HomeMy WebLinkAboutWAT2024-00076 - WAT Application - 2/7/2024 MASON COUNTY I
COMMUNITY DEVELOPMENT
Isermtft,irameGenhr.auddin ,Plannira
415 N 6'"Street, 0) e,Shelton t 4 89594, 5R ECE I V E D
(380)427-9870 exl 400 O Selfalr:(38%275d487 ex1400 9 Elma:(360)4a2-
�O�a\ A FAX(300)427-7787
�\ \�� Application for Determination of Water Adequacy FEB - 1 2024
��Insductions 615 W. treet
1.Ma ,ved
1. No determination can be made until Part 1 is fully completed.
2. the portion of Part 2 applying to the type of water connection utilized3. eted application, with any required attachments for review.
4. buildin site Ian must accom n this a licetion.
Part 1: Applicant/ Parcel Identification
Name on Applicant: 1..� Date.. 2
Mailing Address: 219It (ateffi 141,t NW 0 U/Iq Phone:
Parcel Number: Z1433—a.1-50"
Type of Water System ` Reason for Application
❑ PubliclCommunity Water System(2 or more W Building permit 6LDaZay-"001
(Vq
connections) ❑ Division of land:
Individual water source(one connection), #of Parcels? SPL
O 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 PublicJCommunily 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 connections)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)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 TH Forms,thinking Water Reviaed IR5/2018
� Individual Water Well
'X1 Water well report(attached to application). Depth 15-'?) ft.
Well capacity Test(attached to application) �� gpm god.
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 rapacity 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:Hors.co.mason.wa.us/olanning 14015�
S// 18M22-
Water use or limitation recorded................................... WA /Y/es�
WellDrilled ............................................................... Date
Individual SprinWSurface 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 6.66.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
Cl 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: Date
CSD Director: Dat 2ofz
RECEIVEDOL,pg6g { , p6p(0q
ENVIRONMENTAL APR - 4 2024
HEALTH
615 W. Alder Street
WATER WELL REPORT a DEPARTMENT OF Notim ofbReM No. IffiFfiffi.111A Gt
ECOLOGY ynpwE ology WellE T N I _ lu�
type of Wor6 State Wzrhi%tw
Oa C.- Sim Well N..(if mme dean...11):
❑ Dwom®nim b ongimlimWla8001,101Ne. Wetx Right Perim Certificate No.
Pwpmw U. IS Domxtic ❑mAneiel ❑Mmbipl Ptopery Ow.:m Name ANDY GRUHN —
❑owat,rhm ❑krirtion ❑'rea Wdl ❑Q Well Street Add.eu PICKERING ROAD
Cememdm Type: Memw: City SHELTON County MASON
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WELL CONSMUCf30N CERTIFICATION: I colmtrucmd uWm accept mepavibility fa comwctim oftNe hell,etd ne complienu xiN ell Wuhington well
comwction emMWe.MatmiaM mxd end Me infomration.epmtw above ere brm to mY berlkwxledge e.d belid.
❑MIN'
C)Train.0 FE-PrintNwe DANIEL CARPENTER D.ill'• C nem'Atnedmn Pump&Wiling
1 [a N,/�___ Adev PO dr eoz 14996
Lce.me No.2236 —mf C'y S m zV lurrlwaler WA9B511
IPTRAW S wore Licmm No Conbectm's
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ECY 050-1-20(Rev 08/19)0',,eou.med this docteem,In an a/rcmamformal,P/ewe call&a Wanr Ruarmm Progrmn at 368.401-d872.
Penov wl&hearing lws amr aa11711JwW MrWmn Relay Service. Pemonrwilh"I'd&Abiffycan 1a11877433-6341.
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ENVIRONMENTAL
HEALTH RECEIVED
APR - 4 2024
Vanguard Laboratory
615 W. Alder Strect 2635 Parkmont Lane SW
Olympia,WA 98502
360.967.7010
VAN�>u<ff Report of Laboratory Analysis
LABOR170RY
Collected by:
Arnerican Pump and Drilling Matrix Drinking Water
360-754-7867 laboratory ID: V2403054
Sampling Addrna: Date Sampled: 3/424 12:00
Andy Oruhn Hams Well#1 BPD 942 Dart Rembed: 3/324 8:30
Shelton,WA 98584 Date Reported: 3=24
Sample ID: Andy Gruhn Homes Well#1 BPD 942
Analysis Result SDRL MCL Units OF Date Analyzed
Total Coliform&E.tali by SM 9223B(mEXX) Batch ID:V2403054 Analyst:VJ
Colifonn,Total Negative 1 1 1AP1,1/100mL 1 3/52417:00
E.toll Negative 1 1 MPN/100mL 1 3/52417:00
Nitrate by EPA Method 353.2 Batch M.-V2403054 Arad t:RS
Nitrate(n N) ND 0.50 10.00 mg/L 1 3/52415:45
Notra:
b1PN:Mon Pmtwble Number
loan pwpermillion
cad:nondeten Reviewed by Robert Smallin&Chemist on 03/072024
Na not applicable
Smu. Sm.iteration Reporting Limit Approved by Tori Johnson,Operations Manager on 03/072024
DF:Wail.Factor JILM
MCL Maumum Contemiwn level �Nl4GlRaY Page I of I
Sanitn were received in acceptable condrioa The mamh(s)in this tepon rdme may to the portion clue asmple(s)MM&All aadym4 w terminated comoreat
with au Quality Asstuarme program MVengumd labmnmry.Please wnuct the hilownry dr.darid tome any .in.abom the rnul2
2635 Parlanont Ln SW,Suite A,Olympia WA 985021 Office:360.967.70101 testivg@vanguardlabirmarry.com I
www.vanguerdlaboratory.com
2207934 MASON CO WA
02/26/2024 04;02 PM NOTLE
,NOY ORUHN #195322 R— Fee: $304.50 Pages'. 2
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RECEIVED FEB �a
Return To ? 81074
'
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2; RfcEi
615 W. Alder Sleet
�Lf�io� 9gSG -
Gmntor(s):(1) A l: V4 (2)
Gmntee(s):(1).PUBLIC
Legal Description(1) LOT40FLLSi22-02AFf2200336PTNOFNln NW S3VRe,S53/147
(Abbreviated farm:i.e.lot block,plat or section,township,range)
Assessor's Tax Parcel: (1)2 s 1 3 3 _ 2 1 _ 5 0 0 0 4
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 am based on location of property and/or Water Resource
Inventory Area or WRIA.
WRIA: 14 Gn
Maximum Annual Average Gallons Per Day: �950 gallons
Dated on this day of 20 .
Signatu G or(
(1) (2)
State of We
ington )
County of lSlesen T�+u-fs'br )
Page 1 of 2
I,the undersigned, a Notary Public in and for the above named Gounty and State, do hereby
certify tl at on this `LZx day of y, 209,
�� personally appeared before me,who is known to be
signer of 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.
tTE �STE'"•„• Notary Public in and for the State off Washington,/
�8699j �s residing at �t1ls fS �j l _Gltifl�Y
NOl'ARy My commission expires: O�iulac>a�
PUBLIC ��j
%9 ENE%PIaE`'+�•'P
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Page 2 of 2