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Home My WebLink AboutWAT2024-00166 - WAT Application - 3/28/2024 FWArg_2._ t�-QV-t ( RECEIVED 415N &StMet MASON COUNTY Shdton. WA 98584 COMMUNITY SERVICES MAR 28 2024 Beth;, u�zis-0a67.I:'I 4W euae,�ri...,nr,.aa.,m.n,a iwwrti c,.,,,..,xr ro v Flma- 160A82-5269AA 400 615 W. Alder Street ENVIRONMENTAL Application for Determination of Water AdequaKALTH Instructions 1. Complete Part 1. No determination can be made until Part 1 is fully completed. L2_ 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: ApplicanU Parcel Identification Name on Applicant: Bonnie Miller Date: 3/19r24 Mailing Address: 7188 Wmterbeny Place NW,Seebeck WA 98380 phone: (360)620-0722 Parcel Number 223107990661 Type of Water System Reason for Application I1 ,N Public/Community Water System (2 or more 19 Building permit IMIC&�11 BOO lt� b connections) ❑ Division of land V`v l IKJ (� ❑ Individual water source (one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment ❑ Springlsurface water ❑ Other ex lai ❑ Other (explain) (explain)_ n) ❑ 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 Vf�1 66 3 Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: Frog Halm"'water Water Facility Inventory Invento None (WFp Number: (wile "none'for two-party) I am the manager of this water system. The water system has been approved for 2 services. There are presently O connection(s) in use. This will be the I _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) connection(s) without exceeding the limits of the water system or any limits set byy late and local reguI t � Signature of Water System Manager ��4.../.Y Date .3 Z /'l — This form may be scanned and available for public view at wwvv co mason wa us. J:EH Fams�DrmAiug walm 4 20a �/' Individual Water Well r0y' Water well report(attached to application). Depth \ 1v ft. /'l ,n Well capacity Test(attached to application) /, � opm ?�v apd. 1 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 rapacity 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 (WRIA) Development within which WRIA hLt2:1/qis.co.mason.wa.us/plannina 14_ 1�16_22_ Water use or limitation recorded................................... N/A Ye� —C 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; 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) atisfactory Determination: I/ 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 6.68.040-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: Vkn Date This form may be scanned and available for public view at www.co.mason.wa.us. Page2of2 U9PAd'atEk- O WATER WELL REPORT -_ 'ECOLOGY Notice oflnknt No.WE52723 Type pf Wart: EC Xa'aw:GYegeor Uai9M Ecology Well ID Tag No.BPS-260 FN��I{�(I AIAA nIrAL ® Creawnipn Site Well Name(if more than one well): ❑ Decommission g Oliginaliavallnion N0l No. Water Right Permit/Cerliflude No. Proposed Use: 61 Danetic ❑hadunrlal ❑Municipal property Owner Name Frank g Space Mareinket ❑D raering D❑ligation ❑Tet Well ❑Other Cnastm[flae T Well Street Address 797 NE Sladlsmfth Or ®Newwall ❑Almmipn Dpiven ❑lead ❑Cable TMl City Belfei! County Meson ❑Deeproing ❑One ❑Dug ®Air- ❑M."ous, Tax Parcel No.22310-79-90663 Dimemlans: Impae<r afboring¢_ib,1.In fl, Was a variance approved for Its well? ❑Yes ®No CepJiofwmpl<ledw<Ilne A, Comin<epn Rtally: Wall If yes,whq was the vviance foR Cning Liner thameler From TO Thieknes, Shel PVC Welded Tbreea ® 1 ❑ 6 in. -1_4 176 _in. ® 1 ❑ ❑ 1 ❑ Location(see irelruclimts on page 2): ®ViWM or O EWM ❑ 1 ❑ _in. _ in. ❑ 1 ❑ ❑ 1 ❑❑ 1 ❑ in. in. ❑ 1 ❑ ❑ ❑ may'/.-'/.ofthe NE%:Section JS Tmmship 23N Range _ _ _ I ❑ I ❑ —in. _in. ❑ I El ❑ I ❑ Latitude(Exempt.:47.12745)47.5037I perbralbm: ❑Yo ON. Tyzofpartmlarused Longitude(Example:-120,12345)-122.91637 No.of Driller', Construction or Decommission protection pefirour s Sialow,peomdardisee by_in Log/Construction Perfateed from_O.m_fl.belowgromd mrface Famleion.Dexdbe by color,character.su<prmaudai and manure,and du kiMmd neurtation I(Janad ineachla)xrp<accesse,xIIL el le0a:aM entry(M O[h[hNgC<( Be.,: DYn ®No ❑K-Rcker b DegM1_ft. infonnaim. Vu additional an<els ifnec<avy. Manufacturer's Nine e Type Model No. Materiel From To Nemner_ Srol»m_in.fran —0.1o_R Lt Bm boulders cobbles gravel sand all 0 3 ITM:eer_ Sla via_k iris —A in_ft. Lt Unity cobbles gravel sand silly day 3 28 Snd/Fiber pack-,❑Ye ®Np Sic orMck mamda_to Lt brown cobbles gravel sand silly day 28 125 Meedals placed from_0,k_a. Ltbrown cobbles prawlssb slRy day eaharabd 125 134 Lt brown cobbles gravel sand sift soma water 134 150 Surfam Snl: ®Yes ❑ND Towllatdeplb?SQfl. Lt brown gravel sated silt some water i$0 165 D.d.,Wuria used in coal Bucadde TECHIPS Lt grayish brown gravel sand sift water 165 176 Did any erau contain nnmaWe wam0 O Yn ON. Lt brown ravel sand clayey sill Type orrmee D<qA of mass 9 YeY 176 777 Method or sealing meta o6 Pump: Manolhclanr's Name Type: HP._ Pumpintaked<ah:_a, Deignedeowrae_swa If Were,L<veb: LeM-wrtace eleveion above me ace lcwl A. Stick-up ofkp ofwoll casing r1 ft abovegmund surfxe Stare wakr levO M A.b<lav lap.Fuell main, De<owl)]/pats Artesian pressure_Her,per squam inch Nis Artesian water is comoo ed b) (cap,vahx,ecJ Well Tests: Alder Wn a pumping war readopted? ®No ❑Yes O by when? Yield _gpnl wile_ft.do ski na after_hn Yield_Bar with_ft dmwdown afte_Ins Yield_spun with_ft drnvdown after_hes. Recovery data low-em when pump is wm<d oft-water level measured Iran well tap to comer level) Time Water Larval Time Wale Level Time WmrLeval Dek ofpumpins to Bailer wed spun whh_A.dnwdnwnafter M1n Ainen 24sP vvd1immvnatjDft,prjhoc Dam OOQM023 Minim Bow_sum Temperamnofwam_-F Wasa[hemielamlysis xJa? ❑Ye in gygd�re Completed Dow �fl WELL CONSTRUCTION CERTIFICATION: I constmded and/or accept responsibility for construction of Nis well,and its compliance with all Washington well construction standards.Ma elials used and the information reported above are true to my best knowledge and belief ®Driller❑Train"❑PE-Print Name Mark Wese Drilling Company RICHARDSON WELL DRILLING Signature ./L✓7d /NX Address PO BOX 44427 License No.2432 _City,Slate Zip TACOMA WA 98448 IF TRAINEE:Sponmi s License No. Contractor', syonmi s Museum, Regulation No.RICHAW 32106 DMe 09/262023 ECY050-I-20(Rev09/I9) l/younmdrhiad=omnflnona/nrnarejornnr,p/ean milt).Water Resenrces Progwmar360-40Lh872. PersolB with hearing loucance/1711 for Washington Relay&,urre. Persomwbhasprachdhoblltyc wl1877-8334341. �.�aba� - ob�og RICHARDSON WELL DRILLING RECEIVED Aquifer Test Data Well ID# BPS-260 Owner: Frank Marcinko MAR 2 8 2024 Site Address: 79 NNE Blacksmith Or 615 W. Alder Street Pumping Well Parcel#: 22310-79-90663 Pump On 06/18/23 12:30 Pump Oft 0611823 14:10 ENVIRONMENTAL Date Time Date Time HEALTH Reference Static Level 130.20 Feet Pump Size 1.5 HP GPM Recorded By Time Water Levels Date Clock Elapsed Time Reading In Depth To Drawdown COMMENTS Since Start G m Water PATRICK 6/182023 12:30 0:00 6 130.20 0.00 12:32 0:02 6 132.80 2.60 12:34 0:04 6 133.00 2.80 12:36 0:06 6 133.10 2.90 12:38 0:08 15 137.30 7.10 12:40 0:10 15 137.30 7.10 12:45 0:15 21.5 143.40 13.20 12:50 0:20 21.5 143.70 13.50 12:55 0:25 21.5 1 143.70 13.50 13:00 0:30 21.5 1 143.70 13.50 13:05 0:35 21.5 143.90 13.70 13:10 0:40 21.5 144.o0 13.80 13:15 0:45 21.5 144.00 13.80 13:20 0:50 21.5 144.00 13.80 13:25 0:55 21.5 144.00 13.80 13:30 1:00 21.5 144.00 13.80 13:40 1:10 21.5 144.00 13.80 1350 1:20 21.5 144.00 13.80 14:00 1:30 21.5 144.00 13.80 14:10 1:40 21.5 144.00 13.80 RECOVERY 14:11 1 1:41 131.60 1.40 14:12 1:42 131.60 1.40 14:13 1:43 131.20 1.00 14:14 1:44 130.90 0.70 14:15 1:45 130.60 0.40 ` WATER MANAGEMENT JL.�/lJ✓ OV O — LABORATORIES eeac,. 1315 been ME'Tre a WA 984104 -' RECEIVED 'Raw COLIFORM BACTERIA ANALYSIS FORM °"anen°`OY°"'s Samoa o n MAR 28 2024 Dad 10 DP9 Aa.So(L 615 W. Alder Street Type of Wakr Sesame(bed only on Wa) ❑GnweA ❑GmpB GNw I �„Syeamm Virovidea�G lnaenorylWFl) ENVIRONMENTAL MENTAL SyOm N Comet Perem. Aaron Leeper HEALTH oay Phone:12531 537-7332 CWPlala:l 253 377-0236 Broom Seam furi o.IPnw Nn mane,atltran bMapaeel _Richardson Well Drilling Po Box 44427 Tacoma, WA 98448 SAMPLENIFDRMATION Sample wante0 Whim)) 5p�� s� Q�cruop�e.taa r' e al Wtit 7Y7 NG Spedadi, wt onsmr emmenU: Type of Samyla(eeledclyyon,W eldsemple tram types I Sow bbelow) 1.0 Rm1Une DbMWlion Sample Ui 2.❑ Raget Semple(AW) Chlorinated.yam No Ilmm daed.amri gatem aaeruneet.mutlnp —WI Chbnne ResimW TpM1I Free__ Uneeaslaalorl,were lab number. 3.GrouM Water Rule 9amca Sample UlaalelMoryiMme mllee tlaM1'. S _. Chbhnalec Yes_No_ ❑Triggered INPI Chlorine Re9aual.To181_FW_ ❑Assesamenl (NPl i. Sulnce or GWl Rew90um WaM1r Semple lEnumerslbn) ❑E.col, ❑Feol .. B S ❑sample rdlra�ro•Inkmmlen Onry: LAB USE ONLY DRINKING WATER RESULTS l.musi2Lt ❑UnMtlafagory Toml Colifonn Present and Snlaholdry ❑E.1,pesenl ❑E.myetaent Siatanal remake Raab:TO!CoWonn a100M. Eoea IIM. Feral ColAolm_ Jtftd. NPC,___(1 m1. Repbxemanl8enple RpuNM: ❑TNTC ❑Sellplaboou ❑ Semple Volume ❑DamapeECalNYar ❑ IbbTme � WPelwena Rm11bV 1'R'i�/.I� Re[eiN Tempt-. wMaGaW:S M9217� Gal• mphx Ibblle-Gel, AR183R Goa 089 G 1115 w-.• inn nrc.�.e.�w+w..--:—..,nauzenwr. �. �n e?119&A -0068 2209098 MASON CO WA 0312r/1034 03.45 M MICE 10 4h IA I311111111111111 III1111111811 11,11111lr RECEIVED ENVIRONMENTAL 'il9e 1a;nkh...�i�I.tUIJ ENTAL eta back wa743ft MAR 28 2024 HEALTH 615 W. Alder Street Grantor(s):(1)121,0":4 l)-A .(2) Grantse(s):(1)PUBLIC Legal Description(1) TR 66-A OF SURV 11/17 TR 1 OF SIP#2795#635388 (Abbreviatedfoan:i.e.lot bbck plat orsection, township,ranee) Assessor's Tax Parcel:(1) 2 3 1 0 _ 7 9 _ 9 0 6 6 1 TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA) I(We),the undersigned grentor(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 resMations and conditions are based on location of property and/or Water Resource Inventory Area or WRIA. WRIA: 15 Maximum Annual Average Gallons Per Day: 950 gallons Dated on this 2o' day of t-�r(h .20.LL. Signature e�of Grantor(s): (2) State of Washington ) County of Mason ) Page 1 of 2 I,the undersigned, a No Public for r the above na ed County and State,do hereby certify that on this ip_ry y of ,2l , ITYCY�Y'� � � f-) personally appeared before me,who is known to be signer of the above instrument, and acknowledged that he(she)(they)signed R. GIVEN under my hand and official seal the day an ar I t ebo el� n. EK Se'N 'NOTARY '; o Public in and fo the late of Washington, 23038426 i residing at h \6qq PUBUC My commission expires: ! 7 IDA Page 2 of 2