned pal tsar levy
Qm aframWn lap In sop- a ........... NANd4iaholsan.i)rlLing. Co. _.
T W er Lerni tune W [ Levy T1m W.I., Gvel 'Pa... I.. - eapo t.°.' IType of Dr ntl
N --- Aaaress.r• 0 Eox ort.._Crcharda_;9ach.___
n of WL _. ell Dr111er1 _.
- [Sipe __.
spun,
ol t ) 20 s limin w)di..I ft d .Wdewn bre,
a meend Dour
remann a=e re of W __. w., mlm .°ar•n lo.d.1 re❑ ..-(I ticeflse No 0$20 ___ _ Date.3D.Apr 11 . 1922..
i USE ADDITIONAL NNIITa IT NEC65ARYf .�v
mo to
SPECTRA Laboratories - Kitsa ausrl
FrraP�,e,
2G2"l6 TWclve Tees Lane,Su4c Q Pou!sbo,WA 9 TO
(360)9]9 5141 wrw.xpecrra-lahcom
LOLIFORMBACTERIA ANALYSIS
Dale SempTime Semple CountyCOIISc / Muno
AM112Z<1PuType of Wate onebox)
L'Groroup B (Vpmale,Well
Ercop R and Group R Symbol Pmvldefrom Vla]er Facilllier InvnRpry(WFI):
Byatem Name or Well Address if Private:
Comact Person: (P y
_—.—
Day Phon
e:(3CwO) S 50- 7 S Uell Phone:( )
Emal Aromas I
S r) 7{" Q
Client mlarmatlofnnet ran gamg msulgg aJacseaobull
—y36 C
°'x;r,. ?'o raPE nlwRroaTw�x
Sempb collected by(name):
smcmcloaafion gmpl[colacrad(nett oaim: slrealai lnnroC,uns or romm<:;;- 1
P diJ0.TYS1'9HSFILLdIU''$I)paED kREAl yYA"
I..VP �t`f�je Rlahifiullon'Szmple aY,CeraprrlNPl . .iiyv�
a•?Jor1Y t -,Wma e
�Ch onne�je�]E
�rOUPd elllCeBiruyl e_ 'J y Ff � 4i<.pt.
P fu�45 S '12TD � t .
1�a1 N*11
. . -
..5'.�i-lo d�_ ( ',te73Y3j1bXH�M-
v
L
t3fe_ial`
LAB USE ONLY DRINKING WATER RESULTS LIB USE ONLY
I Unsatislacfory Total l)ehfOnn Present and Safialacle,
❑E co/ipnesent ❑Eco/iabeenl
Splacemenl Sample Squired:
❑Sample taa ald(>30 hours) ❑TNTC ❑Sampll
❑Improper Container CI Turbid Galore ❑ __.-
ctbrial Density Reel Plate Geunt__/raf Feell _Iron,
Dal Coliform _1100mt. recal Coliform___ ._rl00ml.
food Cdder� �� Data MIT, aRCr<ivca '
e RePorte�dJJ} pJD Z Td712
on, ne[pby�
_ _.
101e NumEW lnetl number plus llW Elgns) Paid:
o----12101_.— Z3SfZ�8
.-uoR 0,, ena-tad�mco erem-wa,e,scrnn� cow-Doe noal„cw