Loading...
HomeMy WebLinkAboutWAT2024-00105 - WAT Application - 2/28/2024 WAT -� MASON COUNTY COMMUNITY SERVICES &,3dn4f1amMErnironmmW Nadth CanmunM1YNedIM1 415 N 6-Street,Bldg 8,Shelton WA 98584, Shelton:(360)427-9670 ext 400 4 Beffer.(3606) 74544687#400 O Elms:(360)4825269 ext 400 FAX(3 Application for Determination of Water Adequacy Instructions 11. Complete Pan 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. Ana roved buildingsite Ian must accom n this a lication. Part 1: Applicant/ Parcel Identification rt Name on Applicant: �T{90n4L1C Hg* Date: ✓'�9� Mailing Address: 7#%l/ bol Phone: Parcel Number. ga et1 -15-Of0go Type of Water System Reason for Application ❑ Public/Community Water System (2 or more O-Bullding pemlit gr ,U,'0-0Q9 `f connections) ❑ Division of land: 0- Individual water source(one connection), #of Parcels? SPL O-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 connaction(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 v w.co. s. Baled ma.ue ]:\EH Fams\Drivlmg W.•F Individual Water Well star well report(attached to application). Depth—qe&—O—fL ( Well capacity Test(attached to application)_7,�pm 7?j O Pdjc� The well driller often performs well capacity tests at the time the well is constructed. Resu these tests are noted on the water well report. Results from these tests will be accepted. I well report cannot be located by the applicant or if the water well report does not have a ca well capacity test,which provides stabilization of draw-down and recovery data,must be by a licensed contractor. Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIggA�qqq___)__[[[[[[�����) Development within which WRIA htto/lais co mason wa us/olanning 1ST t�220 Water use or limitation recorded................................... N/A tYes i Well Drilled ............................................................... Data v ) Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection ❑ I have reason to believe that this water source can provide at7rdy,provides water at a rate of 2 gallons per minute based on theAuthor of Statement Relationship to Applicant Part 3: Mason County Community Services Evaluation (staff use only) Satisfactory Determination: Is 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 W DOE water resource regulations. Recommended approval indicates requirements of Sanitary Code,Tifle 6,Chapter 6.68.040-Determination of Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. of 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: Environ. Health: K ll 7\ Q Date z orz CSD Director: Date WATER WELL REPORT DEPARTMENT Or NdiceofldeMNo. W 42828 ECOLOGY wpm FmlogY well lD Tag N BWI`lO TYp=Df wurk S:meafwaskindron o c D m Sit.Will Name(if..mm:om weil): ❑ Uvomidm o 0Amali.mlbdm NOlft WMerR&Nm:Xmifi No. P:uv.edU 0Om::emc ❑Idwuil 0M ipa PmP.IYOwxr Name Mrl.=xuIaf ❑Dcwma% ❑I::ip:bo ❑Tuwdl ❑ah. WcllSoeet Addmss SEArnedla Rd 111 v_oeTip: ODA" ounty O Newwell ❑Ahve:iov ❑Driven ❑3W ❑CWkTod City SMtoe C Mosmi ❑Deepeveg ❑Omen ❑Dug ®Air ❑M:ML..y Tex Pertel No. 22029-75.00020 Mmmlm: oiemua fmmg a it. varienc . 260 fl. Wmeeeppro f.AmvNl? ❑ O'Yen No Oep:I:Dfmmpkud_11280 A Combuedoa Demo: w.0 Ifym,M:d wss the vuienm faR Cmq tiev Oime Fm To Thi3nm SW MWMed Th:M p ❑ a I . u IN 0.251. p 1 ❑ SO 1 ❑ Wmtim(gmimoudiamonp8e2): pWWMaO ER'a3 p ❑ _b. _le. p 1 ❑ ❑ 1 ❑ MN Y,%ofthe NE %:Simi 29 Towntllip M Rmg ZW ❑ 1 ❑ _m ❑ 1 ❑ ❑ 1 ❑ WYudc(Fxemplc 4112315)4Td99993 ❑ I ❑ — — _ m ❑ I ❑ ❑ 1 ❑ Longiade(Example-120.12345) 422.959333 P Iidm: ❑Y. MM Tyll ofpvb iitlill Drlller'a Lag/Camtrveti000f11I...tuioe Pr aunt N.ofpml..liam� sbe Dfpcdmlim_iq_ Fmmalion'.Cnuim iy mbr.dmecmr,vve ormv.:N ane:mn:i...:d me�dd Pummed Em_e.b_Lhlow Im it rurfire ueue of:hem "I Ill uce 6M peretrmed wim Vluumemq fa ewM1 limi &mur: DYv ❑. @pm_L iDhmrYo^ O.tltieaml r6eev ifoauu:y. Mmd.wa'•Neme Alloy Matlile Wake MeleTul Fmm T. Tyre Stalrlless9miad Md M. &wen ae bWn 0 3 Umew 5_ SW rie A,—a uIm 3s@ Lm EB@ L wmew_ sw rz._io Dam _Lm_L BlOvmfine"M li 29 Bravo fire flind.fighl 2B 71 GM saeeWum.P.L:❑Y. ONo 9imD[p.kmw:l_in d8 71 M Mvmi.k p6mefim_em_L Gmy day 76 111 s.rfim sd: ov. pNu T..WdeNF? 19 L &asm firs mrq ill 118 M..:uluWiueeel Berdodle Chi a G dY lie 132 pid.y anu mmeiD wuobkwum ❑Yu Fi Nd Bmvm SIR In 140 TypId—n Depm Ofevm G iA 140 152 Me:6Mofrerling nn:eoR Gm. Fit 162 181 Pump:Mamfi.-INum Typ: Gm da Eaald ravel 161 178 ap._ mmmi:.ke6"h:_L Dedpd ea.s:_Wm Blefkmedl.iIii 8 MMl 178 187 wamr t..6:I.:e.mOa.lewion.bow mmamkwl 21@ L Ga d 187 10 S:icbup ofmp ofwellouin8 t_5 fl..Eow goW evlb Brppgl d 197 201 swkwev leve1213 fl.eelow:apofwdlauL:g DY BRl11 Brw.11 alit 201 206 Mien pmenue_ pmemmka Den_ NIS 212 G ill Mee6Dwmruommlled by (wp.Ww,em.7 seltl8 ravel G ill d 21 210 Well Yen G ghe amd.Y hl 210 239 Wuep:mginglmlpv6nmd? ©No OIS C by wYml Ga mftllum 6aM R191 239 2W YWd_gpmwim_fl.dmEown.flv_hx 25B NO Y6le_®m wim_Ltr.wdmm anex_kx Bl1011 mM nledlufn etdtl,vfeler YMId�gpmwim_0.trnrtlwn.Bv�6t emrvy yv I:ima�rm wEm p^mp v mend oa-wibv 6M mm:M em weY Icpbwmkwl) Tiv Wmlewl Tim Wrmrle.l Tim Wmtml Daleol Pvq,i:pmY�� arika kA_W:°wkF a dnwM+o.av_ma Aemn tf Wodm.mrd 2a0 e.mrt I D.flrL21 M®m0ow_gpe: Tmpmonafwm W •i WuaeMvdmlmM6 mde9 ❑Yen fB No Senn Dale T139R1 Cwnplded Dak 81 �W6Cmimmiudg Wilfialslt;IlI M di flmehm te' pmkd�ehom Mtmtoto myl�f6:owlMe ud ief.xell.eM its cmnPlw:ce wiN ell Weshislpm wdl caE Dnllm p Tmi m❑M-PridN a Josh Koa Dr'll' Cam Amadla DdlOnD Irm. stiml ee z Addrts PG Si 1T90 U N 28T4 Ciry,S Z SIMBan WA 98564 W'fRADiFE w:sofslwmselio. Cammewlg Spenser' S' Re®swtian NO ARCADDI098K1 D:dc 89121 ECYO504.20(Rev09118) IJyal.d Ma dmament In wm1--fwmo4Plmse-Rde Wmer Remorm4Pmdmm N 3 50-10 74812. Pemone.idr Aearin8lo.mmn mil211Jar Warhgemn flebY Ssrviw PereaD vahaapeeah A.mDlliry mn m118y2d33d311. Vanguard Laboratory 2635 Parkmont Lane SW Olympia,WA 98502 360.967.7010 VANGUARDReport of Laboratory Analysis LABORATORY Collected by: Matrix Dri es nkipe Wal Tim Bailey 360-090-0401 Laboratory ID: V240315-7 Dale Sampled: 3/1524 13:30 Sampling Address: I Date Revived: 3/1524 15 50 200 Lary Dog"ne 1 Date Reported: 7/192024 Shelton,WA 98584 i i Sample ID: 200 Lary Dog Lane I Analysis Result SDRL MCL Units DF Date Analyzed Total Coliform&E.tali by SM 9223B(I)EXX) Batch ID:V240315-7 Analyst:39 Coliform,Total Ncgmive 1 1 MP1,1/100m1. 1 3/152417'.IS E.coli Negative I I MPN/I00mL 1 3/152417:18 1 i i {I i Notes: MPN:Most Probable Number am, raper million Reviewed by Robert Smalling,Chemist oa 03/192024 nd'.non-scat Na not applicable Approved SDRL.state Denectum Reporting Limn proved by Toni Johnson.Opcvtiom Manager 0n 03/192024 BE Dilution I.., IMNt]O3rRal] MCL:Maximum Cmanminant Level l -mon4a"Wo Page 1 of 1 sompla wire received in aweptable condition.The mm,is)in Chas report relate only to the potion efthe mmple(s)riled.All analyses were performed consi nam with dw Qusliry Asaurmce Pmb^as^of Vmguard Laboramry.M.contact the labommry ifyou should have any 9uatt"saWut the molts. 2635 Parkmont Ln SW,Suite A,Olympia WA 985021 Office:360.967.70101 l,sting@vanguardiaborat0ry.00M www.vanguardlaboratory.c0m 2208106 MASON CO WA ©3/0112024 10,30 AM NOTCE EI KR ISTIN 6 SON R195454 Rec Fee' $304 50 Pages 2 Return To IIIIIIIIVIIIIIIIIII!IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIiiI lit 1111111 df R'ho-YA1,I W r'a/Srgt Se P.diagowar cr .SNhta1J rs/.rL 98 CBY Grantor(s):(1) 'TiUD�71Ai `.y/yj�S - (2)_-_.-_ Grantee(s):(1)PUBLIC Legal Description (1) 33.9 7-2eJ Z,e (Abbramledform:i.e.lot block,platorsection,townshiA range) Assessors Tax Parcel: (1)1-g—,-,a-1--1-'�---0-D-.Qg—(L 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 andlor Water Resource Inventory Area or WRIA. WRIA: Maximum Annual , loAverage Gallons Per Day: "1 JV gallons Dated on this 21 dayof / iiAal 20_kq. Signature of Grantor(s): Stale of Washington ) County of Mason ) Page 1 of 2 I,the undersigned,a Nc ry Publi in and for the above na ed County and State, do hereby ce that on this r day of 20a, pemo ally appeared before me,who is knowtrtaike signer of the above instrument,and acknowledged that he(she)(they)sign it. GIVEN under my hand and official se y an y r last a wr Iic in a or estate of Washington, �t ( residing at AcFeu. My commission expires: ��Ann Cmeru NOTARY PUBLIC Slate of Cmneq�,t MY Cammisaion Expires r6aY 31,2a28 Page 2 of 2