HomeMy WebLinkAboutWAT2024-00307 - WAT Application - 8/15/2024 WAT 20z-1 -
MASON COUNTY RECE�; A985�84
SERVICES Shelton: -42 ,En 400
COMMUNITY
Ij :360- &*7,F.L 400
mo
El :360-082-x2-6269,Ext 400
615 W.Alder Street
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 Wpmved building site plan must accompany a=mpany this application.
Part 1: Applicant/ Parcel Identification
Nameon Applicant: DAh VrfmAftieC Date: —I'3o'2o2y'
Mailing Address: 2w N-4-UMi'Itch hd Phone: 360 -1W- 0345
Parcel Number. 51m l 'l9 Li_vr 3
50030
Type of Water System Reason for Application
❑ PublidCommunity Water System (2 or more 51' Building permit
connections) ❑ Division of land:
Individual water source(one connection), #of Parcels? SPL
V Well ❑ Boundary line adjustment
❑ Springlsurface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Remodel(please indicate name
ff you have more than one residence connected of water system below if applicable—no
to this well, check the PublidCommunity 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.
❑ 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)oonnection(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.mason.wa.us.
1:\EH Forma\Dnmki Wata a iwd4/4/2018
Individual Water Well
El' Water well report(attached to application). Depth Sp ft.
Well capacity Test(attached to application) 1OJ opm Ogpd.
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.
.5�Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http,//,qis.w.mason.wa.us/planning 14_16_16_22_
Water use or limitation recorded................................... NIA—Yes—
Well Drilled ............................................................... Date
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: andlor
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 only)
Satisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
ter indefinitely in the future,or guarantee compliance with all applicable WDOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-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
mason(s).
Reviewer's Signatures:
Environ. Health: Q-Y� Date ��—
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
w�c-ZozN-- 000zz L-0r3
WATER WELL REPORT • 3$ . Devaal MLx'. ur Nmicedhatm Nn. WE55426
ECOLOGY Unique Ecology Well ID Tag No. BPNO58
Type of WarC 1wSiS.'ve0ingmn
m Comumion sitew'dl Nant'hfmomthano...11):
❑ Oxummiown C lingimlimmllolion NUl Nw Wala Right PermiuCatilinte No.
Prepmed U.e x'Donor I:d ial :Mmdcipal Propwy O vrr Name DAHL PROPERTIES LLC
❑Dewamwg Z Inigatwn =T.well _Ddry Well Street Add. LOT 3 0 HIGHLAND RD
Camtraeltm Type_ Mahn: cis SHELTON CWmnY MASON
a Newell n AReatiun =we Chord =Ceblel'ml Y
I I Dcepcning I fRtr+ :.Oug P:AR- M-4 tatty Tax l'ensl No. =2b4149089'
Dtmamions: D'um. .ft—ing B m.w w 9. Was a reriam:e approved for this Iwll? 3 Yen El No
De,AhofenmpkWwell A
eaaatradoa DNain: wdl If ya.xbat xss the aariam:u fnfl
Caan, Liner Di mmcr F. 'ru IbELms soul PYe:welded Reaw
A 1 ❑ 5 w. «1S W 25 a Is I ❑ B 1 ❑ Location(see inswctions an page 2): 51WW:M or 0 EWM
U I U _m. _ n. ❑ I A J 1 J NE y,_y.oflhc SW '/.;Section�4 Tox,uhip 2nN Ranges
❑ I ❑ _m _ ❑ 1 ❑ > ❑
❑ I ❑ in. in. ❑ I ❑ ❑ 1 ❑ latlmde(Example:47.12)45) 4720ST2
Longitodet[xample:-120.12345) -123.25272
Pntonuom: 7Ya AN. nlrofgafmmormrd Driller's LoglCunxlruetbn or Oemmmbelov Proetdure
Na.afperfomiem_ Si,eafpe:fonlion_'n.by_ Fonmtioo:Ux,ibe by mlur.cbaMaGue ofmtnwlaW mtrltw.and lm kinJ and
PMomW fium_R.m H.bebw P^u^d aorta mtneafnr nmietwl inuch wy.,peaeumtl.wkh allmlace Mryrm en-0ckmge of
Seram: a,Y. IN. GI K-Pecks b DId, M A wfiwnmwn. fire addirinml aF.as ifinee ry.
Mmmf tmer'a Nmm"MON Material Fmm To
Type STAIN E6B N.•dd No.
m SANDY LOAM 0 4
Diamxn s w. sim aK t� r,e_r m
harmer_ m. Sort aue_ klana—rtm_II. BROWN CLAY GRAVEL 4 25
SANDBROWN 25 35
saadl%ilNr Paek:=Ya +_Np s�prrark wxdat_ia GRAVEL SAND WB 35 50
Mav,ula pwccd form_Rm R
Surtaa 3eaC E Ya ❑N. T—bo derah? " R.
Nmcral men in eat 318 BENTONRE CHIP
lhdenyswumM mnaaeabkaal -! ❑Yes ®xn
Typeofwawl ❑ephoforen
Medatl n f reeling mom off
Pomp: Mmuictuox'r Natm Type:
II.p._ %wimakcdTah:_ft. Daigrd Row mR:_gPn
Water Le ; lamgamfan•ekntivacWwm xm kvel_6
Stick-up al mp ofwcllcming 1.5 fl.abovr gmwdsmfxc
SNlw water k+'el 16 R.beI—Ioporwumiog Date 00712UPi
Anaiau ,wor e_edb, Tart iMt Dale
Aneden walmuwnwlkdby (ap.,d.e,mc.)
Wa Teas;
Wavpumpwgtd perfornrA". MNu ❑Ym b bywham!
Yield_arm with ft.dmudwx afler_M1n
Yield_poor with_ft dnudown aM_at,
Yield_Rim wih_ft.Jnuffian efler_hrz
R.,t Nor ftiim-rem wh pump rctmmdoR-.Ir lnusmW boor ad,
mp w xnx,W.Im W.,c
Time Lu.el rme twrr teal rme wma uecl
Daeprrnmphtxta�
Bailera_p viwhe_ad A9ft-h, I ,Able 1W prm vie 49 ILf 1 hrs. OaP R6N712024
Amw'sp Oow_Rtm
'Rmpmvtme nrwata_'F waarbnaiolmtal>va wdP! Cm 914a Smn Dale 08I772024 Complded Gate O6H72024
WELL CONSTRUCTION CERTIFICATION: Iwmhueml mdw+ecept saran Ibiluy for mtsnunioa of Ihi.xxlL and itsmmpliantt xith ill W'ssltiogloa xvAl
conswction nandgds.Maten.la used Gad the information repuned above are nae to my brat ImmvletIV and belief
91 Drille, inec❑ -Print Name ROBERT LAYMON Drilling Contrast,ADVANCED DRILLING LLC
e..,.k..rPl Addrcv 115M SCHOOL LAND RD SW
Li.No.2588 chy slam Zip ROCHESTER WA
IF TRAINEE;Spon 's Mora.No contlxw.
sporsoessignallam gcgimmno Na ADVANDL804DL D+N 06/17/2024
ECY 050-1-20(Rev M 19)1[nn,neN,hu✓«nmem in an wbmmrr,Inrmaq plam•ra/1 tlm na,,Rex,.Pjrngtnm at 760407-M72.
l'rmonr wi✓JnmrinX Ina rnn m/1]I//nr!fmhinX/mt Nrlar srnfer. I'rxnnr nf,h a.rMvxh dimhili0'ran anti X%)-NJ3-6341.
>awnmurnr o3Sa 2aTa .
t.❑Bewb.ortrrouBo.e■roa wP) z.❑ waae.�rubr)
Dwn yNNrMeyabmelwbn bW.
Date Sample Cglladed 11me Sample CVaPIy ChbAnabd:Yea_No_ Uneatlalmlory 1plBlBlAll nurrlLK.
a g Z� Collecb� ^\A� ChbAne PsaMual:Ta Free
v on I Day I Y.w :M PM 1 ,• 3.O..d WaIb5r UI .Soure.S.mPle Uneelefechxy reuBpmlPcltlad.:
BType of Water Spa (dor only ore bon) ICJ —'yam
❑CA A B Dber V ❑TdaDared WP) chbAn :Yea_No_
g GM.P A end Crory B SyF M ❑Asse ..0(W) Ghb"Nedduel:Tolel__ Free_
A ID#
a Sya{tam Nen'. .�e�� 4.SUHuw or GWIR.w Boums Wabr S.mDle (Fn--kn)
P PRIvpAc Will l=. Ir���I Y'«'B�� ❑Emil ®Fed Flkretl Vo_No_
" 6jPtedpamon; a 5. bCdlacted forlMDrmNDn Onty
E.Pho-
Cal Phone( ) FAX( ) ❑U..a fdM Tobl CdH Present AND BI M7
O F ❑E:cdi prerent ❑Fwffbent
Semple Collected By(Nama). DAn'.. B"dlDmBy RnuN.:T.WCV HW Erect NIIDd
SDedlfle LDeahan Whne Samob Sect I nsmUcns Ot Commentx Feed Gofb /t00bL HPC jlL
Collected IAddnla3.M Feu.. ""��
WA-I—WfllA l Aq R.Pl.S.*VNwbRWulred> ❑ 00 ❑SapbboaN
❑ Sanpkvolm. ❑Danugetl Canmbm ❑
C"� LQC 3 ,
�(FN 510? I• �3 o oab PempTMPG' N nwdcude 9zz+ SM9227B
p F.pwbdN.DON
kxx �C+yhland SHeF4o� 09,owrmnwmP.+�mo