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HomeMy WebLinkAboutWAT2024-00169 - WAT Application - 3/25/2024 WAT!.Q` - 415 N.6^Street MASON COUNTY Sbelwn,WA 98584 COMMUNITY SERVICES Shelton:36070,E .400 Belfeir.360-275-04,2754467,Ext.400 eoud„srw,nmy Emnso,.„tai ndimcommwnw.A Elme:360482-5269,Ext.400 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: Two Date: Jh-//&2xF Mailing Address: )Q'{� S IP1k Cr. Poem PM?JPnone: (%0) 650- ?ill Parcel Number: 120P0 24 9DOgl Type of Water System Reason for Application ublic/Community Water System (2 or more Building permit BL 2OVz4-0042© connections) ❑ Division of land: Individual water source (one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water Cl Other(explain) ❑ Other(explain) ❑ Replacement or Remodel(please indicate name If you have more than one residence connected of water system below It applicable-no to this well, check the PubficJCommunity 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 ---p.ool Water System:_ _ Water Fa,,, Inventory(WFI)Number:_ (write°none" -party) ❑ 1 am the manager of this water s .The water system has been app,--d for —services. There are presently - nnecb in use.This will be the. connection. ❑ 1 am the manager of this system.This connection a to upgrade or change the use of an existing connection oryt�system (i.e.: recreational to full time). la se indicate on the following line the nature of this change: water system is able and willing to provide water to this (these)con tion(s)without exceeding �the limits of the water system or any limits set by plate and local regulation. Signature of Water System Manage) . Date This form may be scanned and available fol lAblic view at www.co.mason.wa.us. 1:\En Fans\Drinking Wata Revlsdd 4l412018 i Individual Watery Well Water well report(attached to application). Depth 1 -�l`��, ft. Well capacity Test(attached to application)�V gpm 7 Q..Qgpd. 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 Vy a licensed contractor. atisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http�//Qis.m.mason.wa.us/olanninci 14.�-15_16_22_ Water use or limitation recorded................................... N/A_Yeses( WellDrilled ............................................................... 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; and/or 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) q/,Satisfactory Determination: rThis 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 6.68.040-Determination of Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter 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: Date 2A 1y", This form may be scanned and available for public view at www.co.mson.wA.us. Page 2 of 2 WATER WELL REPORT DEPARTMENT OF Nalce Oflmena No.10YE56"ll ECOLOGY UnpeF<dogy WeD lD Tag No spi S ,.f Work: state of Wasidepaw canma<non Site Well Name(if more than use well: Rwmmieiu b Oull nil itmaaaim HOl No. Water Right PermiVCeniCiutc N. M.it U. IS Dominic O Indamnal ❑Metaled Property Owner Name Hkk B Lin eh C nugliM ❑0wmering ❑Irrigaw. ❑Time Well o r Well Street Address S I F r,:aria rove I 1Cmnnadoa Type: Malh.d: City Shallow, County MR ®New aml ❑Almanu ❑On. ❑harm ❑Cable Tad ❑Detpumg ❑Other ❑Dag B Air. ❑MWAauy Tax Pareel No.220202490DOI bluuemas: Denuder afbonne9 ir.W160_M. Was.,adna eppmved for this well, 0 Yes ®No Depth dxemplNed well Has R, I Caulraedna DavaW: wall fyes,who wm thevafianee foy)_ Canna liar Dluelm From To Tbiekeea Steel PVC WdMd Thread 0 I ❑ 6 a. -1.3 1424 _in. ID 1 ❑ ❑ 1 ❑ Location(see ins iom m page 2): 0WWM or❑EWM ' ❑ ❑ _in —in' ❑ 1 ❑ ❑ 1 ❑ NNW-4-K of the l sJy Ye:Scetk ,Q TowmhiP= Ren8e�( I ❑ 1 ❑ —in _in. ❑ I ❑ ❑ 1 ❑ Lallmdt(E%ample:47.12345)4721052 ❑ 1 ❑ _ _ — _in. ❑ I ❑ ❑ 1 ❑ Longitude(Triangle:420.123{S)-122.98801 mmnNw.: ❑Yn BNo Typo dpufauw mtl Lqmvel riller'.Lag/Coutrudien ar Detester ion Prondun of pefamiu._ Siuofperfna ima_aby_ie Dew.be by colm.ebaac a4nut—1 mdeuunm�e,tied the kind and �`edmded Gom_fl.m_fl.below dmM eurfaee emnenal in eaab]a,.peretued,with ai lnaoneenm foreach change.( Serum: ®Ye ❑No 0K-Paidne ' Deyt 18Q2 fl. e uie Wtuond,eeeeifoaewry. Mmaf.,.HNN Mutual From To TrPa Modet Na- n cobbles quint Send SM 0 2 Di.mem aTw Statdmte_uhee .149.t fl.my49,q-M1 bbbagnvel sand ell 2 9 Diuew Skuaiv_n.ham _fl.m_fl. bbles gravel sand clayey ell 9 27 saadrvmerpeck:oYm ®Na simprPr mu.:d_b' fine sand 27 30 vel fine sand sift30 10{ ®Tn ❑No Towhalddpsh?Aft. y sand Wet _ 104 109 Malend urea m tied m urnurte ru p Gray sift 109 US Die my......main umnbe waver? my. ®No Grey aaM lfl Water 125 134 Typedwner' Daptherfe^Ne saaNgfrvei seed ale water 134 149 ;Meted of.Well may.09 Id bravo SM 149 150 Type' Ipaarp: MwbeNrtiaName . HP p inm_ Turn, depth:_ft Designed flaw,flan m:_kpm '.Wan, Lewle: Lmdamfine ekvuim abpv<me ass lewl_fl. 'Smk-up of mpof well eaaing v+Ua.above around audace Stmiewmerievele¢A.belowlepdwellaeing Due 6111=24 Arwim ree.a._Ibe.Pe Wane iuh Date Ateeim water e.mnetkd by (tip,mva,a ) Wall Tel: O Wa,apunpnemalRReimed? ®No .Yeah bywlpm? Yield _gran with-_it drmdowe eau—_his Yield gran with_it drewdown after_An. Yield _@m wit_a.diewdown unu_ten. Recovery due(sae=zeta when Pump is mined oft-weer hem a hawed fires wall rep to wale level) Time water Lem Time Wee Level Time Weer Level ' ONedPupp{oat___ sailer tea_gram wit_fl.weir i M Na_ten Art IW Dgpin witm u iteldlee flfwl . f One pW13Y10ta Armin lbw_mew, Tempaamrt dwew_'F we ieh®iul mat'sh men (3y. ®No Stet Date 0W12202A Completed Dam 0032024 WELL CONSTRUCTION CERTIFICATION: 1 emetmded as bon accept rmpomibility for cundmalon of Zhu well,and ib complunce with all Waahingteas well comtmdion ladarda.Materiels need ate din InformNdn mponed abovo tee bus in my bed knowledge and bell.? 0Mill.❑Trainee❑PE-Print Name Mark Wiese Dullhe,ceenparty RICHAROSON WELL DRILLING S'gmlua /J 6,t- - Addreu PO BOX 44427 License No,2432 City Stan,Zip TACOMA WA Nal48 IF TRAINEE'Spomor's Liasue No Contndor's Situating's Smusurne Resdistrelaid.No RICHAWa3210B Dfts W1412024 ECY 050-1-20(Rev OWIg) IfFa Neda4da vent mWkmmf m t..pkammlllhe Waer Bmwrcm Prognmal36O407.6872. Pnsau wllAhearm8loe inn enR 71(Jbr Waahingron&lay&rNre. Pace ,with a 4wA demWlly emred1677.833-6341. 2T6 T-kd s <5s..ec " SPECTRA Labnraloric. - Kibsap �wlsbo,WA wYn r.eenrr<r rn<s_._j •pp3n dul COLIFORM BACTERIA ANALYSIS FORM Dab Sampb Cokld Ti. Smgb C I y I Zy GeNcbd IO :ZoaF,,,,i,,o-*, peaWew%y (dwello*onaboa) ❑CmwA ❑Gmme ❑ONW mp A end Grelp B SyebMe-PMVW bMs Webs FarlNS lmmbry sbm Name: mba pmam: J S ar E 4F m-3 7-7 Cetl Plwb: " N,mbb:aYMMnm.ww+reYnWv.iWl,brtb,Nv4vnle<Mbmulul SAMPLE WFDRMAATNIN mpb mtle<ba by Inanrel: Sew C n io Z wcHw bratlm where eamplecalecbd: Special Mbudbrwammmenb: $1 Y L^SCNn [Uvt L9 c6U"rG "aI$wo(dwkc*abboa) ❑Ro .DlaOibutlm umb W) I.❑RagNSwnpN IAR) Chb+kabd:Yea ❑ No❑ pam dMvwnvyalam ahe,umal.mulnl UmMemday roWna kb almbar CM1bMw Ruitlual:Tolel_Free_ Ground WMm Rub 9u,u Simpb ——— ————— S UnutlesapbgmWne mtlea deb: CM1bnnabd:Vx_No_ ' ❑Tsp W (AIP) Chbdns Ruireml:TMd—Fro_ ❑AueawnaM(AP) Sudw e,GWIRaw SaumeW ,SemplO(Eww0m) e ] E.w/i ❑Fecm Fbm r.�—m— �•�L� �s<mpe couo-voa l�.Im<nnmon Dory LAB USE ONLY DRINKING WATER RESULTS USEGN.Y I Unutbbaary Tobl Wk"PP-WlsM b<m,Y ❑Ecah pn nl ❑Ecchabaut e<bdal Denairy Ruulb:Tml CdRmn_Jopo1 ewk MPN"W . Fatal LoNlo,m dWldpM. HPC WlM. apkcemoMSaw&RaqukW: ❑TNTC ❑Sanpbmpow ❑ SanwkYobme ❑DwmWCwmw ❑ W Rew M•,�Ob 'ol ;marwapr: ` ,� xemec mMrraRuu DYIRGG 1 5M • r '. rb ln'. bea.w�anr.r rr.rw�wbb - IYYrYrYwlaYltl. M,MF 1 w.Orr4wbrrwaaYra¢meNiw wbwwlb„b »lue-rroaa 11��(�� 116bYw•.•.be�NwtibeMa. 70. oaN,..wlwsub..w,n 2209316 MASON CO WA 04/0412024 10:54 PM MOTCE pPVI0 STOKES N1963J4, 19fi3]4-C1 A. Fee. $304.50 Pages. 2 1~' I IIIIIII IIIIII III IIII IIIIII IIIIII IIII IIII IIIII IIIII IIIIIII III IIII IIII Return To/` ZI-1<WLD swxes 94112CE CNF69 CT Po�'7 �rL(!Q 9P3(,7 Grantor(s):(1) �wy ST� .(2) Grardae(s):(1) PUBLIC Q Legal Description (1) tor = i S a.AT25310 (A6No Wedlbna:i.e.kt black plat orsecdon,township, range) Assessor's Tax Parcel: (1) Z 2 T TLE 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 ureter use restrictions and conditions set by Washington State Senate Bill 6091 and Mason County Code BA& 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: lq cin gallons n Dated on this -7 day of /'1 ,-, 2A t Signature of State of Washington ) County of Mason ) Page 1 of 2 I,the undersigned,a Notary Pubic in and for the above named County and State, do hereby certify that on thiis��"� day of�n 1 , 20 V� StOKE'S personally appeared before me,who is(mown to be signer of the above instrument, and acknowledged that he(she)(they)signed f. GIVEN under my hand and official seal the day and year last above written. °ey PPatte�s's, l� ,.•`O�a�• E7cP.�i•°� '�� Notary Public in a for the State of Washington, residing at �YY.Yhe Vturl My commission expires: 04"I31I�31 Cy�PUB ,�m•o: Page 2 of 2