The URL can be used to link to this page

Home My WebLink AboutWAT2024-00398 - WAT Application - 12/12/2024 WAT �39� MASON COUNTY l415 N.Mn,W 9584 Shelton,WA 086g4 Shelton:360427- ,E#.400 Public Health & Human Services Helfe'v:360-276-0467467,Ext.400 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 / SLL Name on Applicant: 3OR13 -4 f A(COl-LL6 .�A 1W In)Wate: (2/ I Z Mailing Address: 2�a��/`) G6 � Phone: Parcel Number: ' xJ.O-SO-Oc%SO Type of Water System Reason for Application ❑ Public/Community Water System(2 or more Building permit connections) ❑ Division of land: &individual water source(one connection), #of Parcels? SPL d. 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 PubliclCommun/ty 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. Print Name of Water System Manager Phone Signature of Water System Manager Date This form may be scanned and available for public view at www.masoncountywa.9oy J�HFennA king Waa:r acis 0%8=4 Page 100 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water)Soo `❑_.Water well report(attached to application). Depmfl. I Well capacity Test(attached to application) U apm (4'00 gpd. The well driller often performs well capacity tests at the lime 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 within last year(attach to application). 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. ❑ Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). Revlewees Signatures: hh Environ. Health: 4Q ('Cm- Date AB1Z This form may be scanned and available for public view at www.masonteuntywa.eoy Pare2of2 WATER WELL REPORT a DEPARTMENT Or Niadoeoflntmt No. WES6881 ECOLOGY Unique Ecology Well ID Tag No. BOC498 Type ofw'ark: State of Washington O commmlom Side Well Name bfmorc than one well): ❑ Devernaswn C fraternal wWlatinn NDl No. W..Right P...i erlifieete No. ".it Ua: reDomezric ❑Indueviel ❑Muoi<ipl Property OWTa Name JOhrl Anwine ❑Dcwmving O lrtiptian ❑Tat Well ❑Odhm Weil Str<m Addaas 1450 NE Tahuya Blaekgmi0t Rd Type: McWW: an N— ell �Newwdl ❑Alaeednn ❑Dawn ❑feetl lidGble Tool City TahRYe Couvty Meson ❑Dppnrng ❑Other ❑Dug ❑AG- ❑MW-Raley Tax Paeeel No. 2233050.00150 Dlpmem: Dinome,ofbaing a m..w 200 ft Wxsavanancea dforthiswell? 11Yp ❑No Dcphoftomple¢dwe11300 g pprov< ematracdrr nmaur: WWI if Yea,what was the vadancr for? Cuing Linn Diameter From To Thicknns St.[ PVC WNded Thmed M ❑ fi Fr N 195 IA m. M ❑ M ❑ I.ecation(am instructions on page 2): ❑WWM m❑EWM ❑ ❑ n. O O O ❑ NW SW &;Section 30 Township 23N Range M❑ ❑ — — — — /e n. ❑ Cl ❑ — ❑ ClCl^ ❑ O O O Latitude(Exemple:47.12345) 47A53771 Longitude(Example:-120.12345) -122.9g924fi Pnrmaaom: ❑Ym ❑No Typ,ofpwmwzmM odner4 LaglCopahpNoR or Detrimental..Proeedure No.afpgfm 9ve oflafantianv_m.by_irt Formnion:Devcribe by roloq dwecta,vine ofnumiel entl suucuve,and hie kindaM Pull Gam_ft.m_R below ground surface opium ofth<material in card airar aaW,war m leant one<ntry for cash Were,of Serve: BeYn ❑No ReK-Pocks C Depth 10 fl, Information, Ustadduiorelfieeuifrcenrrry, Mmufmmmi sNmme lrhncon Malaial From TO Til, stainless Model Na. Duman 5 ir. 91m size b in.Goan 13 ft.ad 200 R_ Send 8 grevel 0 3 Dimarr_ or Sranrc in.&om ft.m_R_ Brown till 3 30 31 Samil later pack:0 Yn ❑No Som ofmck memorial_in. Bantl 8 gravel mob 31 S Mnniata planed from_ft to_0. Brownte 31 195 Band and brown 011 195 1g5 Sm9i.1—d val ❑No To what depth? 20 ft. Sand and gravel mob 185 200 Mamial mad inapt benlpmlp Did my road cumin minable ware/! ❑Yer ❑No typ<ofweicr) DepWofauaLL Mnkdaf—ImSstnmoR Pomp: Manufammcr'e Name 9rvntlfae 'fyp, am, H.P.1 Pumpimak<deoh:l 80 fl. 4r nowm<: 12 germ Water Levee: Landwmfine elevation above mean sea lewd ft Stick-Woftyofwellmting_ dIsom ground sums Smcwm ie1cwl 14V ftbeowm 1pofwmlwing D. AnvrwprcuwW_Iheper,mreimh Date _ An nor,one—manalledby (cep,.wlw,em.1 WeRTM: Wm a pumpwg ant Performed? ❑No ❑Yee '� "am? Yield_gymwiW_fl.dnwdrwn and_fan. Yield_mmwith_ft MwdwmaFu_fart. Yield—gpmwiN_Admvdowaaflp hop. Rxavery Jae(nine=zero when pump uwood oR-win kvct mcmuml fiam wall mp wamr kl)vr Time Watn Level Tom them Level Time Water level Wm ofPumpin8 war Nailern120 gyma,Wh 9.dnwd---Ra—' Airvsr_Sam with mom emt U fan. Oats ARrim flow_germ Temp<moeofwrmr_-F WmacMrvealmnlyeu®de? ❑Yin ONr Stprt Dat< 10-15-24 Con latedllete 11-20-24 WELL CONSTRUCTION CERTITICATION: I commucted and/or accept responsibility far conscomen.of ibis well,and ita compliance wiN ell Washington well Consauctian standards.Mamiais used and the information repotted above are we a my best knowledge and belief ❑Dnllm0 Ton ❑. PE-Pont Name Mika Davis fruiting Company Deyia Drilling S'gnemre � Addlms 340 NE Davie Farm Rd License No.07 7 Ciry,Smro Zip Belfair,WA 9352E W TRAINEE:Spa nmr'S Licence No. Conmetora Spo.'r SiKonac Registration No.DAVIBDI1100A Dg[e DEC 2024 ECY00-1-20(Rev W/l9)Ifyap need Our docromenf in an allemalefor mlplease call the WWCI Reswrcea Progrmt at 360.407-6372. Pero wflhhmmVlmrcanen117llfor Wmhingron Re/gv Seavice. Pesaro with a.rpeech duahiliryean call 877-833-041. 17868E MR. HillR,Pwt - Gr .WA 98W (3N)443-7845 Dde Semple CdkW Tm&Vmk Corny L IZ =11A 6. manor, TMe d Welm SyFbm(duds wN m8 bw) ❑G=PA ❑GmpB r A GraspA eM GM*8 SYd"-Pmedeton Web haws Imunby.(WFIB ID8 _ _ _ — _ _ Spurn Nems w AL C..v Peon: Dry Pb Ce11ERlx Emd: Ere.PMnm Send uN1 k pdsu�,.a W i r y ru�pr re.a+rmN.oPT+�rlq Sempeoaleded 1 7 l T Gpedkbdeknufiglpaem ro : SpedelimbuNoo Uaanmmb: we(f k +.❑RouBm Dbt@Won sPmple Wv) z❑Xepen Ampb WP1 CAlpimeled.Ym ❑-. NO❑ pwedmeuknmsumabrwem.mmrre) UmeBabcBey mulne m lumber Cel+ine Raidld:Tdel_Free_ 3.GmndWe We Smm Amble ——-- ----.— UnselbYdw .Un.m dsW ❑TdABemd ( Chbdnebd:VY_NA_ ❑Aeeaemed V) ChbM1ne Res"To _Fm_ 4 ArOmw W RM Smm We r Ample(Enememem) e i ❑ EOW.,❑Peal Raw va_ra_ s. wemaal+wm.pa,anr. ' OWW64Npry TObl Cdbm Pmudand ib<fory []Ern Pnmel ❑ELd.M.t Be+ebl DmenY Raub:TOW C88fwm____�nitphnl.E.mlmpnlf00m1 Feral CdXam,_uWiPOmI. 1WC__cIW1M R1plepemenl AmduRpuR; ❑TNTC ❑Sulo.e m 0800pb9pbm ❑Damaged CmWmr ❑ ! Y7 RIFF Oslo w.�i �' wesw.arn. r yp�rwLtlrdwY�N�ru�w wMla-9�RYY I"�v'._r WNaHXMe nMIrwm�MTmM�`4e�umP` cs re.m�a�eN��nn