HomeMy WebLinkAboutWAT2023-00252 - WAT Application - 9/21/2023 ooa6a
MASON COUNTY
COMMUNITYDEVELOPMENJEP 21 2023
Pormitksmst tenter,6ulldIVAannin{
415 N60 Street, Bldg 8,Shelton WA 88584, 617 VJ. Alder Street
Sheaon:(360)427-9670 ext 400 ❖ Belfair: (360)275407 ext 400 ? Elmo:(360)482-5268 ext 400
FAX(360)427-7787
Application for Determination of Water AdeCEOW RON MENTAL
Instructions HEALTH
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: i Vf( Nev N,%6s Date: ��7�lozi
Mailing Address: 1411 j`I t. Ftcf kmJ 4-- Phone: 7. 9-70 -72.3.f
Parcel Number: 5 Z Ov 4 S 1001201
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more O Building permit
connections) ❑ Division of land:
0 Individual water source(one connection), p of Parcels? SPL
O 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 Public/Community Water signature required)
System box.
Part 2: Water Connection Information
E 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.
laFli Fonts.DonAivg Po'eiu Revised 1252018
Individual Water Well
Water well report(attached to application). Depthl�
Well capacity Test(attached to application) - IC gpm 7 ygiod.
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 rapacity test,
a well capacity test,which provides stabilization of drew-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 http flais.co.mason.wa.us/planning 140 150 160 22M
Water use or limitation recorded................................... N/AQ Yeses
Well Drilled ............................................................... Date O I
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)
�Satlsfactory 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 5.68.040-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).
Reviewer's Signatures: �p /ZJ Z
Environ. Health: l�➢P.UV`i" Date ` � I
CSD Director:
Date 2 of 2
WATER WELL REPORT DEPARTMENT OF Notiocofhltent No. VJE43677
ECOLOGY Unique Erato,Wall ID Too No. BMS095
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site writ Namc(irmme than one mu).
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WELL CONSTRUCTION CERTIFICATION: IconR.,Nd mlNm e.opuupansibiliky forconnructien ofthis xe11,am its compliance with all Washington ,ell
cwsmMipn smnJanis.Mderialsused and the informption reported above arc we to my best klmeieJge mJ hlicf.
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Sharon.. Address PO Born 17W
Urnme,NOL 205) 3 City,Sam zip Sheltw WA 985M
IF TRAINEE'S wr's License No Cammctor's
Sport S'ISnaru Registration No.ARCADD1098KI that,11021
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MANAGEMENT
AED
LABORATORIES arac.
14154I)Ch ME,T�WA aBeaa SEP 21 2023
COLIFORM BACTERIA ANALYSIS FORM 615 W. Alder Street
Gab3ample Collece" Tire Semple County g I to 17 3 ���y{°I O KAM �(� e}� -I
W. Y. Y:,VOxM M W0
Type of Water Systam(check onry are box)
❑GrapA ❑GmpB Olher
Group Aand Group 8 Systems-1Proviidefrom Water adlitla Inventory(WFI):
lot 1A
System Nana:Z ikm
SLEENVIRONMENTAL
Cmted Porson:
Day Phaa:( , P a:(3(:O) HEALTH
Emea Ere.phone:( )
SenorasnIc(Ptlm Nllm-, dmee tldpmtle)
Zf0 w. 14
SAMPLE INFORMATION
Sample collided by(name): (�
S{Pendlicbndon,ahmampleimllkded: Special imdrudlonsorco ments:
f 'sf—9b
Typo-f Sample(NIW only--rypeof angle fmn tyyas 1 Nmgh 5 blew)
t.❑Rout-Uletrlbutlon Sampia(NP) 2.❑ Repeat Sample(")
Chlednaled.Yea—No pmm Gahibutlan system saw unw.moire)
Unsatisfactory routine lab number.
Chbnne Residual:Total_Fme_
3.Ground Water Rule Soma Sample ---
Umadsfedo y mutr a rolled date:
S )�
Chbd-ted:Ya_No_
❑T^SBelod(A?) Chldl-Raidual:Tale(_Fmr_
❑Assessment (ASP)
4.SuH or GWl Raw Soumo Water Simple(Enumemtlon)
❑E cot ❑Fecal chose vo xo
- - 5. swmlxcdl.mtlrwlnxxmmlanony. —
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑U-aadhoolory Total Conform Present and fMSetbWe{-ry
❑E.cnlipmant ❑E.mA'abant T�
Bacterial GNaSy Raub:Total ColMrm H00n1. Em9 100ml.
Foal Colibrm HOOmI. HPC Ii ad.
Replacement Semple Required: ❑TNTC ❑San"tro off
❑ Sample Volume ❑Damaged Container ❑
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2202444 MASON CO WA
E";VIF . . ., 1ENTAL ASHL[E2HUGHES #iSI002 AM 3°Re. Fee $204 50 2
IIIIIII IIIIII III IIII IIIIIII IIIIII IIII IIII IIIII IIIII IIIIIII III IIIII IIIII IIII IIII
I•, _. ,LTH RECEIVED �UDot�`'�'b11�Cp
Retum To - SEP 21 2023
ee Humi Ito
T Ala Alder Street
sklelwfS
Grantor(s):(1) f?S it I U S (2) .
Grarkee(s): (1),PUBLIC
Legal Description(1)NAHWAT ELBEACHKLOT:1&1/B INTL0T120FNAWWARELBCHaWO4
(Abbrewatedfomr:Le.lot,block,plat orsection, township,range)
5 2 0 0 4 _ 5 1 _ 0 0 0 0 1
Assessors lax Parcel: (1)_____ __ -----
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA)
I (We),the undersigned grantor(s), hereby place this notice on record that the de
scribed real
estate situated in Mason County, State of Washington is subject to water use restrictions and
conditions set by Washington State Senate Bill 6091 and Mason County Code 6,68. These
restrictions and conditions are based on location of property and/or Water Resource
Inventory Area or WRIA.
WRIA: 22
Maximum Annual Average Gallons Per Day: 3000 gallons
Dated on this 2-e day of S -6c�. 20_1,
Signature of rantor(s):
(1) �✓t , (2)
State of Washington )
County of Mason )
Page 1 of 2
I,the undersigned, a No�t ,ry.. Public in an for lh@ above named County and State,do hereby
certify that on this �' day of P M kC.f'2g 2�>
,Ac5 �. q�p�_personally appeared before me,who is known to be
signer of the above instrument, and acknowledged that he(she)(they)signed it.
GIVEN under my hand and official seal the day and year last above wn te�
qpq������� Notary Public in and for the State of Washington,
'n Q... Sc
Nt EN . 0...
: '.r � residing of I Vl(A.�h
SOTAar _ My commission expires: I Io
— pPUBLIC
bIlneUr"N`\````
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