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Home My WebLink AboutWAT2024-00128 - BLD Water Adequacy - 3/4/2025 J , WAT 0 MASON COUNTY COMMUNITY DEVELOPMENT MAR 07 2024 Pttml[Aulaantt Q nW,Willing,Planning 415 N San Street,Bldg 8,Shelton WA 98584, 615 W. Alder Street Shelton:(360)427-9670 e#400 O Belfair: (360)275-4467 ext 400 O Elma:(360)482-5269 eM 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: Data: _ Mailing Address: one: 33 S Parcel Number: 3 2 3 3 S Si®Cltn f Type of Water System Reason for Application ❑ Public/Community Water System (2 or mom W Building permit E)Il -DO30ty connections) ❑ Division of land: / 0, Individual water source(one connection), #of Parcels? SPL J91 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 PublicrCommunity 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 lime). 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.vil J r Forms\Dnnbng Water R n W VM018 Individual Water Well / IEr Water well report(attached to application). Depth I _I v ft. � 1� Well capacity Test(attached to application) I gpm 7 C 10O 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 rapacity 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 http//gis.co.mason.wa.usiplanning 14015=ttE3 22= Water use or limitation recorded................................... N/A_I=Yes_= 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 Pan 3: Mason County Community Services Evaluation (staff use only) ySatisfactory 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,Tide 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). Reviewer's Signatures: '7� �)C11f (N11() N' Environ. Health: Date 3 CSD Director: Date 2 of 2 WATER WELL REPORT =DEPARTMENT OF Noticeoflvmnt NO. WE56362 ECOLOGY lah,an Ecology Wall lD Tag No. BM 401 type orwaek State of Washington 0 cow:unkn Sim Well Name(if mme drm one well): ❑ Dzvmmoissiw b Otigimlimaladoa NOIND. Water Right PmmiUCettificate No. Pmpuved Use: N Uomemie ❑admtriil ❑muo a pal Property Owner Name Shaw Huvt f�Deammivg ❑baphon ❑Tess Well ❑Other, Well Street Address 641 NE Tee fake Rd Construction Type: Method: City Tahuva COm:ty Marion W New well ❑Ane:atim ❑Th"" ❑freed M Cable Tool ❑Dossing ❑Om t ❑Dug ❑M- ❑Mud-Resuy Tax Parcel No. 32335-W-00904 DImeam— Diantmmofbming 6 m..m tar A Wasevarienee.,mvedforthiswell? ❑Yes ❑No Depth oFcompkred well 140 fl. Ceanraduaa Denalh: Will If yes,whet was dm varimce for.' Cuivg Lisma Diemen* Fmm To Thidme s, awl PYC Welted Tien" IF ❑ 6 no, +1 1a3 114 m. O 1 ❑ Oa 1 ❑ Lmatim(see amtramims on Page 2T ❑WWM or❑FWM ❑ ❑ — — m. ❑ 1 ❑ ❑ ❑ SE %WA ofihe SE '%;Seth. 35 Township 23N Range 3W [1 0 - - - 0 1 0 0 1 0 Laelnde(egample:47l2345) 47435778 Longitude(ExemPle:-I20.12345) 1 -123.021635 Perforations: ❑Yew ❑ND Typeafpafuuormd DHIeebLag/Coastmetbh or Ds-ra-IMioa Procedure Na.afpMmtivm_ Sim ofPerfamt-,—m.hy_m Fmmown.Neu bycobr,6 a,.iwofmataialandso-uctue.mdlhe land mW FFsfonmd Rom_fl.ro—fl.below FomW surface ommofthemaraielaemhiaymP trated,miN leanoncevtry furmlichenge of snoeas: ®Yes ❑No p A-Paden b DW& IQ ft. iafermatiov. Ux additiotml sheen if:mcessmy. Mannfixt—'a wear Itinerant Meltrial From To Type Maintains Model No. Tops0 2 Dimoerer 5 a Rktvm w a.floor 1W ft.m 1 W ft Light D /J Dammm_ a. siotsim_ iv.liam_fl.m_fl. Wets wn91a ravel till 2 T6 Wet aura entl ravel 78 144 Raad/Fltkepe finer m a ON. ri MPmkmataiil_a. Brown sand 89ravel wb 1M 146 Maknils Domed om—R.b_ft. Surface Real: MYes ❑No To wtw deph? 20 a. Mauviel usedasell tmntonde Did my mua noma wua+ble wmM ❑Yu ❑No TY ofwma+ Doalh ofeaa:a MfW ofsevlivg,reamoR Pamp: Mmufecuuer'e Name Rodtls Type'. sub HP. Pomp mini',deph:143 ft Deaipeadaew Me: 12 Rpm Water LeveW Iced-suture ekrmiov ahore m mlevel—d. stick-uD ofum OlwIrfu ng— fl-f-iig., ,mom Ratio worn level T/.6' fl.belnwtopofwell eating Dive Anesim Pewoe_ lby apureach Due M aimive w is om moflodbY (cap.Wse,<mJ WATesba: Wu ePumPivB uu Pafasmed9 ❑No ❑Yes b bywhom? Yield _,with—fl.lowdownaM—Iva_ Yeld_ wuh_fl.dmwdowo aflm_hn. Yield—,sn-i h_ft bew6 wn nM_Ms. xeeovery dal(time-zmo whrn pump is nwed oR-wmu level measurtd f am well Poor Was P r two atm l.ewl Time W.Lvel Time Water Level Dmo(PomPivBtesl l Beilm¢st 15 ®m wilhm fl.dnwdowo anal ha, Mkm _gDeashskmsmm_fl.for_hm Doc Mmian flow_Rpm Tempmetureofwmm_°F WmnchemiW.mlpis made+ ❑Yea ON. Start DUe 6=4 Complaled Dale 7r2 24 WELL CONSTRUCTION CERTIFICATION: 1 coaswoerod m1Nor accept responsibility for comtmaian ofthis well,and its compliunce with all Washiagsm well ppn aim stavdmds.Materials used and the irdom aim reported above ere we m my best knowledge and belief. ❑a Drillm❑ireistce E-Print erne Mike avis T,Alim Caenparry Davie Dnllin9 S'mmmee ` � /S /y fz Address 340 NE Davis Farm Fie Liaese No. D T f i MF-if C'ty,Siate Zip Begair,WA 98528 IF TRAINEE'Sporn Liceirs,No Contractor's Spore r,e signature ReRi,,,ationNa DAVISDI1100A Drte AUG 2024 FCY 050.1-20(Fair O8f19)Ifym treed this document m an a/manure fornmr,please call the Wafer Resmrrces Program ar 360-407-6872.. Persaa wnh hearing lass mn ml7]ll fw Wmhington Retry&rvrr. 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