HomeMy WebLinkAboutWAT2024-00077 - WAT Application - 2/2/2024 MASON COUNTY WAT R04 -60077
COMMUNITY DEVELOPMENT RECEIVED
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415 N b""Street, Bldg 8, Shelton WA 98684, [[�
V �CLMLn: (360)427-9670 eM 400 8 Salter:(360)275- 467 eM 400 6 Elma: (360)482-5269 ex14W —a 2024
{- FAX(360)427-7787
Application for Determination of Water Adequacy 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 accom2any this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: MARK AND TRESS BERRY Date: 2/2/2024
Mailing Address: 175 E PHILLIPS LAKE LOOP RjPhone: 360 558-2551
Parcel Number: 220051190042
Type of Water System Reason for Application z
❑ Public/Community Water System (2 or more El Building permit 0L VDRq —6017 J
connections) ❑ Division of land:
JK Individual water source(one connection), #of Parcels?_ SPL
b( 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 Public/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 2/2/2024
This form may be scanned and available for public view at wwk�.co.mason.till
1:\EH F=s\Drinking Wmr a id 1/25201g
Individual Water Well
Water well report(attached to application). Depth \0 5 ft.
Well capacity Test(attached to application) WW gpm -'7 yoctgpd.
IThe 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 hftp Hais ca mason wa us/planning 14R'fJ-3 16=22=
Water use or limitation recorded................................... N/A 177 Y s
Well Drilled .......................
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 gall7and/orprovides water at a rate of 2 gallons per minute based on the following obse
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,Chapter668.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applicants 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:
Date 2 of 2
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Thurston County Environmental Health
412 Ully Rd NE ♦Olympia,WA 98506
360 867-2631
]HVnS10N COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Colbcbd Time Swipe COWRY
Collected
I `w I Y.
Type of Water System(dlerk Wly one box) ❑ Private Household
❑GroepA ❑Group B [I Other
Group A and Group B Systems-Provide From Water Fx3ties Imrenbry IWFO:
TDB
System Name:
Contres pmson:
Day Flrone:( ) Cell Phew:( )
Emall: Eve.PAone:( )
Sdd e.(Pmdluaeame,sddressaldepoodeaemyladlress)
�helto-+n W{! `i958y- _---
SAMPLE INFORMATION
Sample Warded by(name): A ,
Rifkbcatianoraddresswhle�reAsampkmllected: B cialinanxtionsor Wmrenb:
ik I outsik - 45ct
Type of Sample(mustcllecb only one box still Through B4lele!bebw)
1.❑Routine Diehibutlon Sample 2.Repeal Sample faster onset routine)
ChbnnaW:Yes_No_ ❑Oidnbution System
Chbme Residual:Total_Frae_ ChbfinasnLy.s_No
3.Raw Water Source Sample Chbnne Residual:Total_Frae_
❑E.toff-GWR(A/P)
❑Feral-ewa,Gvn.edropf l—ean, Wessel acbry mutme lab number,
Filtered.Yes No
❑Assessment Wnitaing(AT) Unsatisfactory routine Wlled date:
❑Oeer _I
S
Sample Colleted for Infomadlon Only
Invesirgalive_ ConebwtionlRWais Other_
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑UmaUstatery Total ColUorm Present and 9etlaeotory
❑EWS present ❑E.WFabsenl o ifonodelected
Replacement Sample Required:
❑Bamplet000m(,30hours) ❑TNTC ❑
Bactenal0ensily ResuUa:Towi Cobham I10Omi. Eons 1itsomh.
Feral CaliloW I100ml EnIaroWWi I1 DO M.
McUrod Code. SM 92238 ❑SM 9222D OM and Tune Iterated,
❑ 9215B ❑Enemlerl® -r-I-Z`I' ((rs{"1'
Dye and Tnw Analynd: pyre
saryk xumbclparrunen lsu Wdgan lab Uaa Only.
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ENVIRONMENTAL 2207366 MASON CO WA
HEALTHMRRK BER111 FY %19 885 R11 eo Fee E300 50 Pager 2
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Refum Te RECEIVED
,w I
FEB -8 1014
615 W. Alder Street
Grantor(s):(1) �l I (2)
Grantee(s): (1)PUB IC
Legal Description (1) TR 4-B OF NE NE TR 2 OF SP#2109#531306
(Abbreviated form:i.e.Id, block Plat or section,township,range)
Assessor's Tax Parcel: (1) 0 0 5 - 1 1 _ 9 0 0 4 2
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 are based on location of property and/or Water Resource
Inventory Area or WRIA.
WRIA: 14
Maximum Annual Average Gallons Per Day: -�9'I50 —gallons
Dated on this--t day of 20�.
Sign re of Grantor(s): f
(1 (2)
State of Washington )
County of Mason )
Page 1 of 2
I,the undersigned, Notary Public in and for the above nam d County and State,do hereby
certify that on this, day of �-E- " , 20' � ,
MN v' bev monafly appea before me,who is known to be
signer of the above instrument,and knowledged that he(she)(they)signed ft.
GIVEN under my hand and official seal the daya d year last above writ n.
p � +•\p9inn '.N
a�W;•F B•2o-?c+�C No1 ry Public i/fa�nd f/o�r the State of Washington,
�.Ve yorAgy' LZ� residing at `�' lfL1C-`}ZSr1
�N3 °ueLIC �, My commission expires: O 7.0-2-
.e
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