HomeMy WebLinkAboutWAT2024-00388 - WAT Application - 11/26/2024 ENVIRONMENTAL
HEALTH wAT �oa� _ nb�P�fs
415 N.@°Street
99594
MASON COUNTY
Sheltov:360427-96-027A670,Fact 400
COMMUNITY SERVICES Beellf�:36600-4754467,En 400
400
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Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be made until Part 1 is fully completed.
2. Com port
plete only the ion of Part 2 applying to the type of water connection utilized.
3. SubmR completed application,with any required attachments for review. ,.
4. An ap building site plan must accompanX this applica[ion. r
Part 1: Applicantl Parcel Identification li yb/Qo Z�I r
Name on Applicant:
- "'� ate
D : E[
Mailing Address: �sif Phone: 366- '�i 3Q37
Parcel Number:
Type of Water System Reason for Application
It Building permit BUD;024. 0 415
❑ con Public/Community Water System(2 or more ❑ Division of land:
connections)
ql Individual water source(one connection), k of Parcels?_ SPL_
Well ❑ Boundary line adjustment
❑ Spring/surface water Cl Other(explain)
❑ Other(explain) ❑ Replacement or Remodel(please indicate name
of water system below if applicable—no
If you have more than one residence connected signature required)
to this well, check the Public/Community Wafer 9
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 ffoornnectionservices.
There am presently connection(s)in use.This will be the
❑ 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:
)corn
the limits of the wale able an Or illing to provide water limits set by state o thandis(me al egulation�lon(s)without exceeding
Signature of Water System Manager
Date
This form may be scanned and available for public view at w--""^^"
hn.wa.us.
Revised 4I42018
11EH Fomn\Dmhing Water
'MASON COUNTY
COMMUNITY DEVELOPMENT
Permit Assistance Center,Building,Planning
1ee Address Request Fomi ARplication
Name: �q ( v 544'no 253— S(Zo— 9979
Phone:
Mailins Address: (?-- gZc,E YtW G
city:_GL.v MA/{ef State: t L Zi 7
P ;r Prefer:Mail or ar �1
E-Mail Address: ($dtt Q 5a>�Ly S✓Ae Cow`
t
Parcel Number. 2Z6 jo — (o _h 4(2 p
-- - (12-0igit number)
SITE HAP:PLEASE PROVIDE DRIVING DIRECTIONS TO THE PROPERTY(and most Importantly a sketch).SHOW WHICH SIDE OF THE
ROADWAY YOU WILL BE BUILDING ON IF THE ROAD INTERSECTS YOUR LAND.LIST ANY ADJACENT ADDRESSES YOU ARE AWARE OF AND
NOTATE WHERE YOUR DRIVEWAY IS/WILL BE LOCATED ON THE PARCEL AND NEIGHBORING DRIVEWAYS.
❑ Application fee:IM due at time of submittal The Mason County Addressing Ordinance❑ Make checks payable to:Mason C ty Tre svr requires you to post your new address
❑ Mail application to: within 30 days of assignment.
Mason County Permit Center ` It must be placed at your driveway entrance
Attn:Addressing Division clearly visible from the road in reflective
818 W.Alder St contrasting material.
Shelton,WA 98584 Address must also be posted to any structure
Addressing questions?Cull(360)427-9670"t. 365 within 30 days of its erection in a contrasting mlor,
'..`*`.•„„." L; visible from the roadway or driveway.
• .ADDRESSRESS IS:•• .M 'THIS SECTIONIS FOR OFFICIAL USE ONLY"^ ...... ........„......,.„„.......„...
YOUR NEW
RECEIVED I LOGGEDIN:: TIDEMARK: FIRE DISTRICT
BILLED PAID RECEIPT#
Rea.12/27/19
Individual Water Well
ft.
Water well report(attached to application). Depth \� m
I p application) p gpd.
�p/�YVell capacity Test(attached to app'
The well driller often performs well capacity tests at the time the well is constructed. Results from
these tests are no on the water well report. Results from these tests will be accepted. If the water
well report cannot be located by the applicant or 9 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
////b����y a licensed contractor.
satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
EDevelopment within which WRlA htto//gis co mason wa uslolanninq 14015n 1f�22�
use or limitation recorded..............
WAS_YesL2
rilled ....._........................................
Date
Individual Spring/Surface Water
EZethod
ttach to application)
fection
o believe that this water source can provide at least 800 gallons per day; and/or
at a rate of 2 gallons per minute based on the following observations.
Date
Author of Statement
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 indiwles requirements of Sanitary Code,Title 6,Chapter 6.68.040-Dersnnination 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(a).
Reevieweer's Signatures:
O n 6 n f Date `�
Environ. Health: 1P`-k-re�, z otz
Date
CSD Director:
DEPARTM ENT OF Npp p[DRept No. WE5N457
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MOERKE SONS PUMP AND DRILLING
1162 NW State Avenue
Chehalis,WA 98532
Phone: 360-7483805 INVOICE#
109184
Date: 12/19/2024
Phone: (253)820-9979
Acct#: APC301
Billing Adress: Sold by yarn Sold by Sarno —_ Site Address: Sold by Sarno
6812 82nd Ave NW
Gig Harbor,Wq 98335 3605E McComb Way
�— Shelton,WA 9g5g4
178 Drilling charge per foot
$76.00 $13,528.00
1 Surface Seal
1 6"drive shoe&well cap $850.00 $850.00
$350.00 $350.00
1 Department of Ecology fee(not taxed)
$2DO.00 $200.00
1 Mason County New We Permit
$312.63 $312.63
1 Mobilization
1 Deposit $950.00 $950.00
-$350.00 -$350.00
RECEIVED BY:
TAX(8.6%) $1,266.61
TOTAL $17,107.24
Mcerte 65ons Pump A Drilling,In"retains[kleto eeulpmeMantl miterph IumisM1eE until Anal
Mperke gspns nnremose viE ryulpmeM ant matenah a[Mcerke&bni WNnent is matle Hp.yment iinM matlexagteetl,
of Moerkeg Sons Pumpa Orlllln&Inc ant/prks affl0at ltom ahanse.MYtlamage smMngnam lan mnnnl shall not MMe re ,xx,ylli,
elRetepmmwnles may tlelm a pan fw 46w,maallalsantl Nuanks TM1nhalkW er wAc wuoa.MlatMtM Me A sons Pump B orilling lnc,antl/arks pmen[instalkC/per WgC60.oa.o}etsee�
TERMS-NET35 1.5%ON PAST DUE BALANCES
WE ACCEPT VISA,M4&DISCOVER
THANK YOU FOR YOUR BUSINESS/ONLINE PAYMENTS AVAILABLE AT MOERKEANDSONS.COM
Vanguard Laboratory
2635 Pml�t Lmm SW
Olympia,WA 98502
360.967.7010
VANGUARD Report of Laboratory Analysis
LABORATORY
Collmled by:
Matra Drialcmg Werm
Moerke and Sum Dr04
LbontoryDr:V25011/-13
360-748d805
Dale Sampled: 1/1125 I5:00
Sampling Add..: Date Racdved: I/1425 16:42
3W SE Meeomb Way
Dme Reposed: //162025
Shelmo,WA 98584
Sample ID: Samo LLC
Analysis Result SDRL MCL Units DF Date Analyzed
Total Coliform&E.coli by SM 9223B(IDE7Dq
Bomb MN250114-13 Annrit:AF
Colifort Total NeBsive 1 1 MPN/100 mL I 1/142517:25
E.mli Negative 1 1 NU N/100 mL 1 1114/251725
Bamhm:V25011a13 Armlysl:KS
Nitrate by 73aeh Method 10206 1 11142515:00
Nitrate(u N) ND 0.50 10.00 �'
Notes:
MPN:MoseProWbk Number
PPm:Pam Pvmilliw
M:mvdnect Reviewed by Duatm N�Iabommry DIRe1nr an 01/162025
n/a M applimble
SDRL'.Sum➢cacaos Repwung Limit Approved by Tori]olmw40pemtiovs Manager ov 01/16202
5
DF:Mo mFactor AMPA 17
MCL:Manmmn Comm.uc rea�effi
sample.xere rtwivd in auepade coMition The msWtls)W Wh rtpon Nmc oWYmdn wrtiw ofde semplIX:)mned,W amlyaer sae Per[omsd wminem
wiM the QuWiry Asamaoce pro®ama(VmgumG Lebommry rieex r°n�the lebmuwy if3nu slmWdhave mY 9u tionc eboW 0m rtsWta.
2635 Parlamtrt Ln SW,Suite A,Olympia WA 985021 Ofcp:360.967.70101 WS ing(Qvangumdlabomtory.Wm I
W ww.vmgwu dlabolatory.pom
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