HomeMy WebLinkAboutWAT2024-00400 - WAT Application - 12/16/2024 WAT 202i - oogoo
MASON COUNTY
COMMUNPPY DEVELOPMENT
vmnrcawv,rcetmnc wna�r,eanMre
415 N 6r'Street,Bldg 8,Shehon WA 98584. R �j f •' e..
Shelton:(360)427-9670 eA 400 O Belfair(360)275-4467 ext 400 4 Elms:(360)482- ext 400
FAX(360)427-7787 DEC 16 2UL9
Application for Determination of Water Adequacy
615W.Ak'- 'r•emf
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. Ana roved buildingsite Ian must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: lCr2JK f t t'�,K Della:
Mailing Address: pp3�p t�I �'"' �� � - � '�l
Parcel Number: �'7�J� 0--7 r— f 07V
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more Building permit
connections) ❑ Division of land:
qid Individual water source(one connection), tl of Parcels? SPL
Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Remodel(please indicate name
ff you have more than one residence connected of water system below if applicable-no
to this welf,check the PuhlfdCommunity 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)
❑ I 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 wvrw.co.mason.wa.us.
}.,CII1',,—, Decokingwa, Rews 1/25=18
Individual Water Well
IWater well report(attached to application). Depth 1 t 6 fl. .l
�j Well capacity Test(attached to application) �s apar 71 VaQ 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.
Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA hfto 1/gis.co.mason.wa.us/planninci 14=16=16=22=
Water use or limitation recorded................................... N/AQ Yeses
WellDrilled ............................................................... Dale
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 W DOE 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.
J Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
R
evi
ewer's Signatures:
Environ. Health:�� ". ' Dam 313
CSD Director:
Date z of
WATER WELL REPORT ipDEPARTMENT Of Naice otbflmt Na.bvEMRB4
ECOLOGY UMT,A, .1ogY Wm ID Thig SM 179
TYPa Wary' Hnte OF WnFMRton
SiH well Nela(ifmwe Bw oM wylq:
❑ pzwnm ^n Ci llneirelinullvtirn NOl No, Warta Right PrnniVCeM1inctic No.
PnNa11 V.: C Vu:xaic ❑IvtlWl ❑Mlaagal poPettY p"':q Nepp ns .t e:u
aw.nnnp In:p:inn ❑TN wdl DO — Well Sbwt AMme 91 NE I Rhmmahi Dr N
eeairanla Yype: McIMa: qry DMlelr COaflry Mum
IIS New well ❑nlmnia ❑Dii— ❑leeM C2b Td
❑ae ,, _:n.• ❑DM ❑Ab- ❑MWAaary T.Pamel Ne,22J10]&90T1J
D,MMERM Wnava:wNe approved falhltw r Y. NO
� alxn afca•�kldwll lSh n.
Ifyu,who wss IM reriemc faW
ill
it,
(tp❑p nP I❑❑:❑na• Da Nnea rae N 1�5 tW
_ m. ® PVC WebcdP. To M ® SN'd ❑ IN I Tla❑
t ❑ 1 ❑ ❑ 1 ❑tl
IIXNEa lktllMeea fM,aMm mlienamVq papeiml: 10 TowmFry❑mWW MRaaF❑E2W
❑ ❑pia _a WM
1uRude(Eaagk:<T,12M5)
❑ ❑ _ — _ n. ❑ ❑ ❑ 1 ❑
Iaigilida IEumpk.-I29.13345)
PnINMYu: ❑YOb 0. TYpa of pmfwNor INE Delnli a IAEICall.O Ma oa De[g11NMe1M PrRlaa<
No.MpnfwN smoflvfiAm—mb)'_b inrmlun:Decnh Fy cnMr, Mzbr i enf mamru�laml.Inrbrc.aM HLatl wl
perfpaYN frvm_M1b_M1bNnw O^Nd aur4a afWn mY mlm aFWyn In ncdvilFmlu..nir pia:exFebNMI Of
,mar: •Wi Yn ❑No fi R-PxYv b 1Y:PW—_a
infdinl'Ipn.UN Witiwul vd�n ilxcurary. rnl:
Mnuitlnn'a lYns AVMMdIEH WIHu MIRREW Fme TO
♦lye WINDOM MoatW &orni 'IL 0 5
fFemnn S in. SN, n fian to a.m 15B M1 5 17
oNrleue_ m. stltis_ n.hom_Ln_IL Tan IW
Bflfe voHreHd ledal hll 9T 80
saNPMn PaeE:❑ve ❑No 9be afpah:�bl_ha taerd 891BM 18n W01 BD al
11
MNebb plxatfmm_M1n_n, Mead Anlavel due wet 91 130
saf,NnMhwYa ❑m Ta RNNdepMm L T' IuMdRrarol down wet 11T 130
MasYllwgisrW Rigighaa T anid8 vat due wet 15D la
pllaryevW caMein n�wbk wYtl! ❑Ya U. ggw,n WdL ApN WD 1$2 15E
Tpwo[wwP DeW°fabn
Mn6tl of Nah�N rmunlf
Pney: MmuYlum a Wart WmMa Trya:nik
N.P Dar4b.ts:15 P
waa l.aaJ: lurJ-.ufaa ekwlun abw:aanw4al_I.
M:d•gp nfuqufvellaaa^t•—. flaFow pwtlalNa
sM[waw keel 124 fthlnu lyuf ucll unmp Me INtI(A
Maun paalne_IbOT�.M Wuna`-F DN[
Mpen vYa nmxmlbl 1:'an,�elvq eR.)
walh4:
WNaparemg nnl lemfomed?❑No ❑Yob 6YNmmi
YkM YN,
_PwnF_ daaOwnaller_aAF
,o_gpn with_R lev.JnwlWn efln_ _
YeM_ryn•whF_n JravJwn anm_hm.
neeonry Nnl �le-nm uRn pumpnmrwJ nlT v mk•tl m'vauM from wdl
mpm wab keell
Tlra wab le.el tine wwn feel TX•e wnn teal
LYe NpangeMSN
Beim ut 2! Pwu15 LSewlbwnabt H+.
Aieen�P^w asaaaa_M16r_Yn. PM 1W1 V10
Mbm w_P
Tayvaae orwenr_'F wra•Hmkelaalyw Rea? ❑ve ■No stew UMe 928IP0 CmpkHd pMe IW11I20
WELL CONSTRVCTION CEIATIPICATION: 1 conanNrea anWA rxat eapatsibiliry fro comhuction of Wu we1L d iMcompliapce wiN en Waahivgtm well
CawlNtYim Malldeffi Melalal6 ut[d aOd 11K intmretpn tePp1CA allnpe ar!lNt b my h6l Lnuwlc48e BIMI btlief.
IE Wier n T.11 PE-Prvll Name EmlN Davla Dn158<'2Tp.yDevis Orglkp
_hi pENos 340 NE Davis Fame W
Y Bepab WA 9B528
Liansc No.3142
w TRAINEE'Sponsor' I.iceae No Cavr«far'a
SamWe R ,Fnlicn NlMVISDIitUDA paMOd 2D20
EER 050,1-N(Rn 09119)lQrW ii Yd thu dawment iw OR""'A"e(.mm.Plerur evdl rise wwmr Rrsovnn Pepg ux ul 3,F47-ap72.
Petwet,jkh PRV lrwtan twit 711 AT,W bilkw Rebt Seni Pemoawftha",*tiiaMllntwc 18374334341.
Thurston County Environmental Health
412 Ully Rd NE 6 Olympia,WA 98506
360867-2631
rxuae/oe cormr:
®� COLIFORM BACTERIA ANALYSIS
Dab Sampta CUlbcW nee Be" c.*
c hcaa
hWh eeYIla .5
-/F��K- Yhfl�a N
uen cm rm
TypedWebr Syslam(check only cm boa) (KPMeb H.WM
❑GaWA ❑GeWB ❑GOer
Group A and Getup 8 Syl«m-Pmdtle bmn Weller Faeltlae Im Iarr(WFk.
IDS _ _
Sysiem Nene
CamatPmm: lRc)lp F L JJQK
oey�(Z ) 1656 icg
FPn«rt )
E t LH Eve.Pb«e:l I
6admgappNNun«im.eara W>baade««ei adlee)
tQOONFG F'LIN I[
SAMPLE INFORMATION
SwV1a.. Wby(naee):
SpedOe bcabnmatldrossxfare 9epp►cOkded: SpeNMbehalons«mmmenb ..
�E'L.p_ HE.Ap 'F'f1l.U%E'r
Type dSemple(muAcheckeay, mboxolli Qm hWlleball,a w)
1.❑Reutlm NMdbWan Sempb 2Rpee15emple(Mbrumat.roullm)
Chlorinated:Yee_Now- ❑[A ibulbn Syebm
cmwieRsvduM:Tebl_Fea_ cl aaw:Yee No_.
S.Rew WeerSwrte 8ampb --:.Nome Residual:Totel_Fina_
❑E,roll-GWR(AIP)
❑Fecal-sinae.cwl.eMropra�ae Umetlabdpryrcudne Nb number.
FIWeA:Yes_ ,__No_ _ _____
❑Aaaaament MonWny(W Umsfidecbryroualeccleddete:
B
A�9ampb CoMcyed y«bbmmtlon pny
kr,dWM_ C«ebabon/Rapdm_ Ober_
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑UnseIYAM«y TOWl Co4bm Pmeanlmd BeBMatary
❑Eceypewl ❑EmlebmN COBonndeYtMd
Repbeeeeei Seeple Required:
❑Semploboold P30Mes) ❑TNIC ❑
1
BacbdelGmMy ReRNe:Tgbl COIIMe__�700m1 Eooa M011". '
Fecal Coffam /1mM Enblgwai_ J100 nd
Matllod Code: SM9223B ❑SMBpp20 OeleNTlr Reeiwi
❑SMW15B ❑ENaobriD
WBNTLwMeM+atl: Bel -�'
aama« WSa LWUw .OeP
0 1
0 Q 5-s--