HomeMy WebLinkAboutWAT2024-00352 - WAT Application - 12/2/2024 WAT.-g?a4 -_0Q36
MASON COUNTY
COMMUNITY DEVELOPMENT
Per itftil nceremen BmidIMPlannmr
415 N 6"Street, Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 O Belfain(360)275-0467 ext 400 O Elma:(360)462-5269 ext 400
FAX(360)427-7787
Application for Determination of Water Adequacy
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: Applicant/ Parcel Identification
Name on Applicant: rh in�r7ituy Ie1]6 vNP� Date: qOq�� ��-� '//(��- r'd1��pal{
Mailing Address: P,o- lox 93 1 Phone: 3W- qtp d- 93a3
Parcel Number: a' 1((e-7Jr" DODIU
Type of Water System Reason for Application
Iffi Public/Community Water System (2 or more IN Building permit BL.D2o2-q-o I A31
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water
❑ Other(explain) ❑ ReplacOther ement)
❑ 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/Communify,Water signature required) .Sri
System box. �ZD16�C�1�, `-'
Part 2: Water Connection Information Y -YC_CDr_ p^
Complete the section appropriate for the type of water connection being evaluated: �p
c�+a
Public Water System
Name of Water System: &VYtyytey
Water Facility Inventory(WFI) Number: nrn14.
(write"none'for two-party)
❑ 1 am the manager of this water system. The water system has been approved for `services.
There are presently I connection(s)in use.This will be the Q nA onnecaon.
❑ 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
4WZI1 'is loc& sOVI �oINGeI a711a'�S - 0001I
This form may be scanned and available fw public view at www.co.mason.wa.us.
LTH F.,\Dnnking Water a Iiei ln5rzme
Individual Water Well
(]Water well report(attached to application). Depth 6�
1(Well capacity Test(attached to application) 9 gpm 7 k o 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 test, which provides stabilization of draw-down and recovery data, must be performed
\/by a licensed contractor.
p, Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA hfto://Qis.co.mason.wa.us/plamino 14015[—_]16[--]22ED
Water use or limitation recorded................................... N/Aj=YesQ
Well Drilled ............................................................... 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)
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 Pennits 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).
ry� 1/) Reviewer's Signatures:
Environ. Health: Datey��
CSD Director: Date 2°172
Thurston County EnvirAmental Health
412 Lilly Rd NE • Olympia,WA 98506
360 867-2631
nroRa-roN covNrr
COLIFORM BACTERIA ANALYSIS
Data Sample Collecbd�r Tim SampleColeow
-1 .3�0
WnN on Y.
Typeof Water SyMem(dreckonlysna box) -a Pdvete Household
❑GroupA ❑Group B IXOlher
Group Aand Group B Systams-Pmvda from Water Fadl'm'es Inventory(WFI).
ID# _
System Name: -
Canted Peron:
Day Phone:( ) Cell Phww:( )
E-mail: .� - �. Fe.Phox:( )
Se awvmfal Mna �ooneoremakdraeal
Ao f8m( k371
Al n S
SAMPLE INFORMATION
Sample oolinted by(narn:
A1*11rY o/lt1M@.Y
Specificlousionoracidreas are sample collected: Special instructions or comments:
120E. R�JC+YA21iad
Type Sample(mug Mack only on box of#1 thmugh#4 listed beow)
1.❑Routine Distribution Sample 2.Repaat Sample(after imselL muene)
Chin inand:Yes_No ❑Drsmbwon Sy'6M
Chorine Resoual:Total Free Chlorinated:Yes No
1.Raw Water Soume Sample Chorine Resdual'Total_Free_
❑E coy-GM(AP)
❑Fecal-Scorers.Gm,eplm9[Imm[aeknf Unsatsfaclory routine lab number)
Filtered:Yes_No
❑Assessment Monitoring(AP) Unsafisfacfory moms,mllaY date:
❑Omer
S
L®Sample Collected fqr ln(ormallon Only
Investigative? Construction/Repairs_ 0#wr_
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
[I Unsatisfactory Total Coliorm Present and Satisfactory
0Ew6 present ❑E.cok absent o lilorm detected
Replacement Sample Required:
❑Samplet000ld(a30hours) ❑TNTC ❑
Bacterial Density Reeutis'.Total Coliform /100m1. E.m# H00,11.
Fecal J100 mI.
Method Code:MM9223B ❑SM92220 Date and Too P wd:�n�
❑SM9215E ❑Eneroleft (L "NDV
Dasand Tme Anarymd'. ;, Drle Peporled: 1 fi
/
smpnlL narlDDH nurtmpe us deal Iub Uw Ony: f
0 8 0
ea.ondwm,.d fins Deyr.(u wyyemdaw Nm. . . . .
oem.d.p.ama<wao WATER WELL REPORT
STATE M WASIEIOrOw rasa w, .... .
i� (1) OWNS C R.- FRlk wmre_177 QY iL1lDL.L1lY-=BIdO...�._Apt�_.F.O.
a (2) LOCATION OF WELL- c a.__..17aw0-. ..-. __. _..._..._.- ...gg.0.54._u w.e_.¢y...T_2_jH.R..2WWx
fY .erring and di r r.,e mew._ anaiweo rn.M. -
(3) PROPOSED USE DmmrD. D )ndydra( ❑ niradpd❑ (18) WELL LOG!
Inlptam ❑ 'sew Well ❑ Omm ❑ M1nM1wa:D.maM b,a••mctee saw.ml•.w.dd•W NeNa•,aaN
.a.a.aame.nd a m eM it 1�and id'
dwn a me rnddr r
waww yenwyida4 a aW find waa.a see wAwe••a ra
(n (4) TYPE OF WORK: ewwe...wmaw. or wed epwrawrwe swot m
m enel.
-.-
ynew w.D R7 memmd: Dv q - eo.ed ❑ T !oil . .2 .
C Udeppm ❑ 641e Q DI p - �— -- —
O aeom wwd❑ amass❑ same ❑ Braun cone _ _.-
9rmyn muddy wwnd_b.-4 -_�_�
C (5) DIMENSIONS: Damae. dwda __`. rams. resin nlwv ____.._—._..__ _ .28
're D.med.....ti8.._......ft. DepNofmuwmea ..a....._.(11j._..__rr. R slay A wand .A, H2O-_... .44 _
W
E (6) CONSTRUCTION DETAILS: FI s rwnd A grau.l �,Ala},w _ 58.
FCasing instaueL,_...6......use. t .m...IL_. n a__WL a
C 7%v .d❑t ....._._.a.a fire. —
Waded p
.L.. Perforatiom•: yr O we R - - -
T>pe d praaaw died....
9 _
C —._..._....._»vmndie w nan_..... _ x.b _........._ _w.
(6 —.—_........._p.derrem find .......
._—....._.__pedradeed laws
A RC[Oewr Tr K.p •-_
0 r»s ee o e41 nse_.r.�7 h mnyn•� .._ _.
•41 Tne—yW'--------�Fm
mat She- ..a._
a® _.--.._.a.r
RGeavel poked: vr❑ Ne Q. u»aa»w:__—.-- ----_
Gn.d sewed few. M1 a
Stnla« seal: r» s•❑ T•W a»rer -
F- mme w wed a rd.__8«tt0"4l—
O lid ..I W4 a W- u.W Ta
end wi41 ❑ milb
Z 'lYpe a w.an.._.............____DOIY M.rel�___..__.
uu. ea
$r (7) PUMP:
10
`J. c.�.a..�...... w..��a.
(8) WATRR LEVELS: .bm.e mrn e» ewe' I...L
g wnml.w wnww>•. -. Ib. y..tlwn aN pa___.._..—
W wmwum wear a mntrdled aW...._..._( rrv�,arJ ---
(9) WELL TESTS: 3xe.dobae wwoo wed Ji a -._.. .-_3-�7-79 ..---.. ��.�r.7�.
w.b aa. n_—. nmpaad—
C Wr.yumv ten m.der Yr p Ne❑[m>r.br.dwma..........
raa: —Jw�eun.Xle n-d..weewd.ra. .._....b*w. WELL DRILL R'S STATEMENT:
1 —_-- WT b inwell
best o[rmr knowledge urvd�eV a d hel�it aM tfiie roporl a
a.c.x.a Na lundw.sen ad n»wean pcmp turn off) (wrW la.•i
Wwwaaad firme aid awnw, ) n,.ed._.._.T.Y.Rg...(!W.B. ...._D.F.,,I.��tt.S1...�in.....Ina...............
rune W.a. teedI rind Wndr tame find wrw Lrel (ywre. arm.or r.pdida.) Mae r VdmG
.....___......... ...... P.C.L_....�__...—.... __..._.._..__.._—.._
"LIW 1r.6Y.._fdJma.w(rt3_..Jt.ar.wdw.n.and p . .
Adadu "---_.—....,._.aaa., ba----'---- tlemta No.- 0A7... ..........IML.
s►my»•a•a•r ndw..___...Wr.mndrd.nd>.a fiats yr p e8 p
,USX ADDMM"SRZX"U MCZSSASY' R .
to ew.w
2071217 MASON CO WA
03/16/2al7 12:2a " WTM
IS019110IN11�R �1����1��1�
Return To:
L
NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM
I(We)the undersigned,unify the the water source located on parcel situated in Mason County.Stale of
Washington,herein described..Z Z//G — 7f— oo er//
OR Z �L
Subdivision Diviaion Lot Range Townshp Section
And having the Tax Parcel Number of 4-2 1 LC _Z s'—O Q o / 1
Has been designated to serve a source of water to the following placate situated in Meson County.State of
Washirgbn;heroin desc lbed (abbreviated legal description and tax parcel numbere(s)of property(ies)affected)
OR 2—
Subdivision
Division Lot 2erg a Township Section
And having
Tax Number of 2 'Z / / -7 }' ' O Or/ p
�" OR
Subtllviabn Diwsoon Lot Range Township Section
And having the Tao parcel Number of:_____-__-—____.
The system owner is responsible for keeping this systern in compliance.
The name oftne,system is Som/'s'! e✓
This system Is designed to provide for two services. Planning and design approvals must be obtained
from the department prior to expanding beyond this number of"Mims.Additionally,a water right.
obtained from the Department of Ecology, is required if the water system exceeds exemption standards.
This system (has/ On epn granted one or more waivers from specific provisions of the
regulati
Signature Signature
States of Washington I
County of Mason )
I, txMersiglxd-lt Nolsry pubkc in for ow rel ed County ant State araby pad 11�on mb
day of //✓v 11k lT.n .p0 o.nn4 onasy tip eonO Eelore
me,vde Is known to be sipper of the above instrument 9pg Inowbdgad the a he)(tneYl t gned n
GIVEN under my hand and official seal me day a e written.
PO ••N/T
P'.' �gYa F<• Publetn rthe of Washington
E NOTAA/, reAMi at
mistanexpires: I Y
y��iF UBLIG o�O?
F '4aFR 29:ti'V�
Op WASH\�
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