HomeMy WebLinkAboutWAT2024-00118 - WAT Application - 3/5/2024 r MASON COUNTY wAT
COMMUNITY DEVELOPMENT
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Application for Determination of Water Adequac�AR -5 2024
615 W. Alder Street
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:AnA,-6 rt 01 Oct C Date: nj lfa-N
Mailing Address: 2 f V hone: 3!'Od-`14U' 318".3
Parcel Number: 9.a-433- �...1-r700da
Type of Water System Reason for Application
❑ PubliclCommunity Water System (2 or mom � Building permit jbLOoZOa�-boa8q
connections) ❑ Division of land:
Individual water source(one connection), #of Parcels? SPL
�113 Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Remodel (please indicate name
If you have more than one residence oonneded of water system below if applicable-no
to this well, check the Pubic 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.
1\HH Forms\Drinking Water Revittd 1252018
Individual Wafer Well
Water well report(attached to application). Depth� _R
Well capacity Test(attached to application) I J epm ()L7 pit.
T c
The well driller often performs well rapacity 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 htto//qis.co.mason.wa.us)plannmq 15p 16M Y2LJ
Water use or limitation recorded................................... WA Y
Well Drilled ............................................................... Data 3 L
Individual Spring/Surface Water
Cl 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 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).
Reviewees Signatures: /v1
Environ. Health: Date
CSD Director: —� Date 2of2
RECEIVED
ENVIRONMENTAL WE 024� APR - 4 2
WAT2RL7 kPORT _ DBPAAM5_W, A��m�Ceo Itmwrt No. WE55618
ECOLOGY Unigm Ecology We9IDTag No. BPD043
ryp..M.o u: smteef Wmhmgton
O Cmuwcdon Site Well Neme(ifnt.ffieeeMwell):
❑ DmowNuw. C 0igi::el®blbiionNOl No. Water RightPmniVCvtificet<No.
Pmpmed U.. a Da®atio ❑mdomfal ❑Ma:i<ipnt Property Ov anon GRUHN HOMES INC.
❑Rwamme ❑briptim ❑Tap Wdl ❑qbr
Well Strmt Addmv PirkednD toetl
Cona.W
❑ ❑uw
MN— aalype: McWM:_ City Show Comlty Meean
❑D Newweg ❑Almmim ❑D, ❑3 ❑Crble Tod
emmiog pM ❑]w ❑MW-gavy Tex Pereel Ne. 221332150002
Dlnwmlem: Dluoeimofbmm46 m.,m 14S g Won evuienuapp.ed fu this we117 El Yes 13No
Depthofeoaplemdw 142 g
Ceuwmdm DeadL: wag Ifym,whal.the Yuieneefor7
Cash, LLm Diembr Fmm To Ttticloava Sbwl PVC Welded T Ond
p 1 ❑ e in. *2 137 1M in. ❑. 1 ❑ W 1 ❑ Load.(I.i".tim on Page 2): ❑WWM Or0Em
❑ 1 ❑ is in. ❑ 1 ❑ ❑ 1 ❑ NW V'Aoftbe HE M;Scctien 33 Towmhip 21N Range ZW
❑ 1 ❑ —in. — — —in. ❑ 1 ❑ ❑ ❑
❑ 1 O i . ig ❑ 1 ❑ ❑ 1 ❑ Witude(Fiunpk 47.12Xi)4727163
Lo,itude(ExamPle:420.12345) 12294471
Pedo,nd—O OYm ONO Tyvnofpv(mmrmed
No.ofp.bneou_ Simofpwmmion_imby_m. Drillers Log/Constme6onor DeeommWion Prmcdnre
Pu6:pW8om_8.m_gbbw 1pomdewfim Fmvutio¢Daa,Letywbn chmclm,dtt efmamiJ aoe ati¢la:e,Wtln kind eod
sieve ofthe maedal meats pumJed whom Imrom emy 6x eats ogmi of
8meem: ®Ym ON. OK-Pecbm b Deph 1S6 g mRrmatim Uu addidomlabwO.eeb 9vexury.
Naoog<mm'a H.A ndd Meddne Warpe Materiel Fmm To
Type SSTnl. Nodd No.
Di.6 m Sletaba 12 m5tm IW 8.m la g GRAVEL,CLAY SAND (BRN) 0 6
Diu::mm_m Sbtah:_ e<dom gm_d. CLAY GRAVEL,SAND (BRN) 6 24
GRAVEL CLAY W/SAND (SRN) 24 43
Saaem9m paeh❑Ym ENo sift ofpul:mamial_iv. CLAY, SAND OCC GRAVEL (BRN) 76
M.:ww.ple<Nsom_gm_R
Sm AceSeal: mYcs ❑Ne TewhadVdd t8 It. KAJM CLAM GRAVEL SAND BRN 76 84
b4u.rial meabmd BadonM SS ON, GRAVEL,SAND,CLAY
(GREY) Bd 121
Die.ay toes<mteio:mmebb wmn ❑Ym ONe - GRAVEL SAND CLAY W/B BRN 121 142
T,,eofwemn Dethavram GRAVEL,SAND WIB BRN 121 142
Mahodofu.h,gtovboff CLAY GRAVEL SAND (BRN) 142
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Tempebave ofwm_'F Wmememwwlymtmm7 ❑Ym ONO StaNAb 9/if2024 ComPleled DeOa 9/4/2024
WELLCONSTRUCTIONCERTIFICATION: 1wnstruckdadluuceptmgp ibilhYfanwmbuc6mofthiswell,andiMa Piia withell WNWngwlwall
mvwclian almdafdr.Meterielauled end the ivfwmation rePortd above art true to mY bert Imowledge sill belief.
O Dnllu❑Tteumc❑PE- ' tNamc DANIEL CARPENfE Dnilin Compn,Amedmn rump B Offing
S gNtme 4 Add.PO Box 14996
Ucmae No.2236 Cry s%ft Zip Tumeater,WA 98511
IF 7RAM S U..M NO, Contractor's
SpO Sigmtme Reotmtion No AMERIPD781M De1e
ECY 050-1-20(Rev 0L19)If,..,dlhia dxamem in an almmamJoro:a4 please-11 the Wamr RmourcesProgram ar 360-107-6872.
Person wld hmring bsd awl m71]fl fw WasWng(m Relay&rv6s. Peraov wlfh a speech dUab!!Iry can rat/8J]-033-6311.
ENVIRONMENTAL RECEIVED �i✓paD� DoaB�(
HEALTH
APR - 4 2024
615 W. Alder Street Vanguard Laboratory
2635 Parkmon[Lam SW
Olympia,WA 98502
360.967,7010
V-kt? jkf ID Report of Laboratory Analysis
LABORATORY
Collected by:
Amencen Pump and Dnlling Matrix Drinking Walcr
360-754-7867 Laboratory ID: V2403054
Sampling Address: Date Sampled: 3/424 12:00
Mdy Gruhn Homes Well g2 BPD 943 Date Rredved: 3/524 8:30
Shelton,WA 98584 Date Reported: 3naO24
Sample ID: Andy Grotto Homes Well M2 BPD 943
Analysis Result SDRL MCL Units DF Date Analyzed
Total Coliform&E.call by SM 9223B(IDEXX) Batch ID:V2403054 Analyst VJ
Coliform,Tom, Negative 1 1 MPN/1W mL 1 3/52417A0
E.toll Negative 1 1 MPNIIW not, 1 3/52A 17:00
Nitrate by EPA Method 353.2 Belch ID:V2403054 Analyse RS
Nitrate(asN) 0.542 0.50 low mg/L 1 3/52415.45
Notes:
bffN:MoslPmbeble Number
ppm:Pens permltioa
ad:nondereet Reviewed by Robert Smalling Chemist on 03/072024
as:asvinenbie
SDRL:Sure Dexcdao Repobng Link Approved by Tan Johnson.Operations Manager on 03/072D24
DF:Dilution Futw , ,
MCL:M=i Cnauaimnti l wI,r� ,r
m Page l Of
Samplesw =hod in areepmble wohhon.The usult(s)in the rePed adore only lc de,portion ofthe sunsets)tested All sndyaea wam pertmmed coesount
orh lbe Qetity Aatmvne pmgmo ef%guud VhonsmY Pleue mono the lsbont,ifyou shown Mve any qucedau about me noults.
2635 Pmkmont L.SW,Suite A,Olympia WA 985021 Office:360.967.70101 testing®vanguerdlaboratory.wro I
www.venguardlabolatory.Wm
2208335 MASON CO WA
03/07/2024 03 51 PM NOTCE
RIGHHEL JOHNSON 41956 J 00
IIIIIII 'I III I IIIIII II I I II I' I
Rohn RECEIVED
_ 2 13 ace lvrn�
MAR -5 ppyq
�Inr�vOia.Iw�A � 615 W.
Alder Street
ENVIRONMENTAL
HEALTH
Grantor(s):(1)N a C A P 0knSwL (2) 1-- QV�y1A _� oV�NS oK
Grantee(s):(1)PUBLIC ..
Legal Description(1) LOT2WU,"22.02A =003MPTNOFNl2NWFXS,31/ra.a531/7
(Abbreviated lb m is.bt block plat orssdibry rownsMA raw)
Assassor's Tax Pareel:(1)2 2 1 3 3 _ 2 1 5 0 0 0 2
TITLE NOTIFICATION OF WATER RESOURCE-INVENTORYAREA(WRIA)
I(Wa),the undersignedgrantor(s), hereby place this notice on record that thex escribed real
estate situated in Mason County,State of Washington Is subject to Water use restrictions and
conditions set by Washington State Senate Bill 8091 and Mason County Code 6.68. These
restrictions and conditions am based on location of property and/or Water Resource
Inventory Area or WRIA.
WRIA:, 14
Maxim um Annual Average Gallons Per Day: 950 gallons
Dated on this day of MAR-Q k ,20a�.
Signature of Granter(
State of Washington )
County of Mason )
Page 1 of 2
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189
A notary public or other officer complating this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document.
State of California )
County of Santa Barbara
uw )
On 1 RA-i .7. U 4- before me, Brenda Cho,Notary Public
Data Apt Here Insert Name and Title of the officer
personally appeared _1'l1 G'1fiP.� J. &bosbr� �tV1Dl L0.v Ina )ohln,thr1
-Name(S)of Slunerls)
who proved to me on the basis of satisfactory evidence to be the persons) whose names) iefare subscribed to the within Instrument and acknowledged to me that ha/spwthey executed the same in
hislherftheir authorized capacity(les),and that by Nsil arltheir signature(s)on the instrument the pemon(s),
or the entity upon behalf of which the person(s)acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph
B°°10A D is true and correct.
. M°tery i°btic-faaf°m1b '
WITNESS my hand and official seal.
Canmlul°n a 2159728
aVl�mm.ExyNes Aup 15,262r �a�Signature C
Signature of Notary Public
Place Notary Seal Above
OPTIONAL
Though this section is optional, completing this information can defer alteration of the document or
fraudulent reattachment of this to" to an unintended document.
Desoriptlm Of Attached Document
Idle or Type of Document:Tt{{p, (Vpt-j�ca�o 06 �htu- QzSDurs„�,l tltavt�{�Y�LA
Document Date. Number of Pages: 2
Signer(s) Other Than Named Above:
Capacity(les)Claimed by Signer(s)
Signer's Name: - Signer's Name:
❑Corporate Officer—Trtla(s): ❑Corporate Officer— Tritle(s):
❑Partner— O iceri ❑General ❑Partner— ❑Limited O General
❑Individual ❑Attorney in Fact Cl Individual ❑Attorney in Fact
❑Trustee ❑Guardian or Conservator ❑Trustee ❑Guardian or Conservator
❑Other: ❑ Other. -
Signer Is Representing: Signer is Representing;
C2016 National Notary Association•www.NationaiNotary.org• 1-800-US NOTARY(1-800-676.6627) Item p5907