HomeMy WebLinkAboutWAT2024-00165 - WAT Application - 3/28/2024 WAT2614 - 66111
MASON COUNTY
COMMUNITY DEVELOPMENT
PermftA slime renttr,Mdlm,PlannIM
415 N 0"Street, Bldg 8,Shelton WA 98584,
Shelton: (360)427-9670 ext 400 O Beltair.(360)276-4467 ext 400 A Elena:(360)482-5269 em 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 aeproved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: )j/M Delew Date:
Mailing Address: Z429 Sc1i/i7 /.0 /?o/NPhone: ,kaQ -Z.Sb - Z&4,0
Parcel Number: ,3202z/- 7- - 90U,y
Type of Water System Reason for Application '1
Public/Community Water System (2 or more 0Building permit �iGi�b -W'TN
connections) ❑ Division of land:
❑ Individual water source(one connection), It of Parcels? SPL
❑ 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. / � 00Z_ 7
Part 2: Water Connection Information 00 co"" v t ^^ O
Complete the section appropriate for the type of water connection being evaluated: p11tr `�'otict,'L7.-g0�
Public Water System a�
Name of Water System: ei- GcJ ,f,1L�` 1Ujri
Water Facility Inventory(WFI) Number ' / Cn fc
(write"none'for two-party)
aLS
❑ 1 am the manager of this water system. The water system has been approved for 8 services.
There are presently -7 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 (Le.: 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)connections)without exceeding
the limits of the water system or any limits set by state and local regulation.
Signature of Water System Manager Date 3'ZQ'25l
This form may be scanned and available for public view at www.co.mason wam .
J'.TH Fans\DnW=g Wuer Revised 1/252018
w1 Individual Water Well
p Water well report(attached to application). Depth 7
` y ft.
Well capacity Test(attached to application) 7� gpm 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 (WRIA)
Development within which WRIA hftp://Qis.co.mason.wa.us/planning 11�aa{vl �15 18022�
Water use or limitation recorded................................... N/A IT I 1�-1 Pees I-1
Well Drilled ............................................................... Date—ti�
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)
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 6.68.040-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
reason(s).
Reviewer's Signatures: h �t
Environ. Health: �� Date Ut I (� I I�L I
CSD Director: Date zvfz
NO.
FILE:SECOND CST COPY-RTHoD ECOLOGY WATER WELL REPORT STARTCAELLID oa66 j
SECOND COPY-OWNER THIRD COPY-DRILLER STALE aF WASHPIGTrM1 IGIHT PERMIT lD ALNB3a
/� I/ WATER RIGHT PERMIT NO.
(1)OWNER NNAE MDELANEY I Iv l ADDRESS: P.O.WX2M35ELTONWAmw
(2)LOCATION OF WELL: Curdy MASON NW 1/4 NW 114 SEC 26 TWP 24M R SW
(2a1 SR1EETADDRFSS OF WELL for reaw[atldrex): XX%AGATE AD., PA nir32a oossW
(3)PROPOSED USE GRDUP-e 1 t1W WELL LOG OR DECDMAISSIOMNG PROCEDURE DESCRIPTION
(4)TYPE OFWORK NEWWELL I
tlff"MOO: ROTMY
MATERIAL FROM I TO
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Type H.P.
(B)wATEa LEVELS. surface Nev maw m®nsw level M1l-.._
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ye,n ww.Rm �
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and/OERTIFICATION:
rau amm.. m rts.mnmw nwI this
at Corplianc rash ell Was for inton Wmction of
Recovav�. 1 Standards.
wall, its compliance with all WasbVgton well e0I131l11dlon
Time WV LM. Txne WtrLvl. Time Wtr LN. l abweMa to
beetlarnd theWledge and belifepMed
1 above are true to Ivry best knowletlge and belief.
jNana: WCHARD ON WELL ORIWII IYINC.
Daledmel: Igd169: P. BDJ 7TAM ._
Bela wet elul. rtOv.ramaw I
A male 46aeWnina e mmsal fifiR tor1 wel(SiBred) Lk No. 3623
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Tenpeeerte 0 water Weedreniclaneysxmetle? NO lCanaedons Reperalian No.WCHAW321M DATE SM6106
Thurston County Environmental Health
412 UNY Rd HE®Olympia,WA 98SOG
3W 867-2632
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