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Home My WebLink AboutWAT2024-0316 - WAT Application - 9/4/2024 WAT Lo _- 0o31fo 415 N.0 Street MASON COUNTY WA 98584 COMMUNITY SERVICES R cltf A 07,Ext.40 e -2 ,Ext.400 Id,Pe. ,g.e,wea,,,n.m.i x..hk EI 360482-5269,Ext.400 SEP �4 2024 Application for Determination of Water AMVIACINar Street 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 approved building site plan must accompany this application. Part 1: Applicantl Parcel Identification Name on Applicant:, SP.t7Y'rF!''/nifr,r 5.....,.„E„ Date: Mailing Address: / Phone: ?G0 -401-17&_ Parcel Number: y2/),E 61 Na0 O O Type of Water System Reason for Application ❑ Public/Community Water System (2 or more CPL Building permit IbL0107L9 ' 01015 connections) ❑ Division of land: Individual water source(one connection), #of Parcels? SPL kr Well ❑ Boundary line adjustment ❑ Spring/surface water lain❑ Other ex ❑ Other(explain) (explain) ) ❑ Replacement or Remodel(please indicate name ff 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. 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) ❑ 1 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. I TH Fans\Drinking Water Revised 4/4/2018 Individual Water Well Water well report (attached to application). Depth/� ft_ ' . Well capacity Test(attached to application) T 6 gPm 7 Cc pd. 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 htty�l/ais.m.mason.wa.us/olanning 14_ 15_ 16Y 22_ Water use or limitation recorded................................... N/AV Yes_ WellDrilled ............................................................... Date 7 Z3 Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection ❑ I 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. F 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: Date This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 WATER WELL REPORT =DEPARTMENT OF Ndiceoflmenr No. WE50333 ECOLOGY Unpm Ecology WelllI)TN8N0 6PF099 Ty,fWnrk: State of Washington ❑a Cmmv .. Site Well Nam,(ifmom than we well). ❑ Demnmdmiom o Or®d immll.gm N01 No. Weather Right PemliUCatificme No Trammed the M Damage ❑immmial ❑shoed i Property Owner Name Scolt Sam ploo ❑Downturn, ❑xnptbs ❑Tm Wa ❑Omer Well Street Address 14651 N NphWav 101 *ew,-11 Type: Meldne O New,well ❑AMmm ❑Uieo ❑lasso ❑cmle Tod Ciry BfleltM Coumy Mason ❑Dmmed:M ❑Omer O Dug U Air- ❑Mad-xmmY Tax Parcel No. 42126-24-00060 D �nation: Oimamofbwq 6 M,m SO R. Wasaummnce a,mwd for this well? Q Yes O No Deghorco�ired—H 80 a. Carmmetb Deus: cons If"what was The w:mew can, Limn Trouser F. To Tbklmem Sr wewrua Tula IH 10 a M 0 Is .025 in 0 1 ❑ a 10 Lmeduat(s«hotmcaoeempegcz) cl w or❑EWM ❑ 1 ❑ in. n. ❑ 1 ❑ ❑ ❑ SE %&ofte NW %;Sd ins 36 Township 21N Range 4W ❑ 1 ❑ _in — — —ins (II ❑ ❑ I ❑ ❑ 1 ❑ w. — n ❑ 1 ❑ ❑ 1 ❑ Latitude(F.xenlple.47.12345) 47282976N Longoode(Esemple:- 20.12345) -123.159133 W pantomimist ❑You 01 No Type otpmform:med Driller'slag/Constme400 or Deeomm .Pomough e Nm.mfperfudom_ Simofpm6mmer_mby_ Formation:Dexdbe by Pobr.clu,ctn,eau efinemrildmumaa,mdtb YitlmO emLmed mans Lm_at.Mw andnmaee m<onxe mans:iah in emnl.Ym menehaNd.wvnml.m meemybulmlmep or Sermm: KY. ❑per O K-Pm#m b Depth 74 L e%:mniem ux.ddiaaml blue ir:sa..my Mmufactme:a Name A loy Mach"Wmb Material Form To Type Wlre Wrapped Madel Ne. Terror 5_ Slmeim.ata ufiom 75 &WED 6. RTpWT1511e lO Rlgdillrll sandy IaVC,811DpIx1, D 19 Dimame Sid ea_ubom _Lm a. M.dry s.m/Faterwm❑Ym BNo sisorpalmmil_ie Brooms The to medium salts revel, ,wet 19 31 Sauniolapleud Rmm_0.W SL &own fide sandyravel,ti M,sRbound,0 31 43 Surmuu suss: M Y<. ❑No Towlvdel 19 A Multiwloletl ravel br ie rie to Ireawm sera,loose, 43 coal 51 M.,. send ssd in eml B2r110nMe Chips Di seoeonurnminunmebkwneo ❑Yee CM Multicolored medium to coarse mand,gravel, 51 TYpemfweml: Deghted. warted, 72 MelF,tlafxelmgamNaR Multicolored comae sand,gravel to cobbles, 72 wakr 80 Pomp: Menuffichareir Type: Hp.— H.P. wwp webhgx:_g. OmyNtbw me:_gpm WaWlamelm WW-emfexelmes"I"samummalerel 281 L foick-upofmp ofwell using 1J b.ebm pdrM wbm smliewmmle-I 17 IT belmwmpmfwellcnmM Dm W123 Anmwn peenrve_Ibe.p+gha:e inch Due_ Amin wmer a cuwllal by (up,vane,ate) Well Team: WuePun'pi^a xm Perm^mud? NNo ❑Yet bywh ? Yield_gym was_R.dnwMwn aht_has Youl_mac was n.tlnrvtlorvn.Mr_br Yield_term with_IF slowdown eeee_No Rawery"a Vino-um when pump u tamed off-wap Not momuW lion mail mpmwnakwD rime wan level Tama w.mLew rma wNmlax D.m mfPmwingw pi mad_gpmwiW_R,dnwdown<la_hn aria 40 gym«ins mmmu 75 R.lint Na. Due, 3/723 Manor Row,_gym Tinummeeof. 51 •F Wn•Tuncelueltni more? ❑Yes VINO Start Date 12.123 Completed Dare §a/ 3 WELL CONSTRUCr1ON CERTIFICATION: 1 cwmructed MWw accept respmsibilay far constiuctim ofmis well,eM its mmplmrce with all WMhingkn well mlmmclion smrder is.Winds used and the info rramon repeated above are Ime to my best knowledge and belief O Driller❑Thimmee❑PE-Print N Dipply PhytNan Drilling Co nReny Amadia Ddlling Inc. S'gmture / Address PO Box 17N License No 2053 / Ciry,Some Zip Shelton,WA 98584 IF TRAINEE'Spe ma's Liuxse No Conhmlor'S Sponsor',S'gmhne Registration No.ARCADD1096K/ Date W123 ECY0561-20(Rev09/18) yymm medfhis daumem in an alrcmale/wnmr.pl<ax mllrM Water Remurrer Prog:mm ar 360d0)fi87I. Persona Wih Among loss can wit 711jer Washington May Service P<rmmwithanyeechd.b,litycanrn11877433-634/. ' .'ILY environmental Health 412 Lilly Rtl NE•Olympia,WA 88306 T�oxw¢ 360867-2631I. 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