HomeMy WebLinkAboutWAT2024-00209 - WAT Application - 5/1/2024 [WAT
MASON COUNTY
COMMUNITY SERVICES
Bul4linq PbnnF%Emmme l HwIth Cwnmunip WaM
415 N 6-Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 O Belfairr((60) 425-4467 ext 400 0 Flme:(360)482-5269 ext 400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Pall 1 is fully completed.
2. Complete only the portion of Pan 2 applying to the type of water connection utilized.
3. Submit completed application,widl any required attachments for review.
4. Ana roved buildingsite Ian must accom an this a lication.
Part 1: Applicant/ Parcel Identification
`-
Name on Applicant: • �1 1 . Y1 Date:
Mailing Address: O C- T hone: i(e A(o�• 0 0 b 3 _
Parcel Number. 4a po l 41q o yyl Shot,W A
Reason for Application
Type of Water System
Public/Community Water System (2 or more Building permit bi 1IDIZA-00415
•connections) ❑ Division of land:
X Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Springlsurface 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 PublWCommunity,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-parry)
❑ I am the manager of this water system.The water system has been approved for_services.
There are presently conneciion(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 mRasoon.WiI e
]:\EHFame\D-Av W"v
Individual Water Well
Water well report(attached to application). Depth I 1 1L� 1./����
Well capacity Test(attached to application)�pm!.SdL9pd.
The well driller often performs well capacity tests at the fine 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.
�L1 Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRI"A))),..�y
Development within which WRIA htto'//qis co mason wa us/olanning 14�' 15I=1661=22I1
Water use or limitation recorded................................... N/AQ Yes-4
tz�
WellDOW ............................................................... Date 3
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 me distribution system,guarantee an adequate supply of
water indefinitely in the future,or guarantee compliance with all applicable W DOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Time 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: 1 Date
CSD Director.
Date z of x
WATER WELL REPORT DEPARTMENT Or Noticeofl jigo. WEWM
TSPefworE ECOLOGY Unpuc&olagy WellmTeg No, BPF001
Stewof Wuhinglon
❑• G:ueadoR Sire Wdl N.(if..O one well)'.
❑a:omm®mp 061iwl in dao NO No. W@r Mghl PClmiVCe km Na,
pm LLu a W ❑mdmbivl ❑Mn."I
❑0. .,i g ❑lmmdm: ❑Ten Wea ❑Olkr Prcpedy O.,Name Hill MCIMMa
Cam:ma.Tp: Wdl Slreel AWd Wad lake Rd E rvew wall ❑AXemioo QDfi.OOdwn ❑lmud ❑CtlN TwI CiIY SMNmI CowtY A198ar1
❑0.ePwm8 ❑omm ❑am Only ❑Mmeomy Tex Pmcel No. 4200141-90M1
elmeulam: pimmkeafwd,8 iam 79 a.
DamafwmpkW well 79 a Wmav 'i eVp M Rn dda well? O Ym 19 N.
CwtaaWV Osuvr: wal Um.x tvee the ren.r w
Cednv Lir D'omenr Fmm T. Thietmu $my PVC w.aw TEm 1
W ❑ o in 0 74_ .028 io. Cl 1 ❑ a I ❑ LamGal(me inslneliWl9M
❑ ❑ n ❑ 1 ❑ ❑ ❑ WBe x): �WWM a❑EWM
❑ ❑ — _M, ❑ 1 ❑ ❑ ❑ NE Y,11..of Me SE Y.:Salion 1 Tomnkip 2(IN Range BW
❑ ❑ _ n. ❑ I ❑ 1 Utin (&mplo:dT.1x3/5)47.289898
h.mntlom: ❑vmin ET ONo Typeefperf or:ntl L.Dgiede(Example:.120.12US) .123.120819
Na.ofp:fondone_ Svc ofpm4uuom_in by_m Dr91m'a Log/Cooalnelion or Deeommimloo Proredum
Pa4rYtl 6om_Aro_ftbelawpo:ud eurfim Fumarion:Drunk by calm,chenner,sve ofmomnel end IIIW.,and:k kits UJ
nve alWe mamJ m mah hyv Percea:ed wiN a 6u arc wmy fmwch cbopo!
Seweu: ®Ym ❑No pK-Frio O prPlh T3 6 inm:®tiara. Dm adiilnnlaheen:fnmem:y.
Mmufe.:uu'r N. Abv Malidlm Worts
Tvsa BMInlessSMtled Mold No. Mmenil Ran To
Dumear s_ slmr&.020 aeon 74 e,m 79 e. Brown MI NMand 'Rocohdea 0 8
Umwur_ s&.®_kSam _Lm_e. &o5wl SNNsandaM raWw.I M g 14
snemum.pek❑Te. ®Na simofp.ek merul_io. Multi toed ravel,b mMlan"M,loo,e 14 38
Me:eneb 0.Ee _d n_a MJlicalorad ravel,d0wDmedkgnsaM, 3g
Surfvm Srwl: OYv ON. T0Nm 6ghR le A M�¢'WPt 52
Mu Wwdinmai Mulfiwlored ravel,Crown medllml sand, 82
OJ my.......omm`blew.raR ❑Yv CK. I...water 72
TId .ufl Dmmormw Black medium saW eM ravel,water 72 78
Molkdofmmlinera.aod Muft d revM proem----mend weIT 78 79
PvmP: Mm::fiaNrtr'.Nme Ty .
H.i_ TmPimWedeNh:_fl DuiPad Ba•r:rM:_v:m ".
%W,Lnele Lvo' -u ,l......vbown _kur1 250 a.
Slkkup of:Po ofwrllauing 1_5 fl..bow lPou'd eur&e
slni.wuu level 2I n.klow apofw<O cuiq pus lflB/23
Mmim Puewe_&.puWw irch peu
Muin wemeemmlW by (up,nlw,uv.)
WeUTmu:
Wu.p,:gi .Pv&m.y)0No ❑Ym O bywbnR "'
Yield_gpm wi:h_ftdmwdawo.em M,
Yield_Spo wiW_ft.dnw6�wn.hr_l:n
ywd_®:owiW_k 6.wtlown.ex_hn
gmo.mr a.a(dmr-wm wl:m w:m E nnnw art-wmminW muwM som.ell
Tinu W.w4wl Te:rc W.l<wl 'Iti:w W.mr level
i 0.m nfpumpiryku
a.ilmmn mm wim e.emwmwn.ar._m,.l
M:.0 25 gpnwiw.sema5u 80 e.& 1 y:. JF o.m Kl&23
Mmwo �gm
Twgnewofwnw 09 •F wm.Pkmiul.mlyri mdrT ❑vm MNa 91vt DMe e2(i123 CompldMDale al wm '..
WELLCONSERUMONCERTIFICATION: Icmalmded.nW.emepl,.,.Ililityfofcanst ctionofNisvell,andieaenplMnmwithellWwhiWMwell
wndludion smNeda.MelenW usd end tlm inflama5ion rep:mN nbave ere oue to my beR knowledge and belief.
JB Dnikr❑Tmime❑PE-Riot Nwe Josh Kp Trilling C. Arcadia Wiling Ink
sigrAwre Md.PO Box 1790
Limse El 2874 City,Smle,Zia SMRan WA 9B58/
IF TRAMEE:Saaaar's Laa¢e Ka vac Commclois
Sponsa's s,mmre Regidm5ion No.ARCADDI09gK1 pde 4x8123
ECY05 1.20(Revp9/I8) UJmuneed rhls dorwnem man alama5e/amnApleaae mll Me Wamr Rem:nem Progrom ar 3d0I0Id8)2.
Perwv wiSAManrg boa mn roll Alfor Washlrlgron Relay Benin. Persons With a xpmch dWaellilyc W118II4334341.
1786 SE Mlle HlU Driv¢
Pat Orebard,WA 96366
8P6CTBA Lnboratoriae-Pi'my Www.epectrsleb.¢om
(360)443-7845
COLIFORM BACTERIA ANALYSIS FORM
Dam Sampb Glecbtl iMa Senpb Cant'
4 ) rr ) 23 Galatea
° iD
om Mason
ma
Typ dwaNrSWkm fineamryane Bm9
❑G pA ❑GWB ❑i Gdmr
Gm AandG PBSyalvia-RdAOenom Wa FxIiAealnvenlvy(WFIf:
EY — _ _ — _ —
Sybn Wma:Bill Math ig
Canmd Parton:Arleta EIWWArcadle Drilling
Day Pdme:]adsSa3BBa CtlI Pnom: —.
Emen: erlabQ$arcaaladdllin.00m Ela Pdda:
a g . b: Llnme,ademud4pm4mewq
.rlw@.rcadlabadnle9.eam
Arcadia Orleft,Inu
SAMPLE WFORMATION
Bmrya D7MtlN6y(nme):Ataz
Spetllc batim wfiwvnPle mYeawa: Sptla NeTa/onevmnmagn:
aBPFaea
bbrW LaMa Road,BMIbn
TYDa of amps(Aed a^ly'ela ppr)
1.❑Raba lAnmbuam Saryb 2RepmlSmak lMvunsYmubel
ChMn Ya❑ WO 13Gmeauam Synmm
CNadneR "ToW_Fre¢_ Lblabbr&rymllNe NE ninber.
3.8ame Gmmd Wa Rubii.&
5 Luantlela+m rouBa wbd da:
O TdgwW CNainaed:Yes❑ No❑
❑Am .t CWA.RmWM:TnNI_Fr®-
1.Fnwnnlmsauuwaramge
❑Ea $❑Fed.a.0 am,yxl�Fa..r r_❑ wQ
5.❑snde cdsr¢a for Nlom,donady
LAD USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Umaoshmory idol Cdilmm Prea,Mad
❑E[ap Pie++ml ❑E"&a
Rapbcemam aanpin Rqulrea:
❑Sanp4fooda(>aOlwun) ❑T= ❑
Bs81Y DwWyfleellt:TOYICOYdm__/IOOmI.EW tlD
Feral Calbm 1 dgyd, RPC n W.
IaE loN. l [ PremilneP Md
APR2880 2 5 �{S
1bPotl wa WihuAWEeaa
SM 9PP3 B 9
IffiA � L oarn"°°jra hcllZ3
ooNuesa ma LY My
2 plE�1-
2210269 MASON CO WA
p IZ2034 0994] AH NOTCE
nATH01G r'9,096 Aec Fu f304 50 Aaga 2
Re mTo IIIIINIIIIIIIIII�IIIIIIIIVIIIIII��l[Jill
111111111111111l11 Jill 01
i1�1o.VNl 1
N iha I h r WA J6584
Grantor(s):(1)�'1 ��ILrYYL mn �{1r1)Y� (2)
Grantee(s): (1) PUBLIC
f-i .kk..� .Ir. 21a a. � �1�' I
Le at Description (1)'vi L i I��`r'�� a �n e (yr� nr )
(-9L)- 4 (Abbreviated form:i.e.lot block,plat or section, township,range)
Assessor's Tax Parcel; (1)�����-�
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(MIA)
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 water use restrictions and
conditions set by Washington Stale Senate Bill 6091 and Mason County Code 6.68. These
restrictions and cendltions are based on location of property and/or Water Resource
Inventory Ar�eaa or WRIA.
WRIA:�1 ._ /��
Maximum Annual Average Gallons Per Day: q'5 .^gallons
Dated on this I day of Ma4 20,LLL.
Signature of Gremor(s):
State of Washington )
County of Mason )
Page 1 of 2
I, the undersigned, a Nptary Public' nd for the above na County and State, do hereby
certify at on this dayof 0. 20
perlonally appeared before me,who is known to be
signer of the above instrume t, and acknowledged t (she)(th 'gned it.
GIVEN under my hand and official seal the day a d as ast a4 ve� n.
tl."IIYYp
�pr.•�siori ¢'
osoNOTARy 4"1 �' otary Pub c i for� State of Washington,
to 23038428 i ! residing at
`•� PUB�t0 My commission expires: O 6 a
41YIIIM,IMM",
Page 2 of 2