HomeMy WebLinkAboutWAT2024-00322 - WAT Application - 10/8/2024 MASON COUNTY
COMM[JNITY DEVELOPMENT
Pm:rnsusnnce remer.Suildnii,PmmIr
415 N r Street.Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 wd 400 a Belfei�(60) 75.7767 xt 400 d Elm:(360)4825269 ext 400
Application for Determination of Water Adequacy
Instructions
s fully completed.
�1. Complete Part 1. No deteaination can be made until Part 1 i
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 ap2licallon.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Bill Fisher Date:
Mailing Address: Phone: 4064904089
Parcel Number: 322237700130
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more O Building permit
connections) ❑ Division of land:
p Individual water source(one connection), #of Pamels? SPL
O Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain) ❑ Replacement or Remodel(please indicate name
If you have more than orte residence connected of water
re required)�em low d applicable—no
signature to this well, check the PubliclCommunfty Water 9
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Fam
ter System:
y Inventory(WFI)Number.
one"for two-party)
manager of this water system.The water system has been approved for_services.
re presently connection(s)in use.This will be the connection.
manager of this system.This connection will be to upgrade or change the use of an existingion 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.a r.IWnols
/:\E}I F.\Braking water
Individual Water Well
Water well report(attached to application). Depth
,,( t1 opm�pd-
1`� Well capacity Test(attached to application)
"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
1 by a licensed contractor.
Satisfactory bacteriological test(attach to application).
T Water Resource Inventory Area (WRIA)
Development within which WRIA h�s co mason wa us/olanning 14E3 I5016022=
Water use or limitation recorded................................... N/Aj=l_Yeses
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 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)
1,1 atisfactory Determination: guarantee an adequate supply of
7Recommended
his determination does not address adequacy of the tlistdbution system,9 ulabona
ater indefinitely in the future,or guarantee wmpliance with all apPlicahla W DOE water resource rag
approval indicates requirements of Sanitary Code,The 6,Chapter 6.68.040-Determination of
dequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
6.70A RCW.
nsatisfactory Determination:
pplicant's water supply does not appear adequate to meet the needs of its intended use for the followingason(s).
�Reeviieewees Signatures:
Environ. Health:
n NV by Date (d Vz-'
z orz
CSD Director: Date
CURRENT WE55445
WATER WELL REPORT a uN NotlDeotlntesNo.
Orielaal&I'nPY-LmIas,T"fepy-ease, BPC 842
• ^^^ "` Unique Ecolo Well ID Tag No.�---
ConStruction/Decommission(':x in circle) Water Right Permit No.
QConstmetjon W i1Eam Fisher
❑ Decommission ORIGINAL INSTALLATION Notice property Owner Name
afintent Number Well Street Address 361 No Saumfldge DR
PROPOSED USE Domestic Lidmnial Munklpal Cjty Delta, Colmty Mmo—
Iim hen TN W[II Olxer 22 3. EWM ❑Mk
❑SEDD.W.S ❑ m Loo+fion aa° 1/4-1/4 m 1/4 Sec 33 Two n R_ w
WWM ❑°ae
TYPE OF WORK: Owsr'a numaer of well of mon man oral
®New wal ❑RecondnioneE Mmaed'❑Cehle ®Boma ❑D are Lat/Long(s,t,r Let Deg 17374716 Let Min/Sec
❑Deepeneed O Sfill REQUIRED) Long Deg -123 Long Min/Sec 025462
DNIENSION6e reame.of wdl6 inexa defined 477 R
Dcpdofmay,dnoJ tilld]7 R Tax Parcel No.32237700130
CONSTRUCTION DETAILS
Cmbg mwcwod 6-- Dia lyab+ls R.w477 R CONSTRUCTION OR DECOMMISSION PROCED[IRE
Imtalled: BLinnimbdbW Dian Gom�ftm R amldmbMand
Thmded ' Diem from Femabon: pcecnle by solar.chaacw.aba of mamas and slnu:mrc,
Perbntiom: Y. No monefflicemodaine.bsmmmpSH,,T.aim alma NECESSARY.
fore.M1 cAmgc of
TY ."o-enmrmwl inform•limm USEADDITIONAL SHEETS IF NECESSA FR M TO
in.bY�in.and no.of perh_fmm�fl.m_n. MAT[TtNL 0 22
SIZE of pare_. Brown.silt,some praml
Sereem: Yea ON. K-Pac Location 22 30
Menufuwrcr's Name BnamNbneamed
vo J0 82
TYPc Madcl Ne. a OnnRWrown,sand and ptasl a2 85 i
St.sir ftem a'al d. Brown,.wosaamd
Duna ti. _ Own R,m g5 147
Dives' Slates Brownish-R¢Y pavd
GnveVniterpseed; Yea No ❑Simofpnv[V.ed Itl I51
Memnab pled Ovm g,to Comae sand/sill I51 175
6. Gnvel
+errue Snl:Q✓Ym ❑NO To whe:dcgM1?18 Grey.daybmund Rlavel 115 178
182
'annid med in seal mmems em Ve 219
Ym ON. Brown,1 xmljo pl 92 219
Did any nraucwub.usable weer? ❑ 0 YSilt mad Rmvel I19
Typeaf want. Dcgx mfanu 2 262
Mamma oM1mline suau[n OnnRnFMan,silty Pavel 26262 275
Be.,amid,fine 275 333
PUMP: Maw6murcr's Noma H.P. Taa.°illy Rnvel
Typo: 373 355
6. Ca.y"OLsome Rnvd 355 370
WATER LEYLiS: hma-wamcc devnion above mean sn level •alit -1
Sufic level W B.below sW ofwell eae]QBf(4—_ Oba 394 396
sme
gnesiw prtuwe
Ds.per s4uaa imx Dale Gray.sand,Ran.some add
el 394 396
grurian wee,is manned by Grev.cbvbound send end Breve 396 602
aabe.era. Gney.saM.coarse
402 40
WELL TESTS: Onwtlewn is amm:nl ease level la lowered baba smeic level Browv,amid.rim.SWin 407 454
Wu a pump bee made?❑Yee ❑NP IfYm,by whom? Grey,sand and penal Fine 456
n.mawaewn slier hrs. 454
Yiel& ®VslUm wim n.dawdown aa[r__nrs. Grey,clay 456 465
YWa: mumin.wah o aAwmwe am+ xer. gdhrowm,Fine send and ma•el 5 Rpm
Yiidd. +allma.aim 465 467
+emrtry dam pima rdsn a¢emn'Mn4emP tamed of/I Pemrre level meoabij mroll Om,sill 477
mp.—n/anll wau,Lcvcl Redlbrown fit.
Time Water L send and Rnsl,10 Rpm 467
Level Time Waniilu-I Ti—
Dam of ma Job 9
Bailer.1 'Id.a.wim Ranwdewn aaer__Im.
Ai.110 sallmin.with seer t m470 nfor—brl'
Am.inn Bow .m. DYc
Tmipmxlurcofwmm_.Wm a cxemid uWYaia made? ❑Ytt ❑No Cpnftmbd Dab JI20124
Sbd Dale 3I1A124
WELL CONSTRUCTION CERTIFICATION: I cunetcomod and/or accept responsibility for consfmction of This well.and its wmpliance with all
Washington well cUCTIOiaD era^lard+. Ma�erials usW and the or reported above+ce tme to my best knowledge and lachtf.
cmb Heron DollingcmilanY Tecmna Pam &Drilling Co.Inc.
❑Drills n Em .r 0 Tie Name7Pdy _ l Addeas N
30316 Mvuuv Hi
DnllerlEngiseAfrtins Sigsrme ' Ciry, ZiP Gnham,W A 98338 �2�
Driller or Hein.Li...No. ,an
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VTRAWEE ";aodion No.TACOMPD203PFDa`
OnDer'e Li;;a"Ne. Ewlo°':s weFgml I]pponumiry Employer.DrilDi a Sbmam- -
ECY 050-1-20IBea 3N5l The Department of Ecology does NOT E48rtaOtY the Data andlw IrlformahoD on this Well RepoA.
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