HomeMy WebLinkAboutWAT2024-00157 - WAT Application - 3/5/2024 WAT RCR4 - DDP
415 N.6a Smxn
MASON COUNTY Shd=,WA 98594
0 COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
Belfaic 360-2754467,Ext.400
Elma:360-482-5269,Ent 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: Applicant/ arcIel Identific
ation
Name on Applicant: 7 I! Date: ✓ J "
Mailing Address: 66
Phone: - 3 b0- 9.gLOg
Parcel Number. �r w 1 -000yP7
Type of Water System Reason for A� pp�p�l-liifcra�^ti1oI1n -7q
�PubliclCommunity Water System (2 or more ❑ Building permit B a>.90O1,4-Z 1
connections) ❑ Division of land:
[7 Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other ex lain)
❑ Other(explain)
eplaceman Remodel(please indicate name
ff you have more than one residence connected o r sys em below if applicable-no
to this well, check the PublkXommunity Wafer 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: AI G Oe_
(mite'none"for two-party)
❑ I 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.
❑ 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.masonma.us.
1 TH Foms\Drinking Water R ,vi 414n018
Individual Water Well
Water well report(attached to application). Depth�ft.
L�Well capacity Test(attached to application) 0 pm O pd.
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 httod/gis.co.mason.wa.us/olannina 14 11-916_22_
Water use of limitation recorded................................... N/A Yeses •Y
Well Drilled ................................................ C
............... Dale
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 on/ )
�atisfaetory Determination:
is determination tloes not address adequacy of the distribution system,guarantee an adequate supply of
titer indefinitely in the future,or guarantee compliance with all applicable WDOE water resource regulations.
emmmended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Determination of
equacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
8.70A RCW.
❑ Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the follovnng
reason(s).
Reviewer's Signatures: /
Environ. Health: Reviewer's
This form may be scanned and available for public view at www.co.mason.wa.us.
Pne2of2
Thurston County Environmental Health
412 Lilly Rd NE h
Olympia,WA 98506
r 360 867-2631
THUPSION WUNIV
`! COLIFORM BACTERIA ANALYSIS
Dab Sample Collated Time Semple County
1201 �* Dd� Xod A anon
wm Day Y. -1-:20 Ono
Type of Water Sydam(dmdr only one box) ❑ Private Housebolo
❑GroupA ❑GroupB other 9
Group A and Gm p B Systems-Provide from Water Fadlities Inventory(WFI):
IDN
System Name:
Conrad Perron:
Day Phone:( ) Cell Phone: )=I. 60
E-md: d,U /d rh Exe.Phone:( 60)1/26-513
SaMPgWa ( name.SlM1w end vp atle a mad admit
IJ QlUtpn
N49/ E• odh Zsan nve
S_elfonf1A/R 4858
SAMPLE INFORMATION
Sample I (nynp t
� n
Soadygl-,9[add No �j sam byietl.r Special'eispadonaacomanm:
Typedf Sample(mustMak antyons box of RI lhmmWb A fated below)
1.�Routina DlelNhutbn Semple t Repaid Sample(after mad.mudne)
Chlodnaled.Yea_Nomilj_ JeDisblbution System
Chlorine Residual:Total_I'm_ Chbrirmbd:Yes -No_
3.1tew Water Sourcetampb Chow,Residual:Total Frea_
❑E.MU-GWR(NP)
❑Feral-a .W.mew tmm.nmsl Unsatisfactory routine lab wrmber.
nowed Ya_No_
❑Assessment MonMmg(AN) Unsatwfaory routine odeddate:
❑OM. d-
6
d.❑Semple Collated for lnfomabon Only
Inomfigaim_ ConsmctiontRepeim_ Cited—
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsetlefeetery Total Colton Present and fa ey
❑Emm present ❑E.mAamend
cted
Replacement Semple Required:
❑Samplet000ld(>30houn) ❑TNTC ❑
Balefiai Density Resuds:Totel CD$dmm IiWrN. E.mN I100mL
Fecal CDNmm /tOknl Emmcaad N00 mI.
Method Code: M9223B ❑SM 92'12o pweam�Tabn�e :tool"
OweaMmmeAnalymd'. I'a DAa Repalek 2 C
soma xunem lDml mma sire rt+e dq'ml lab Use Dny:
0 8 0 -7
. m�rSramsetara�iamnq .,..r v5
Arcadia Drilling Inc.
P.O.Box 1790
Shelton,WA.98584
Customer: Ruth Newton Well Tag#: None
Site Address: 4441 E North Island Dr,Shelton Depth: Unknown
Date of Test: 3112I2024 Static: 125'
Pump Set: Unknown
TIME GPM LEVEL RECOVERY
1 Min 30 127.1 TIME LEVEL
2 Min 20 1 127.3 1 Min 125A
3 Min 1
20 127.3 2 Min 125.3
4 Min 20 127.3 3 Min 125.2
5 Min 20 127.3 4 Min 125.1
6 Min 20 127.3 5 Min 125
7 Min 20 127.3
8 Min 20 127.3
9 Min 20 127.3
10 Min 20 127.3
15 Min 20 127.4
20 Min 20 127.4
25 Min 20 127.5
30 Min 20 127.5
35 Min 20 127.6
40 Min 20 127.6
45 Min 20 127.6
50 Min 20 127.7
55 Min 20 127.7
1 Hr 20 127.7
1 Hr 10 Min 20 127.7
1 Hr 20 Min 20 127.7
�OlNp�los�butCopy NN WATER WELL REPORT ApIlk.U.. No. ._.......
•H`ra room ml�n r.�Co�prpy STATL OF WAMEN6TON Prtmx Zoo, .... .. ........
_..._
(1) OWNP.R: Aaws.
O (2) LOCATION OF WH.1.: copra--_-1(Axp11.._____.__..........__._...._........
_.-.R6....a ..WE_..iy en.�'.._. T.. si,af�l'✓wAf.
G Bo."oed awn n., euoa of sumliawonSec. 25-21-2
W
(3) PROPOSED USE: nomwuc if( tdux m ❑ Mm dVol D (10) WEI.r. LOG:
h dooL ❑ Tot Wen ❑ oln< ❑ reem.tlon:D—i .by eowr,ccno M of eM n11u9N..oM
3 .M alekvo of ae m..d 1M Wdex
xmtw perlrpW. A a hood w..tfp Iw eeaese a le.oex.A
(4) TYPE OF WORK: (09— nwaew of. 1 .___ W�� YaO1[ M
y Ili mun mu wo).,.. ._.__._ _
x.w wW .p( xeNod: DYl ❑ _..Bald ❑
DeeDwad ❑ "'kW on'❑ O 1 r
C Beamdltlaned❑ 1bw[y❑ Ixia O
p blue claY 10
C (5) DIMENSIONS: Doomelor.f wall ..........__6.__.. tea. wand 11�
�O of namVicled wex___1,bV __tt. cmented xmval11 1 p-
E gravel xater 1 1 _f_
(6) CONSTRUCTION DBTAIIS:
Casing installed: 6 m.m.ram .. __.
TWbda❑ ....___^Dwm.1wm
Perferatidm: vw❑ xo jf ¢
V Type a Wf*nW awe_.....___-----�— J
p a®of peitwell.00--- too by
9 ..........._....._po 000 fwm--.n.
W ._paRmxlm.tram
qScgeane Yw❑ Iloff
Yedol x0_
53
^
R Gnvel packadt Yn D xs s oo,a s...a:_--..
Unvx pwced rmm. --..n.m—.--d �DEPR—� o�CSLDC ICE
3 s(Irisce seal: Yn,pj a❑ Ts. pmu> —1B .— It
afwnx ma 1n °_„__„ J
f' Did eny N.Y wntm lmlaeW we1M Y. "-
0 yyno.f weteef_.______._..__._.. Mpt a amy-�
Z Memdd a wWN.D.t dx .-..._..._..._..-.-- _
(7) rump'. x funr ,Flint WaluN
v
G (g) WATER 12B ELS: c'ol m;^"fw'n".e Wie.MOOnoto .___11 __.a
................_lV lJaw by of wall DW
U A.le.lu pwwpn Woo pn WYa+a ink
ale.... _......_
V wnetl.n be,L mnlmLed y.__- vYv., eml
W
9 WELL TESTS: nra.Woo b wnouat w.wo wex is
( ) m e oouoeo wax wd.e el.o -A,z8.211- 79. ompin _ kI1:s1 u�
Cwn.pomp tot mini Ye.❑ x x yn.by vllwnl......._____.._._..
W Yuld- x✓mm wit n.dr..eown odor m+. WELL DRILLERS STATEMENT.
Tht Wen won dylnei lode my )urlddletlon and Nb Monet is
true b the beat of my knowledge and belief.
i
TL aewrery de4 Itma tebn o wo wbm pump beaed eel (wato levoo
mee.pne crow wool wD w wMtt xxtl)
tF ...T...M Water fAe.l� TwI . Water L .
NAME
._.B1 Bd3al_l$.._.D_..Dh.a...f.i....... St. .._.
IP..'fim'.1 ofeWoWl (Typo.a........M....t
Shelton. Wash
.................__._ ......................-------._....._..._.-.
-_--.-.-_._._
............................... . ...._...................... ......I............................
............._................ _ n............._.............. .
%,// f1
Dow of toot -__..._...__-._.__..._.....- _ (8lgned]-�!-U!
dn.ddwa .nn_�-.so.. (We D:uiui . ..:
one-----
_.... _- __._.... 8
Teame.etw x w.we_____ww.rbeevcx enxfel.mans Llceme No........_.4.031__.._..........Dab..............
(Un ADDIITONAL xlX13l9 W NLCESSAaY) _e
eDY m61-H
2208852 MASON CO WA
N 121/2024 02.33 RR NOTCE
RUTR NEWTON 019fi008 Rp FRe 30R 50 Rppps 2
jinn mnii N i11INiiiii1mi
Ret To
Grantor(s): (1) �,Pii i,, usje24 6,wli,n , (2) 1A,Affel1 l� - 1fP�aItC9
Grantee(s): (1)PUBLIC
Legal Description (1)
(Abbmvialedlonn:i.e. lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1)_.�_LL J——L S ---/--I---J1.L C' -'LI.L
01221 23 - 11 Coo 10
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 6.66. These
restrictions and conditions are based on location of property and/or Water Resource
Inventory Area or WRIA.
WRIA: 14
Maximum Annual Average Gallons Per Day: V15O gallons
Dated on this A (3 day of 20��
Si�nature of Grantor(s): (2)
State of Washington )
County of Mason )
Page 1 of 2
I, the undersigned, a Now Public in and for the above named County and State, do hereby
certify that on this 'RO day of P _ 20 2
1:u ` N t uu�arranzr Ily 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.
��"�oLA iAuu� L4, ry P isyi�n a^nd for the State of Washington,
�•.�ef*O*n % residing at�Yd a •(�O
My commission expires: '1I 3A
a N.n PUBLIC ffi3' c
b
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