HomeMy WebLinkAboutWAT2024-00085 - WAT Application - 2/19/2024 WATT- 000
Q� MASON COUNTY
COMMUNITY DEVELOPMENT
_AV`a v>mnA..6oMeumar,ami4np.>i.nmru RECEIVED
415 N 6-Street,Bldg 8,Shellon WA 98584,
Q.Shelton:(360)427-9670 ext 400 O Belfair:(360)2754467 eld 400 4 Elms:(360)482-5iTBS149)2024
FAX(360)427-7787
�Gr Application for Determination of Water Adequ&* 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: Ronald Preston Date:
Mailing Address: PO Box 3032 Belfair WA 98528 Phone: 206-250-8170
Parcel Number: 222 09YO0190
Type of Water System Reason for Application n
ElPublic/Community Water System (2 or more ❑+ Building permit &Lpg0a 1(1— 0019 R"
connections) ❑ Division of land:
O Individual water source(one connection), #of Parcels? SPL
❑+ 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 PubliclCommunity,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(W FI)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?EH F. Dm i,Wear Key ix11125,c018
f
individual Water Well
Water well report(attached to application). Depth Oft.
❑ Well capacity Test(attached to application) gpm 7 "VV 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). y(�7,/2B7
lyl Water Resource Inventory Area (WRIA)
Development within which WRIA htiD I/als.w.mason.wa.us/plannino 14—1 T 1f�220
Water use or limitation recorded................................... N/Aj=Yes_E)a_Afl/`ZWS97
Well Drilled ............................................................... Date L.RI&K
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)
pa Satisfactory Determination:
/ This determination does not address adequacy of the distribution system,guarantee an ad 6 py of
water indefinitely in the future,or guarantee compliance with all applicable W DOE water re sou S.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Determi
Adequacy for Building Pemlits are satisfied. Additional Growth Management requirements may apply. r
36.70A RCW. /,4SO,, Of Z®
❑ Unsatisfactory Determination: 'iCO IBZQ
Applicants water supply does not appear adequate to meet the needs of its intended use for wing Zy
reason(s). OV'lp174./FNT
A�
Reviewer's Signatures:
Environ. HeaRh: Date L�1QL�
CSD Director:
Date 2°f'
WATERWELLREPORT I=DEPARTMENT Of Ndicaofbl,Al WE5w59
ECOLOGY LM,m,Er..,W.II1DTag No BPF174
TYPedWwk SIMeor.,ld,lon
s cwwmerk. Site Well Name(if mom tMn ore well):
013,exa :Meman Onx-alimeNum NO1No. Water Right PamrxCenificale No.
PropmM Uae M Dan . ❑Itlmwl ❑Muicipal Property Owns Name RIXt Preal
❑Dewmen.p Dhnprim ❑Tat well DOlher Well Street Addreav ?070 NE North Shore Rd
CmnaeBm TTm' Manama: Mason
I Nw wdl ❑Al.... ❑Omar ❑hate ❑Cnbk Tow City BHfalr c ty
❑Dwpenna DO — D Dug m Ai. ❑Mud-Rana,, Tax Parcel No. n2093400180
Dlmeumm: DkmererwEuing B M.. 101 ft. Wm a variance eppmved for than Well? ❑Yen (' No
Deem ofeariylvmf wwl 100 8.
Commetlan Demur: WWI If ye,Wfiat Ww the varierree for?
CarimB Liner Di merm Fmm To 'IN[Ercm 91eN INC Walter!TLmtl
N 1 ❑ e m 0 9s .25 ire. 9 1 ❑ 0 1 ❑ Lmation(xeimtruclionaanpo,i BWWM a❑EWM
❑ 1 ❑ in —in ❑ 1 ❑ ❑ I ❑ SE 'L-Y.oflhe SW '/.;Smile. 9 Towmhip 22N Rmlgc 2W
❑ 1 ❑ _ —n ❑ 1 ❑ ❑ I ❑
❑ ❑ 1 ❑ ❑ 1 ❑
W nud e(Example:4?.121d5)dT.40183 N
I ❑ _ n.
Longitude(Example'.-In 12345) -122.94480W
Nmoraanna: DYm Ill Typaofperfmluued DrillersLop/Cmmlruction or Deemmmifalom Prmxed"m
No.ofpeRmliom_ Sizeofpsf m_¢bY_In& Forrmlion:Doerr"eolnr,eMixia.siss ofwlmaluN xwevue,and.he 4id not
Pemwemd hoar_a lo_fl.kin-ppW Wa6u raarreof1he wrerial in—a m r:pnrevmerlr ihat oirenvy fe,—a eMoq of
Seem: 9 Yn ❑No m g-IYYee b 0.pm 96 l nfmrralian IHe Wdiliarul rMeu ifnecnsey.
Mun.Dcmren Na—AWhlclan
-Wales Mnerial From To
Type W:re-wrapp¢tl NI.Je1 N.. Brain firs,to Men lure sillm sand aml oral dR31
8
Direr., 5 SM aimc.030 w.fiom IIS km IN a.
Dien ur_ akr.ae_in.awn _am_e. Brown fide ravelly earM 12
Green sticky G 16
5aodMdmrpcLDYa E1No SveofpeErmmi.l_in R¢tl en brown 88n sill Nntl¢r 31
waridx Pkud win_a.w_n. Broom fire to metlium sill bouts eats and roWil 48Aad—Sad: myna DNo TawmtAo? 18 8GR WN 9111 b1ntl¢r Sl
mJ BBrltonite ONDYm ON. Goa BMhoWn ind ill d¢IIS¢ 88
Typewwamr? DepAMrmnRMeMblownsantl sill B]
W&A.faalMaaael.na RadeMbroomfireMmetlllmeantlantl rase)
Wet 101
Punp: Mmnfmvaer'a Nane Trye'.
HT.— Pump ImleFe deNh:_fi. OdipN D'w Ne:_®rn
Wine.Leve4: LaiWxumc<elewtkneb.w:menwhrvvl 30 fl.
Buck-uP.fate Mwelluaina 1_8 fl.Jnw pour auf
Smticwmerkvel 39.3 fi, a "ofwellaire 0.Y4104
Metianpsmmrt_Iba pra9mn iocF Pam
Meun—mr-mambedbY (ngvaMrm)
WaLaen:
Wexapungire rnl perfixmat? MN. OYmo bi, M
Y.w_,m wire_8.mawdowo alkx_hat
ymWYivM
_ypm wire_a down.ma_M.
_Wm wire_fl.JcmwrwJumuller_M.
Raovery date D'ssm when prury u nuMon-wwrkrel named win wall
Fare,
rer level)
Walulsvel Time WYmlewl Tate Wn>level
Derc ofpmnpirN ma,
Bwaa, an_a,wire_"dnwbvnaAer_h
M teat 20 Man war.wm elm80 B.mrt M. oau 4W4
Meaim Mw_spar
ttnperwuwofweur 52 •P Wre—'analamlmuraiv? By. EN. $1w FiM Ag124 Completed Date 0/821
WELL CONSTRUCTION CERTIFICATION: 1 cOnaW01M aM/Or Mxepl respamibiliry fa cpmlrlLL9ial of this well,on0 its cmnplaac with ell Washington Well
construction maMMds.Materials hied tax the infommtm.mewed above are tree in my hem km 'Iedge aM belief
❑Driller O Trainee PE-Print Narrm Cory Johnson Drilling C ArcIxfia Dolling Inc
si Address PO Box 1790
be.No.3YI 3'f` C'tY Share,zip SaaBm WA 98584
IF TRAMEE'.S r'a Li.No 2053 Contract«s
Sponsor' S' Rego w No ARCADDI0981(1 Dace 4 41
ECY 050-I-20(Rev 0W18) Ilr.n nmdtlrix dOrwnenr in inn almmnmJmrnwe plane rmll rM wM,RexM,-,m grogram of 360 401E8T1.
Perzmm wid lnwnrrg luv ran ell Alfa Wmxeingron Re MY�^ice. Pmmu rvuhaxperh dtradlirY rnn mll8)b83Jfi3Jl.
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA.98584
Customer: Ronald Preston Well Tag#: BPF174
Site Address: 7070 NE North Shore Road, Belfair Depth: 100,
Date of Test: 4/11/2024 Static: 37.5
Pump Set: 80'
TIME GPM LEVEL RECOVERY
1 Min 4.1 38.5 1 TIME I LEVEL
2 Min 4.1 39 1 Min 1 37.5
3 Min 4.1 39
4 Min 4.1 39.1
5 Min 7.1 39.2
6 Min 7.1 40.2
7 Min 7.1 40.5
8 Min 7.1 40.7
9 Min 7.1 40.7
10 Min 18.5 40.9
15 Min 18.5 47.4
20 Min 18.5 47.9
25 Min 18.5 48.1
30 Min 18.5 48.3
35 Min 18.5 48.5
40 Min 18.5 48.7
45 Min 18.5 48.6
50 Min 18.5 48.8
55 Min 18.5 48.9
1 Hr 18.5 48.9
1 Hr 10 Min 88.5 49
VM&UM LaWnllo
2635 Pwkmoat Lane SW,Suite A
Olympia WA 98502
v{,Ar!pAlp 360-%7-7010
COLIFORM BACTERIA ANALYSIS FORM
oat Sa,ryle rodnm Tmesamp, Canty
04I112024 '� ow MASON
pn —gym
type a wary sysa lawck anM ad oml
Ca Aa GmepR Sys+and-Rwitle hall Wa1w FaJleahedeyry iWF11,
IN _ _ _ _ _
Sham1— RON PRESTON
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MyFn (360 )4263395 CaERnad.l 1
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SAMPLE INFORNATIpI..
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I ❑RaNM ftuIk-d"SaaaN Wel 2 ❑ 119"S&a A WRl
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LAB USE ONLY OR MNG WATER RESULTS LAB USE ONLY
❑onuftbc"TaaC ;, M =i �BtlbNcNll'
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2207542 MASON CO WA
02/1312024 10.44 AM NOTCE
ENVIRONMENTAL 3
illlllllllllllllllllllll1
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HEALTH
RECEIVED
Return To
Pion o" Kim -PVfebfD11 FEB 13 2024
7.0 C 0 a 615 W. Alder Street
e( u v✓ 1aS2
1
Gramor(s):(t) ew'l P2,'S TQAf .(2)
Grantee(s):(1),PUBLIC
Legal Description(1) TR 19 OF GOUT LOT 3 S 53/37 2- Z L
(Abbreviated torn:i.e.lot,block,plat or section,township,range)
Assessor's Tax Parcel:(1) 2 2 2 0 9 _ 3 4 _ 0 0 1 9 0
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIN)
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 property and/or Water Resource
Inventory Area or WRIA.
WRIA: 15
Maximum Annual Average Gallons Per Day: 950 gallons
Dated on this 1 3 day of k ,20 z`4.
Signature of GreMor(s):
State of Washington )
County of Mason )
Page 1 of 2
f '
I,the undersigned, a Notary Public in and for the above named County and State, do hereby
wriffy that 1on this da of 202
�Ib c ICJ+ 1CInAxr (2SkUl person 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 andyear last above written.
,,... EM,� 1L3� ,UlC �.11.1
,;CC�(�e Notary Ftblic in and for the State of Washington
residing at
2t009497 w = My commission expires: ZL2
�'••.,CF WASH?"��
ua„w�no
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