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HomeMy WebLinkAboutWAT2024-00267 - WAT Application - 6/24/2024 I WAT aool - o�_] MASON COUNTY COMMUNITY DEVELOPMENT Perms AumW.Cants.8.11,11m.Pl..mm 415N6' Street, Bldg 8,Shelton wA 98sm, RECEIVED Shehon: (360)427-9670 ext 400 O Belfair.(360)275-4467 ext 400 4 Elmo:(360)482-5269 ext 400 FAX(360)427-7787 JUN 2 7 2024 Application for Determination of Water Adequaty15 W. Alder Street Instructions 1. Complete Part 1. No determination can be made until Part 1 is full n 1 i 2. Complete only the portion of Part 2 applying to the type of water coo LQ N M ENT L 3. Submit completed application,with any required attachments for review. HEALTH 4. Ana roved buildingsite Ian must accompany this a lication. Part 1: Applicant/ Parcel Identification Name on Applicant: 7:k0mc.S Dd y 1 S Date: fo Zt{ Zy Mailing Address: 2 hone: 50-3 4'Sj-S 11054�- Parcel Number: -3 MD 1 — DO-0001 Q Type of Water System Reason for Application ❑ Public/Community Water System (2 or more jC Building permit 13LOao�V connections) ❑ Division of land, ❑ Individual water source (one connection), #of Parcels? SPL Jil Well ❑ Boundary line adjustment ❑ Spring/surface water lain❑ Other ex ❑ Other(explain) (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 stale 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. J98H Fm \Dri Y ng Water Revised 1k52018 4 r„ Individual Water Well I/9/t�ul Ia Water well report(attached to application). Depth ' (O 54rdr. 5*4 a+ Ibr of ( 110Yr 59 Well capacity Test(attached to application)2� gpm 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.Ft Satisfactory bacteriological test(attach to application). 3//3 /ZQ LLl Water Resource Inventory Area (WRIA) Development within which WRIA htti)�//ais.co.mason.wa.us/plannina 14C�15L]1fi0220 Water use or limitation recorded................................... N/AQ YesA2 Well Drilled ............................................................... Date V+ 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 Part3: Mason County Community Services Evaluation staff use only) ,p. 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 lations. Recommended approval indicates requirements of Sanitary Code,Tite 6,Chapter 6.66.040-Det n of Adequacy for Building Permits are satisfied. Additional Growth Management requirements may ap ter 36.70A RCN. Ili ❑ Unsatisfactory Determination: �q Applicant's water supply does not appear adequate to meet the needs of its intended use fpg folld�fg J ^w- reason(s). N S f.,/[/� / o ryFN� ?QZy O `/%%/ v Reviewer's Signatures: %4�N�FNT Environ. Health: Z Date lly, CSD Director: Date 2vf2 RECEIVED &� o'lDPK-0077� .IUN 27 2024 ENVIRONMENTAL. 615 W. Alder Street HEALTH WATER WELL REPORT DEPARTMENT OF Ne Pflr xo. WFSM ECOLOGY Unfgm&Dl Wweum➢ wo. WFI16 Tpparwmm Smle olwmNngmn CA Camawum Siff Well Name(ifmortlhenane wTll): ❑lkco®imm q OnpelimmWum N01No, tarter Right Pertnit/Catifinh NP. PraPma4 Vey ODmue'e Dlal®Y []h6®v9d RPpedyO NmeS DhKgeDavie oue«umip ❑f:.ipgw 0Tmwe9 ❑o:e.r Wdl3l.e Addrma 5100SEE LVOM RE Cou'lype: MeM: 9 N N—am—U wau ❑Abemon ❑DM ❑AP- ❑seta Tad city ShellDn DovntY M aAm ❑D.Pa®g o0mm ❑D MAP- ❑MmWtmmy Trt Pe:ml No. 31901-00.00010 D;mPmlam:Dimetrofbwug8 a,m 159 a Wuevarimmappcovd Pof Ods wo9t ❑Yes RN. 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PeesarN with a.rpemM1 aimbihy mn raRBAd33fi341. 2635 PRrkmoni Lane 5Wt 5tite�A Ua I y Olytnpie WA 95502 , v'�SSE4 ® 36k-967461 OLIFORMRACTERIA RECEIVED DOW smpl.w lmc Tom S.PW C My colodw 02/07/2024 d d [lua MASON �JUN 2] 2024 ■m. Wlx Syg,m��o"—bm� 615 W. Alder Street Ty5.ol ❑GmopA ❑Gm B 20m Gmp A and Gmp D Syemsm—P &flan Wm&FmA6m Imm"(WFI): 1w - - - - - - E WIRONMENTAL sr N : STEPHANIE DAVIS HEALTH Gm Paam'ArrEtlia Ddlllw1Inc DeM.,(3W )4N8 385 E.L IE.Ram:( { Almd ggp)¢.{P,Yn u,mm,amrma aW Wp mee a emaq -------------- awpmadaO n,paom uno i«+g�asaeillnp mn ....___.__... SAMPLE INFORMATION smnpk cdlmim by NemeI SETH -- Specificbcffim wfiae m,pWwlkckd: Spmial elabucUmsawanm,W: 5100 SE Lynch Rd, Shelton '.Typapl 'I fyo 'oTd# ebaR... .. ,:I.,.;,-. 1.0 Roumne DIVAMOn 61m1k(Alp) 2.0Rgwd SopW(An CWM,aWd:Vea_No_ ry�tllma .a mwl UmamsW"mumm ab numW alwi%R&*J NA Tgel_Fme_ 3,G and Water We sou.sampN Ummmleclaymubn aYWcldda: - -_J I —I—J— CmWlndw.Ym—Nd_ ❑TMmw (AP) Cekdne RmWud:TdW_Fme_ ❑Amemmml(Am) e. Surkee a GM Raw sdume Wake sampk(Emmem§W) I ❑E.col ❑Fecal .m.a rw_w_ 5-�sani6Cdbcmu Wramdrmmron Only. IAekIONj:!. D KING` AT ]il:BULTb` ❑UnaaUakdmy Tdal CaWam RawO Nd nsmbfeddry ❑E.mf eM ❑Eaiasamll . Ba ,W Density Resume:TOW Cdifam ndad. EaY /1OOmL Fecal Cdibmi ItOOnt HPC It ml Reylxemenl sample Required: ❑TNTC ❑sample wow ❑ smpeVduma 01)w e; dGdnmmm ❑ Vim- Rxagr«npc: �{: ll Dme Aepone3ro ODN laa Ilea Ody. ooN Imsm.Fw 285-