HomeMy WebLinkAboutWAT2024-00260 - WAT Application - 6/7/2024 WAT?A24 _
MASON COUNTY
COMMUNITY DEVELOPMENT
Permft MsimnceQ W Bulleft Plannire
415 N 6^Street,Bldg 8, Shelton WA 98584,
Shelton:(360)427-9670 ext 400 O Belfalr: (360)275-4467 ext 400 O Elms: (360)482-5269 ext 400
FAX(360)427-7787
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/ Parcel Identification
Name on Applicant: travis Rowland Date: 6/7/24
Mailing Address: 1091 se Craig rd Phone: 360-870-1287
Parcel Number. 349653696801 31`1 D 5 -2 i-CI 000 ._
Type of Water System Reason for Application G
❑ Public/Community Water System (2 or more El Building permit TId 2-6214 -00 q
connections) ❑ Division of land:
O Individual water source (one connection), if of Parcels? SPL
O Well ❑ Boundary line adjustment
❑ Springlsurtace 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(WFI)Number.
(write"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.
❑ 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 6/7/24
This form may be scanned and available for public view at www.co.mason.wa.us.
];\Ea Fame\DrmUng Wata aadsed 1II5a018
Individual Water Well
Water well report(attached to application). Depth'7ft (,/ '1
Well capacity Test(attached to application) 7[1 gpm 7 `�v 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 (W IA) 'P�M
WOU
Development within which WRIA hit :// is.co.mason I nin 1401 �22=
Water use or limitation record ................................... N/AII_Yes�
Well Drill Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ 1 have reason to believe that this water source ovide at least Boo gallons per day; and/or
provides water at a rate of 2 gallons per a based on the following observations.
Author of Mont Date
Rel nship 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,Chapter 6.66.040-Detemina on of
Chapter
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply.
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:
. _1/1
Environ. Health:�Y'(�- 3 N 1 Date
z or2
CSD Director: Date
WATER WELL REPORT Naiec all lmidNo. WE56731
ECOLOGY Unique&al.,Well ID Tag Na. BPN 059
O Con:o-nulinn site IA Name lif mare plan one w60l:
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pmpated ilea: • naneuf< hnlmri l vmlki'l Prapmy Omer N:nlx Travis Rowland
❑maaedny =1niF like _fell to _00mr
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eonnrarlinn Type: Udkd: co, SW IM son
a Nan well =,Waaw. -w'. Chid =('.life lawl > Co.,,J'
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lkplh.rfa'mpiPlnl n.11 173 IL
Cxntrnnlrn.chill: WallIf ymk.'hut xas like oanalm hr.'__—____
Cooing Liner Uiamnar Pmn: Ib ILrlmu Flat PCC4t4ad Ihrold
D I ❑ 6 in. •2 173 25 in w 1 G 3 1 J i. -.Iial(sa HkIka'Iionsanpage3): ❑• WNl/orU EWM
11 I '. I _ _ —in. Ll I '.J i NW /!...aflhc NE -4;Salon. 5 Tutorship 19N Range 5
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SaLerls: -.Von lNo ?R-PM11dab Rpa 168 a. inewmn.n. C-11131olial n.if rlaasary
ManuhwoOais Name Johan. M.'xill Foam To
type stelmaas Not
Dinlmn6 m. Sbnlx l2 in.fmm 1W r,,. 13 BraWn Top Soil 0 4
[All i.. soon six_ in.Iiom_a k.+_0. Blown Clav 4 20
Gray Clay Gravel 20 40
5antl/piher pack:=Ya ;Sn SimnlPnd ook id_in Gray Clay 40 80
Maerwls Mnecl hxm_s.w_It Gmy Clay WB Sald Mud 80 100
Sarbcn Sal: 3 Vol, ❑Nn To wan drTM' 19 If Gary Clay Gravel 100 120
Mokenil Iced in':11 3ni Benbltlle Chb Gray Clay 120 160
Pid anyneaa armor rm.:.able+.mer' r,. ❑srr Rail Sand Mud WB 180 165
Tpin Pfw.11er! Mutlfiavng O.TIh M'+1mm 110.100____
M"hodarsalinpxmmaff Cased Past Gray Send Coarse WB 165 173
Pump: Manahminr's Nato Type:
Pampinmkcaaaw._fl. Ihripral flow mte_!Tm
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5mlir wales hrel 96 0.hebw nT xl'aaelicmi Dore n.
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WF.LL CONSTRUCTION CER3'tFiCAT1ON: 1 mnstmaad and m u¢cpr raspaL:ibilfp for vaeswnlinn uUshia oalL nod ilx compliance with all N'nrhinclon'ell
canswdian nnnJaNs.]imenals usW ad the inl'armalion lepuad above arc we to me hell knmvldge and belief. '
❑Driller❑Trainor❑PE—Prim it Rodlen Layman Otllli.'Conni,nal, Advanced Drilling LLC
Signature lioAdd.11530 School Land Rd SW
L'cerm Na, 2588 p Coy sub zip Ruchester WA 98579
W I[IVVU F,S lka iai'nxe Nr C(nlram's
Sp 's si'lvlrewtr Re'idmlism No AOVANDL804DL Dale 09/24/2724
El'V 050-1-2II 111,IN lul It Inn ararl rf is rAwnmrul/n.nr aht F'ornnl,"ecru" ,,If Jrr Il bmr Ramon:.NvAPenr at J611467 6N72,
Pcrarxm.1r4 Lrndnp bons rmr nr/I 711/nr Uahll A'I^n llrlm'S".w', Pennrn oilhn"'ll I;.nM1ililr
Thurston County Environmental Health
412 Lilly Rd NE•Olympia,WA 98506
muamaw courrrc
360 867-2631
COLIFORM BACTERIA ANALYSIS
Dab Sample Outboard Time Semple County
6 �26 I t 9D9Oa :v CV A(- tM�
Nm91 Dw Y. ctal
� ❑M
Type of Water system(diKk only one box) gpdvab Houmhoid
❑Group A ❑Group B ❑Other
Group A and Group B Stateme-Provide from Water Fao bs Invenhay(Wny
m#
System Name:
Contact Porson: libms Ariled
E-mel'.//WrS116ch 0pdk.
9amtl rtsuXs blP�MWlnmw,�m�a eM dpmtle oremayetlde9e)
?'roods Krw'svC
I it r tyyct tow
SAMPLE INFORMATION
Semple collecled by(nwne): fidW} 6j
Sppeeciafic location or addrew where eample mlaoud Spedallnehucbonaor.mw
'116 % emC e(n
Type of Sample(mudohar,k onlyane boxot#1 Ihmu9h t4liebd below)
1.❑Routine Distribution Sample 2.Repeat Sample(after unut routine)
Chbd adect Yes_No_ ❑Dldribullon System
Chlorine Reddul:Tobl_Fm_ Chbdnated:Yea_No_
S.Raw Water Seem,Semple Chleme Reedual:Total Free
❑E.ocy-GWR(AP)
❑Feces-sum ,amwivlo�l UnsaOdacbry routine lob number:
ppNmd:Yee_No_
❑Auemmem Monitoring(N3) UnuWbcbxy muffne Polled deb:
S
N Semple Collecbtl for InforMW Only
Inwdpetire n/Repelrs_ Omer_
LAB USE ONLY 0 INKING WATER RESULTS LAB USE ONLY
❑UnuUefecbry Total Coliioml Present and Satlefacbry
❑Eooypmsem ❑E.cmi.baent Cdlbml debdad
Replacement Sample Required:
Q Sample hmold(>SO hours) ❑TNTC ❑
Bacterial Deny,Results:Total CollMn .....JtODmL Emtl HOGm.
Fecal CWQM /tOOmd Enbmmad /1OO mL
Metlrod SM92238 ❑Sot 9PYY0 cite-v�fyN°�lFro RxN
❑SM9y19B ❑Emembrlly �'µ'
Deb erd T»Anriywd: Oele Repod
BemY xneer(ownurerpao-+emqul taE Vae pay:
0 8 0 3 Ly
' 119 wZ _l
mod. [aqq Lf