HomeMy WebLinkAboutWAT2024-00104 - WAT Application - 2/28/2024 WAT
MASON COUNTY
COMMUNITY DEVELOPMENT
FerminmigraMe 2111v.BYII41ry,PliMlry
415 N 6-Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 a Belfair:(360)275.4467 ext 400 d Elms:(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 Date: 0-12.0I2.02_,4
Mailing Address: Phone: 360- 964-0747
Parcel Number: 2zio-76 -4 82_ £HM4-WA %641
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more 'r Building permit 1)iA 2DA- 002-`I1-
connections) ❑ Division of land:
36 individual water source(one connection), #of Parcels? SPL
,X Well ❑ Boundary line adjustment
❑ Spring/surface water❑ Other(explain) ❑ Other(explain)
❑ Replacement or Remodel(please indicate name
h 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:
(mite"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.
L\ED Forms\Drinking Wnra Rc,,,,d 1125,2018
Individual Water Well
Water well report(attached to application). Depth V I ft.
Well capacity Test(attached to application)—A�gpm -;;, Lf oo 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 hfto://ais.co.mason.wo.us/plan[nAm 148(]161=22[=
Water use or limitation recorded................................... N/A r-1 Yes
WellDrilled ............................................................... Date l
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 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 Grovrth 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).
Reviewees Signatures:
Environ. Health:� Date V
CSD Director: Date 2°f 2
Dc) N
RECEIVLD
APR 15 2024
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? ECEIVED
Arcadia Drilling Inc.
P.O.Box 17M APR 15 2024
Shelton,WA.98584
Customer: Tim Olson WeIITag#: BPF172 d'✓. Alder Street
Site Address: 148 E Fox Run Lane,Grepeview Depth: 83'
Date of Teat: 4/5/2024 Static: 33.4'
Pump Set 60'
TIME GPM LEVEL RECOVERY
1 Min 8.6 37A TIME LEVEL
2 Min 4.3 37.6 1 Min 38.8
3 Min 4.3 37.3 2 Min 37.2
4 Min 4.3 37.2 3 Min 35.9
5 Min 6.5 37.2 4 Min 35.1
6 Min 6.5 38.4 5 Min 34.5
7 Min 6.5 39 6 Min 34.15
8 Min 6.5 .9.3 7 Min 34
9 Min 6.5 39.7 8 Min 33.8
10 Min 10.1 39.7 9 Min 33.5
15 Min 10.1 43.7 10 in 33.4
20 Min 10.1 442
25 Min 10.1 44.3
30 Min 10.1 44.4
35 Min 10.1 44.4
40 Min 10.1 44.4
45 Min 10.1 44.45
50 Min 10.1 44.45
55 Min 10.1 44.5
1 Hr 10.1 44I
1 Hr 10 Min rr 10.1 44.55
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COLFORY BACTERIA ANALYSIS FORM
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13267 W. C (oguJo) i t-d RECEIVED
APR 15 2024
615 W. Alder Street
Grantor(s): (t)T t G. Dlsos) (2) 5 A"we 4. 0(4012
Grantee(s): (1) PUBLIC
Legal Description (1) 094 .,1., l'5 -2l N-2 u) /i a 6 SP 1VoY I
(Abbreviated loan:i.e. lot, block, plat or section, township, range)
Assessors Tax Parcel: (1)
_2_-2--1—-L- 2—
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: I q
Maximum Annual Average Gallons Per Day: gallons
Dated on this 3 P-1 day of 4pnt� 202-4 .
Signature of Gr
State of Washington )
County of Mason )
Page 1 of 2
Ft
he undersigned, a Notary Public in and for the above named County and State, do hereby
certify IV on this day of�—, 20�,
ihoAn 7L.fMtt niteo.1 personally appeared before me, who is known to be
signer f 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.
vuLyDIC %
T-?QP'e�-o F'yr'.
o?e^•..�y Notary Publ c in and for the State of Washington,
NOTARY ' Z r1
residing at
1I
`•'••� �°•_� My commission expires: Ta
9••a
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Page 2 of 2