HomeMy WebLinkAboutWAT Application - 3/14/2024 WATlie
MASON COUNTY She f,W 98594
COMMUNITY SERVICES Shehm:360427-9670,Ed.400
BeVart:360-2754467,Ext 400
aae..aPw yEmwmeb HmI&C ftHH Elora:360482-5269,E.xt 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: Applicantl Parcel Identification
Nameon Applicant: L2WiS Date: -3-12-I-A
Mailing Address: ZISZ(G Z38Rf AVE-SE- Phone. Zao 007g
Parcel Number: ZZl07-50-0003G
Type of Water System Reason for Application
❑ Public/Community Water System(2 a mom � Building pennR�Id202`{-(bS21
connections) ❑ Division of land:
Individual water source(one connection), #of Parcels? SPL
X Well ❑ Boundary line adjustment
❑ Spnng/surfaoe water ❑ Other explain)
❑ Other(explain)
eplacement Remodel(please indicate name
If you have more than one residence connected m below if applicable-no
to this well, check the PublialCommunity 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 maybe scanned and available for public view at vrim .moson.wam
1:TH Forme\orwl'nr Wata Rwieetl4/4 018
Individual Water Well
,$( Water well report(attached to application). Depth 92 k.
j9, Well capacity Test(attached to application) 20 opm 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 RIA
Development within which WRIA htto://ais.w.mason.wa.us/olannina 14_�15_16_22_
Water use or limitation recorded................................... N/A_Kyes_
Well Drilled ............................................................... Data -7—'-30—*ZC:OS
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
E 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: Date
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 ot2
WATER WELL REPORT N` . ,Nae
Yd�ril�'i Onglao&1st cop,-Fcolugy.2nd copy-owva.Trd copy-"Ic, Umque Ewlgy Well m Tag No. nKC 916
ConyyDeBon/pecmmnigtimremnretd � 383a5
y,l 0 ComA tmu Wmer Rigk Pemit No.
0 Decommission ORIGINAL CONS7RUC77ON AIM.,
CL of Imem Numbs property Owner Name Fd Eh 1my
PROPDSEDUSE: ®Donmahc Olmmmil M--PW WeI15Deef Addroea 1420 E Nasm Lk. Dr. 8.
❑Dewalc, Olmpuoo OTel Well OONa L}tyrrapeview Caney: Masm
jOPwoRx: Owvers nouns of wdl of more thav a:e) EwM c,mr
&]New wen O ReconEmonm McMM O Dug ❑Ram ❑unvev inn�Evd-vd Sal/a sm� Two2L R21r� a aM
wwM
N0 Dupevcd }]CaNe ❑Roary ❑laud ,at/lun8: Let Dcg _— Iqt IvhNSec
yDIMENSIONS: Dmocmr of wcll is t,
Jocb9R — REQUIRED)
ED) L-g Deg— Mn/Sec2
e DepNnfcomplam wm
O Tu Parcel No. 22107-50-00036
O CONSTRUCTION DETAUS
O Casing Qwoldor 6 Dorm 6nm .7 n N RLft CONSTRUMON OR DECOMMISSION PROCEDURE
ft m_R pomuoo Drscnhe by mla.chmxmr,sve of maNvlam swaurt.evd Ne
RImlalled: Olane losdlm Dam Rom hm end nahire of Ne orals,il lv each snaNm penenaN4 w,N al leastoa
E ❑1'hmadm Ulmn bur° ftm—fl uoy for each change of mformWoo lu&UU ell water eocouoarm
C Perforafia : ❑Yes(.]No NSE ADDITIONAL SHEETS IF NECESSARY)
H TYpeof pefurmms used MATERIAL FROM T'O
C SIZE of"_m by— A ammo ofpoRr fkoo, _ft m_ft .
Ld Screen:0Yes O No f]K.Pac imtmn 8} soil 0 2
a Mavufecwefs Name 1Z
0 Type stainless Motlel No BL.agpl till 2
V Dam 5 Sw Si f 87 ft N 92 R
C Dom Sla Slre ho ft N ft
A 56 92
GnveVFllta puhm: ❑Ya ®No ❑Sve orgnvcVsad
A Maleomlr r ff N R
G Sus eSemi: ®Yes ONo To whm deP&9 18 ft
d Mmenils uscd m,at m t i t
Md my soam conwn mouble wavy. Oyes D No
Tyl ofw=c Drytbofsmm
C Mcthvdofs ngs off
PUMP. ManufacoWaName C leiw
f?fj •type SL_ - HP
S WATER LEVELS: laud-vmfece daWwabove man sa level R
f' Sanclwel d6 hhbw by of weV Mh
0 squme,ah Date
7— Anes,a wara,s wotrdlm by
N ,valve.W'I
0 WELL TESTS: DmwrlownLI amvuon was lcvd a bwerm below aunt levd
V wnamivw tetmade+OYea ION. Dye.by whom+ -
ys Y,dd_gal/mm wib fl dnwdowo afla hrs
Ymm_--- el/mm wiN fl drawdowp aftm be
_ Y,eld_. {Y/mm w, ft dnwdowna ten
8 Recovery dam f,mw mbeaasu,o wMn pump mmrd nffwvnr levrt memueedJmm
VEE
W weE vsp co wrrrkve0
Tome Wamr Level D. Water Level To. Wale,level
2003
d pmeufus as InitlD slute
Rma Rm 2n se/wowW 4 ue rlmentD Ecolo
AiWnf__gil Aom wsNNemsm n fa brs W/30/D3
p� Amon now aaPm Dam S.wrc 7/22/03 CompleW De
y6 Tempenan of wma_Wasachcvunl enelY iNdey OYe ON'
Q WELL CONSTRUCTION CERTIFICATION: I amSINtted and/or accept respooD6lR1Y fa conswrnoft of tlms well,end ID mmplreoce wlth all
W WuNngtm well epvslrRehm standards.Ma¢ als used and the mform m reported above are Rue m my best knowledge and behef.
L ®Onus ❑Enmaa OT,mnee Name(Pont) Address Onikn/&lgtoeedl'rgna Srgow �� Dnlhng Company Davis Dri111119
~ "�Y / Adds Belfair, WA 98528
Dnikr or T moee Lice¢u No. 2284 City,SIm0.Z p Belfair, VA 98528
Coo—t&s DAVISDI1100A Daro July 03
U tml.,lkeoaed dri j; Registration No
Slgwom and Ucrose In. EmIOD,s m Fqual Oppmtumty EmpinYm ECY O5D13
CUSTOMER: Lewis Griggs AQUATEST
25216 238th Ave SE INCORPORATED
Maple Valley,WA 98038
Email:wakenutfiive@gmail.com
(206)200-0073
Dale: 1129123
COLLECTION DATE: 1128/23
RECEIVED TO LAB: 11/28/23
SAMPLE ID: 1420 East Mason Lake Drive South
Grapeview,WA 98546
Outside pi got
ANALYSIS RESULTS
Presence/Absence Coliform Absent'
Total Coliform Absent'
Fecal Coliform Absent*
E. Coli Coliform Absent`
-Results comply with EPA standards for these parameters.
Sample was analyzed in accordance with
Standard Methods for the Examination of Water 8 Wastewater.
22nd Edition,2012.
PREPARED BY: KsuL KBE 111/29/23