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HomeMy WebLinkAboutWAT2024-00247 - WAT Application - 5/30/2024 MASON COUNTY WAT COMMUNITY DEVELOPMENT Mnmll AsslsGrce Quin.gugEing Manning N M ENTAL 415 N 6-Sireat Bldg 8,Shei[an WA 985 M, `�L-"ton:(360)427-9670 ext 400 O Beller(360)275. 467 ex1400 O EInia:(360�' D 1 1 1 FAx(360)427-7787 Application for Determination of Water Adequac)OAY 3 0 2024 Instructions 615 W. AlderStrep 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: Applicantl Parcel Identification T Name on Applicant G� N�4+c5 �+IL Date: Mailing Address: 23Q1�q( (QS1�1 L&d Q AAA)Phone: ��QOt790`31g� Parcel Number: tjoU 11 -1-1i ov) Type of Water System Reason for Application Q ElPublic/Community Water System (2 or more �Buildingpermit L3LVgoaY-onto&6 connections) ❑ Division of land: Individual water source(one connection), #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 Public/Community 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) ❑ I 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. ❑ 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 www.co.mason.wa.us. J LH Fnnns,Drinking water Rg,v a Ifa52018 r - Individual Watery Well Water well report(attached to application). Depth Well capacity Test(attached to application) gpm � WC lgpd- 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 drew-down and recovery data, must be performed by a licensed contractor. Satisfactory bacteriological test(attach to application). �,f„ Water Resource Inventory Area (W A) � r " /% {7 Developme is.co.m m 1 Water use or limits' rded................................... NIA riled ............................................................... Date Individual SpringlSurface 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;andfor 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) --YSatisfactory 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 Pernits 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: Ir7 l Environ. Health: y '�— Date CSD Director. Date 2 of2 WATER WELL REPORT DEPARTMENT Of Noticedlatent No. WE55980 ECOLOGY Unique F,,I Well D,Tag No. BPD945 Typc of Work State of Wazhlope. ❑I Cmuoucdan Site Well Neme(ifmom then one xell): ❑ D—nunummoo uroom iauallnuon NO]No. Water Right PermiNCariBak No. Prapwel we: aOD-1., ❑IMmrul ❑Moo.io property Owns Name ANDY GRDHN HOMES INC. /DeMl3 Severs ❑Dewemmg ❑Irriprion ❑Ten Wd1 ❑Other Well Btrea Address 97 SE ELLIS ROAD 9 New 11 Typ<: Mom' City SHELTON County MASON a New well ❑0floo n ❑Dal ❑Tmm ❑Cobb Tad ❑Deepening ❑Odws ❑Dug D Air ❑Mad9tomy Tex Parcel No, 319041490030 Dlmemiom: Dlmcterofboring n m. mBt n. Waevaimtce approved fo thu Wsll] OYa ❑No Depthofmmplekdwell 7r B. Comnved"Desalts: Wall Ify whetwuthevRnandoW Caring Lkm Di., From I. T iolmeu Smd PVC Wtltlel 'Need R 1 ❑ 6 in r2 T2_ 114 m 00 ❑ ❑I I ❑ Location(se,instruction on page 2): ❑WWNI or0RI ❑ ❑ —in. ❑ ❑ ❑ ❑ SE LA-Kofthe NE Y,;Saboa 4 TowwhiP 19N Range 3W ❑ ❑ _io, _in ❑ ❑ ❑ ❑❑ ❑ in. ❑ 1 ❑ ❑ 1 ❑ Latimdc(Fxemple:l].12345) 4]16534 1 Longitude(EkmnPle:-120.12345) 12305878 Perfcs6aa: ❑Yes @No Typeofperfo.aaad Drifter's Log/Comtructiao or Decommission Procedure No.ofpfwaoom_ Sam ofperfanliom—m by—me. FOnagee Dwiba by cob,,Gme b,sin ofwreivlreed mncnae,ant the kind lod Performed fiom_B.tn_R.below,gouts anb:e move athe meWial in ach ld v em000x,win m Net om entry(mach duoge Of Sareem: @Yea ❑No 9K-Pcka ' Depla 71_1 adbrmNm. U.additional them ifineeasary. Menafm Nara Allied Machine Woda MRarIN I. TO Type SSTde Model Nu In.5 is Sim tin 14 iv Rom 7V ftro 71' R GRAVEL,SAND,CLAY (BRN) 0 4 Duemac,_ i Slmaue to Rmn_flro R. GRAVEL BAND,CLAY (BRN) 4 23 S.mmaur p.da❑Yen ©No Simoflwck metmel_k. SAND,GRAVEL CLAY BRN 23 38 _a GRAVEL,SAND AND CLAY BRN 36 63 MercmaN pla Ra ced m n.m— GRAVEL AND SAND WE BRN 63 78 smr—ikal: RYm ON. Towhmaepx? lB R. CLAY WISAND AND OCC GRAVEL (BRN) 78 mantrde ed m caI 3'B AIO Balknhe Didcyammemamuaomblewem!/ OYe RNO NO WATER Typeaf—ax? Depnef. Metlndofteefn,tnataoR Pamp: Mmuficnaer'a Name Type: H.P.— FLmp ulake depn:_n Reigo idow nra:_gpaa Water Lerela: Lend-eurnwo elevmim vbw,mem ea Yw1_a. SBek-up ofe,ofw'du uvng_ &above gmiod onax, Son,waaled37_-11- n,below top ofwell acing Dove 4I4=24 ArkaunpWnae_Iba.paau n—IN Om Anaa--anaecmviletby (aNvdw,ero.) Wag Too: Were apwopingtesl perhmW4 ON. ❑Yes b bywbm1 Yield_gpn win_R dtmtlown stem_Ma Yield_gp wid_n dnwtlown Ner_hn Ykld—mmwin_R dnwdom eder_hn. Raavmy den(thus-zmv who Pt�u mmetl od-wamr kd marmad nom well mp wIm IeM) Too Wma Level Yee Wmerlewl Titm WeN level Den ofptmrywg WI Beilmn No .wlb _A.dnwdo& anm_n,. Ano SB gpm with mem smm BT fl.fort M. , pens H4T1024 Tea,on Sow—gpm J Tevryenmrt ofwmm—°p wuechemicalamiyeismetle9 OYm ❑No Start Daze AL4.12024 COmplefM Dak 4/4l2024 WELL CONSTRUCTION CERTIFICATION: I wnstruc[ed a We,accept rtsponsibildy For connotation ofthis well,and de compliance with all Washington well constn etioo smrdards.Materials used and the of Lion reported above art ho,to no,bat ImowdiAp and belief R Dnfla❑Tminee❑PE—Pont Name DANIEL CARPENTER Drilling Comparry American Pump&Drilling g wt 4. x{.1r.. PJ Address PO Box 149N License No.2236 f Cry sta,zip Torrents,WA M511 IF TRAINEE Somorx L'ceae No Cannella," Spo si m Registration No.AMERIPD781 dK Date ECY 05D-1-20(Res OWL 9)If,.need ebu docmnenNn on allemateformm,Please calf de Water ReavoI Prorram at 36a 407-M72. Pnsom wirF heating lam mn mil]lljw Wwh'rgsm Relay Servin. Pn.v ihaspachdimbd o.m8877d33-6341. Vanguard Laboratory 2635 Parlmlom Lane SW Olympia,WA 98502 360.967.7010 VA1dGUAR]D Report of Laboratory Analysis LABORATORY Collected by: American Pump and Drilling Matris Drinking Water 360�754-7867 Laboratory ID:V24040" Sampling Address: Date Sampled:4=!4 15:00 91 Southeast Ellis Rd Date Received:4/B24 17:07 Shelton,WA 99584 Date Reported:411 MON Sample ID: Dennis Sellers Analysis Result SDRL MCL Units DP Date Analyzed Total Critter.&E.coli by SM 9223B(IDEXX) Batch IDN24040" Analyst:VJ Coliform,Total Negative 1 1 MPN/IUO mL 1 4/8I241910 E coli Negmive 1 1 MPNAW out, 1 4W419:10 Nitrate by EPA Method 3531 Batch ID:V240 OM Anobv RS Nitrate(as N) NO 050 10.00 mg/L I 4/10Q41100 Notes: MPN:Most Probable Number ppm:pans per million on nooleten Reviewed by Rohm Scanning,Cbemiston N/M024 Na:notapplicable SDRL:Stele Detection palmetto Limit Approved by Tort Johnson,Operations Manager on 04/1 M024 DF:Dilution Favor nMa6l7 MC!,:M rnum Coro —I i<uel Page 1 of I Samplemmemcerodinecaptvblecordinus, creadpa)suit repot relate oNym the portion ofthe sample(s)tested Allmwyxs were performed romisunt with the Quality Assurance program of VangurE laboratory.Please conduct the laboratory ifyou should have wry ques essabom in,results. 2635 Parlwont Ln SW,Suite A,Olympia WA 985021 Office:360.967,70101 testing@vanguardlabotalory.com I w .vangnerdlabommry.emn