HomeMy WebLinkAboutWAT2024-00142 - WAT Application - 3/6/2024 ENVIRONMENTAL
HEALTH I WAT � ' DD
?ECEIVED 415N.6mStr
MASON COUNTY Shama,WA 98584
COMMUNITY SERVICES MAR 12 2024 Shd�w 360-427-9670,Ext.400
Belfai 360-275-0467,Ext.400
,4 Pldfhn ,Enrx,n.1 Hee1Mcamm-lnaeYm 615 W. Alder Street Elm:360482-5269,Ext.400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Pan 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: Hatchery Woods LLb Date: March 6.. 2024
Mailing Address: 1553 H 38th St,Seattle,WA 90103 Phone: 347-694.OB57
Parcel Number 421242200000
Type of Water System Reason for Application
- ❑ PubliGCommunity Water System (2 or more � Building permit e)t-,09Laq- *1AU
connections) ❑ Division of land:
Ef Individual water source (one connection), #of Parcels? SPL
9 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
am presently connection(s) in use.This will be the connection.
❑ 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) oonnection(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 co mason wa us.
.NF,H FormsV Dru kma Water Revised 4'272021
Individual Water Well
® Water well report(attached to application). Depth 297 ft.
® Well capacity Test(attached to application) 10 gpm TYPO 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)
Developmem within which WRIA htto//ois co mason wa us/olammna 14_15_16X 22_
Water use or limitation recorded................................... . N/A_Yes_ E'xMPit-
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 onf
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 resor lations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter6 68 040-flat of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may appl err
36.70A RCW
❑ Unsatisfactory Determination: *4SO qpp F
Applicant's water supply does not appear adequate to meet the needs of its intended use folloJieJ'g�?
reason(s). ryF��✓/ �?y
Environs Health: Date
Reviewer's Signatures: ^qOu^'FgTq(y
/�- ff�Z3/ta2 � NTH
This form may be scanned and available for public view at wwvv co mason.wa.us.
Page 2 of2
RECEIVED OL9300?"o-"10
ENVIRONMENTAL
MAR 12 2024 HEALTH
WATER WELL REPORT DLPARrMlNr o 5e9� °'cwBd2382
ECOLOGIC Unique r. iM Well W TU No, BPFC76
TyNdWwk: stateofwarl:NBton
R L'mv:m®n Site Wall Name(if mme asn orc welll:
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I•r"a Uan ®D<ana< ❑IN.. ❑Mwi i w Prollert)owner Name uanneR�l Mnt
❑Rwaraka ❑I:dawioo ❑Ten well ❑O W Well Slicer AW. 141 NE Ert&.a Iri H60W Or.
Cambu<Ibe Tile: Miami, city imon Comity mmn
ON<wwall ❑AhaeiN ❑Meal 03m<d ❑('abk'foal
❑D<ym<iaS ❑OiIN ❑Dy lid r- ❑mwato TIc N,,cl Na. 42124.22 00000
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CNMR Lwss Diaaax From To Thkhma StW WC WA W Theta
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❑ 1 ❑ __in. —m. ❑ O ❑ I ❑ 123.142748W
I oneitude(Esemple-12013145):
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Mamak Idxed fi<m_R.m_R MUIH cdared fine M metlium ravel,hose, 53 18
amivn Sml: fa Ye. O No TuwM1adaa?fie Multi colored ravel YSM fine Maven 98 0 78
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NP.— PeeP'reeke tlaph:_R. D.a®:eanowram:—e0m rounded cak,all 273
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WELL CONSTRUC 10N CERTIRICATION: 1.,tnmtW andlm eccepl mpon[ibility fen cmmmaion oftbe well,arif bs pomplaem with all Washi igra,wsll
tminll Aioa saManlx MMermhwal and the infrwmalion reportN ,b",are rcue m my best knawkdr and we
0 DnIk,13 T..101 E-h PhYlblan Drdli,Cmpany Arcadia Or'flkg Im
5 8 e� Address PO BD%1790
Licmise No.2083
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ECY050-1-20(Rov09i18) Urau pmd this docemem innn wlteremeJummr.Plepkaallee Waae R,,"',r Prograaras360-407.072.
Pndov wia hearing bss cnn colt)ll(pr lYashirgron ReWy.S'ervlcr. Perzws widrasyrrch dimbiliy ran arll8)7A33.6311.
Vanguard Laboratory 90 aZc?q &3�0
2635 Parkmont Larne SW,Suite A
Olympia WA 98502 RECEIVED
v!j3j D 360-967-7010
COLIFORM BACTERIA ANALYSIS FORM MAR 12 2024
DWSmpa Cdk T' Sample County
08/03/2023 ,G DaN MASON 615 W. Alder Street
Type dWam syk (mad my.ha)
❑G.PA ❑cw B ®gher______
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sya R MARSHALL CLEMENT H EALT i ,
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Day FNmw(380 )42633%: CM=Pm I _
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SAWLESMORMATMN
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Typ MBalepk(ededardrapegpedaarob ban lrP9a 16 *5bow)
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LAB USE ONLY DRIKKW6 WATER RESULTS LAB USE ONLY
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