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HomeMy WebLinkAboutWAT2024-00215 - WAT Application - 5/9/2024 WAT - MASON COUNTY COMMUNITY SERVICES E ;�I "20NMENTAI. BWNIn4�WHSC mmm nhMesBM1 H �� 415 N Be Street,Bldg 8,Shelton WA 98584, EI he on:(360)427-9670 ext 400 0 Belfaiirr((36600) 455-446787 xt 400 0 Elms..(360)482-5269 ext 400 RECEIVED Application for Determination of Water Adequacy MAY -9 2024 Instructions 1. Complete Part 1. No determination can be made until Pan 1 is full m le .r \bl f1derS reet �2. Complete only the portion of Pan 2 applying to the type of water connection ti 3. Submit completed application,with any required attachments for review. 4. Ana roved buildingsite Ian must accompany this a lication. Part 1: Applicant/ Parcel Identification Name on Applicant: t15M4P_rll0 LY16 ^6AX13ate I" 8o8., S2- I dd r y�.II Mailing Address: 617- KL�.IQA )04 rl�AU1l)[.t4kr, llPhone: Parcel Number: 322-02 7,3- 0D010 Type of Water System Reason for Application 1 / (j ❑ Water System 2 or more 11 Building permit foli--Q c onne Public/Community Way connections) ❑ Division of land: X Individual water source(one connection), #of Parcels?_ SPL IK 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 PublicXommunify 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. ❑ 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 by state and local regulation. Signature of Water System Manager Date This form may be scanned and available for public view at••-•^•• ^^ masRevion wau Bs. J EH F.V Drinking Individual Water Well M Water well report(attached to application). Depth /5G _tt. @v Well capacity Test(attached to application) 9-0 opm -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 lest,which provides stabilization of draw-dawn 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 hlto//cis mason we us/olannino 14_15S 1S_22_ Water use or limitation recorded................................... N/A—Yes 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 gallonjpeday; and/orprovides water at a rate of 2 gallons per minute based on the following obsery 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: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reasons). Reviewer's Signatures: Environ. Hea@h: Date �p 2 of2 CSD Director: Date RECEIVED �J� � o20oL4"UO`✓� � MAY -9 2024 ENVIRONMENTAL pb r vwT �Fider Street HEALTH WATER WELL REPORT NPri«orl NP.WE M7 ECOLOGY uniau.&x uw.umT.3Na.B w Ty awA SbyofWmNn3mn SS.WdINmm(ifmomlhm—m l): ❑O Cm mum ❑n.am®m y q�ImmWamN01 NL Wym Ri�rc PmmdK'm1iE.am No Fn pOeUi.evq oNii.fl^ o 001himd P.WmlYowvrme s W.,St Addmm IM NE Ot4�la Rd Cws.eio.TFlr: DO.iw olsq f]CtYTw1 city AA Co:M' ••• O Naw wdl OAImY �� iAb OM.daomY Tex Paul No. +^"^'•-]SUW10 ❑n.mma aotm pimmy.m;0® amiSB u.m 153 n Wysvmimu epptw.d hctldaxlli ❑Ym �No pmtafmpYm.w.3 Im t 1fY•0.wM1uwv We Fa:iamm Port Cwtr..d�atlY: wo 0❑1 1I I0❑ D_iatri o.. 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TemP°h`°efwm 'F Wu.rBmlodmalnu WELL CONSFRUMON CFJUB lcAum- IumauctW.M1m eccePtmspmmiLiOtY Oxcwmictimtoflhiawe143M ib comPOavm wiN dl Weahin3loaw.0 con.au.Uaa 4edmd3.Rlamriala uuAmdtlm io[olmeo.nmWdedehove emavemmYbmtkRow'1.dge evdbJief _ .s Com Ar.adia Drib Im. �Orillm❑Tmm OW-P J' t . an Addr.s PO Bmc 1]W - -- Ci 3 Z 3hapan.WA0B384 _ Y' � Covtmcmr'e WTRAQMF .1amo..No. No.ARCAWIMK1 D.m IM 4 3 'a3i ECY0561-20(N. DWIS) (/Yritm.d Ods da.mn.yMano J^^^°Pn�'�a .hdimbl rycmicd3t81 d360�O1fi812. Pnmmwltl h,. ns(ovm wU711fo Wmhln3l.. loy Vanguard Laboratory LDdoa�-oos�� 2635 Patkmont Lane SW,Suite A Olympia WA 98502 v}„!gq(L}D 360-967-7010 1 _ COLIFORM BACTERIA ANALYSIS FORM - `�E C E I V E Oak Semple Cdbdetl Tme pk Cmnry 02/07/2024 eDdkd3 our MASON MAY -9 20211 Yom M Yr —•—EN Typadwakr Splwn(d"Q*Mbw) ^/. Alder Street ❑(1m A ❑G+ 13 MGM G"Aw Gmup B Sye -Pmkdeflan WaM Fgf Wmbrl'(WFI): up — _ �Nm OSMENIOVINORAY ENVIRONMENTAL Cab Paam:Arcedle DHIRW,Inc HEALTH Dry Fllmw(W )4263395 CNPhme:( ) Emai Ew. Sem rsuu¢a(Poor ew oars,emus em rq wd a emaal wicQ9d+duao.y.wm arob�. -ue'aanuiq wr SAMPLE INFORMATION Sange mlle]ed M(name).MAX SpwkbtatimwMre semyle mlleckC: SDmal bsburdons a mmmm6: 162 NE Dewatto Rd,Tahuya Counts Please �Typeol SamPk(sdeamM omryyeafsampkhan OPm 7 hmugh 5 beluw) 1.❑Rautlne DidHhWbn SemPk(AA') P.❑ Report SmnPk(NP) ()h A kd:Yes_No_ Ilmm htNlv�knaYewm lwruwl nMiral UnsakfaddyiauE'nekE laxlEer. Chbka Retiduel:Tolal_Free_ 3.GmunE W&W Role SoumlI Sam* UwbsWayrouMo.WGEeIw ' Chbrvlebd:Ym_No_ 07-99e (AP) Q�bnne Reeiaml:Topl_Fne_ ❑A Mmmt(Am) 4. Surfaceor OWl Raw Source Weteraemple(Enumwdm) I I I ❑E. ❑Feat 5.®amps Cdata brinmmman any Le usE ONLY DRINKING WATER RESULTS LAS.USE ONLY ❑UnsetiAk gTOW Cdi Pmsmt mE S,b q ❑Ea prmml ❑Ea .e t 8a flm NnftR Uft:Taal CcRom_ ioor I. E.ml nWml. Feral Cddo. /IOOmL HPC n d Repl¢emewtsngkRequww: ❑TNFC ❑Smp wm ❑ Swrpevdume ❑Dwo*Cavt*w ❑ Dwdrme : Releleru kr Beeld Temp C: LbeaE Cafe: Dem RpawOb DGH lab UU DaM i I%IH taebmpM I r 285- aa. 2210595 MASON CO WA ^ i3ME910 VINORgYfiA1P9]359 Fec Fee. $304 50 Pa9es 4 ENVIRONMEIINIITIAIILIIIIIilllllllllllllllllllllllllllllllllllllllllllllllllllIl1 HEALTH 't oo� Relum To RECEIVED OS iV12r\io Ili vlor� (m- le)' MAY - 9 2024 wcit,,,.� rkt' `fretR3 n15 W. Alder Street Grantor(s):(1) ©5yYlQ Nk� VIIV�rAt� (2) Grantee(s):(1)PUBLIC Legal Description(1) TR A OF SURVEY 3/6 S 2. -Fz 2/ 2✓ (Abbreviatedform:to.W bloclh platorsecgon,fow ship,range) Assessor's Tax Parcel: (1) 3 2 2 0 2 _ 7 5 _ 0 0 0 1 0 TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA) 1(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 State Senate Bill 6091 and Mason County Code 6.68. These restrictions 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 gallon, Dated on this a day of a y ,20-1 V. Signature of Gmntor(s): i (1) 60VK'A'� �. .� ,(2) State of Washington ) County of Mason ) Page 1 of 2 I,the undersigned, a o�PubliP�c�kn.wladgad fothe above na d County and State,do hereby certify that on this_ ay of 20 0°Z ppeared before me,who is known to be signer of the above instrument, a that he(she) (they) sign GIVEN under my hand and official seal the day and a'?las} bove aiM ............... �..a ublic nON d fort S e of Washin on, NOTARY 9u; ' residing at i 23038428 i = My commission expires: mom: PUBLIC WAS Page 2 of 2