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Home My WebLink AboutWAT2024-00237 - WAT Application - 3/11/2024 WAT 70Z` - MASON COUNTY COMMUNITY SERVICES \ euuamyammow EnvemmeNd NeelN,fanmmlylkal�h 415 N 6m Street,Bldg 8,Shelton WA 98584, Shelton:(360)427-9670 exl 400 4- Belfair:(360)275-4467 exl 400 4 Elms:(360)482-5269 ext 400 FAX(360)427-7787 Application for Determination of Water Adequacy Instructions �t. Complete Part 1. No determination can be made until Pan t is tulle comdeted. 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 "R 1^M:s,4i C.&'an tai• Dale: Mailing Address: '7'707 - 6641'Ave. G-,r4W. Phone: (253) 6&6-(0427 Parcel Number: 19 di O5S2- 0002°I loi —N.6, L-AJ e-t RJ.BgLA464 GJA Type of Water System Reason for Application ` 16528 L4' Public/Community Water System(2 or more "wilding permit &I BZY •661pl connections) ❑ Division of land: X ❑ Individual water source(one connection), #of Parcels? -L SPL ❑ 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 Publlo/Communlfy Wafer 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: Tiger Lake Water Facility Inventory(WF0 Number: 04237 W (mite"none'for two-party) 3a I am the manager of this water system. The water system has been approved for 40 services. There are presently 29 connection(s)in use.This will be the 30 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 mgulatlon. Signature of Water System Manager Date 03/11/2024 This form may be scanned and available for public view at www co mason wa us. J:\GH Fonne Dnnkiny Wnlcr Revised 1/25nOIS Individual Water Well ❑ Water well report(attached to application). Depth ft. ❑ Well capacity Test(attached to application) gpm 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 rapacity test,which provides stabilization of draw-dawn 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 Ygis.co.mason.wa.us/planning 14_15_16_22_ Water use or limitation recorded................................... N/A 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 Part 3: Mason County Community Services Evaluation (staff use only) -,,o 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 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: �J Environ. Health: K�1`G�h4�/ � Date CSD Director: Date 2°f 2 WAT MASON COUNTY She41l Wton,n,WA 9584 8594 Shelton:360427-9670,Ext.400 Public Health & Human Services eclfair:360-2754467.Eat.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 Name of Applicant: Ir1(.{gar-A i5w:.hri-4✓l Date: Mailing Address: 6bZ 'I�-b -l' ye.SC )1r`f�n 3 D09� Parcel Number 17,27 1 3H— qo*3 Z 7S Type of Water System Reason for Application ❑ PubliGCommunity Water System(2 or more `E�Building permit connections) ❑ Division of land: Individual water source(one connection), #of Parcels? SPE q- Well ❑ Boundary line adjustment f5 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 wall, check the PubliGCommunity 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 stale 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.gov 1:\FH Forms\nriakin8 Water Revised 05/08/2024 Page 1 of 2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well Water well report(attached to application). Depth 7 Well capacity Test(attached to application)_ 1 �- gpm 0 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 within last year(attach to application). 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 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). Reviewer's Signatures:Environ. Health: K Date J? "/ZS This form may be scanned and available for public view at w .masoncountvwa.aov Pag<2 of 2 WATER WELL REPORT DEPARTMENT of Noiceoflmmint No. WE585n ECOLOGY Unpue EcolM Well IDTMNo 8DC082 Tsar of W ark: 51att M WasMnRtan Commnm. Site Well Name(ifmare Ilwn t m moll: ❑ Do--aion O I]riwn,:l Not Ne, Wluu Ripon FnnniuCMifrw No Rrm-1 use: ■Dsswmir ❑udannal ❑Mmspt PropenY Corner Name Richard WOW ❑Dewwtt-, OMy:oll ❑T..Wdl OQMr Wdl Suer Addrtm 4251 E Slane Rau10302 f m .n typm MaNM: ON N-ew oral ❑Abaio. ❑Drum ❑last OCtlrTad City Be8a0 - Caunry Mason O Deanna, OOlhu ODM Qy ❑MdReYry Tw N.1Na 12221-3 -IIOM Dlmmde: Dimr°lbons,8 ,m B2 R. 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O.0 MAM An..Dow_ppin Temp —.fwaur 49 •f Wm.MmdmlmWYeavuael arm SIM 51mI DRt 1117f25 Cm1lPIeRd Dale 1I1M[5 WELL CONSTRUCf10N CERTIFICATION: 1 carmm oW ands mcept rmpmeibilvy for wion offt bell,anal its cmnplume with all Washington melt rormroaim alandeNs.Metmiels umd end the informatlm ropamed above arc true m mY box kmdNgeud Ids! E]Driller❑Tmiore❑PE-PrbR N e JOM Koa Drilling CmnPm'ArraRle DRRrg Inc. Si live Add.PO Bon 179D Lieaae No.2874 City,,Sus Zip ShelleDm WA 9858/ IF TRAMEE Sponsor]Lie mNo, _ Cmaeeloh SpauvS Si®mare R,,Rnjhon No.ARCADD1096KI Date 1/2M25 ECYOS0.1-20(Rev09/18) /fyourrrtdrbra docmgm In nn ahernale/orMTc pleas mll lM WMrr Remama Pfogavar ar 360.10).68J1. Permry vuR Memrg br]mn mll)llfor Waobhrgmn Relay Srnin Prnmv rvnhv yeedr✓nmb@rymn mll8TJd33-631/. v anguar0 Laooratory 2635 Parkmont Lane SW,Suite A Olympia WA 98502 peLtvgD 360-967-7010 COLIFORM BACTERIA ANALYSIS FORM Dab Sarryls Collected Time Semple Cony C01e° MASON 02/04/2025 p p ❑ap umm on Yr — —aw Type of Water System(cI my one lw) ❑GroupA ❑Group s ■OVer Getup Aand Getup B Syssum-Plwidefrom Water Facilities Iwo"(Il 1 D a _ _ _ — _ — sysbmNeme: RICHARD BUCHAN Contact Person:Arcadia Drilling,Inc Day Plbre:(3e0 )4263395 Ces Plwe:l I Email: Eon.P :( I Siol rsnyb b'.IPdnt tell came.adAn!uatlnpmtle wenwq anew®.ceaimnnino�m u+oym�®aivm.erp.mm SAMPLE INFORMATION sempleoollecbdby(nem): SHAD Speaficl«aGowMmsamplaokcted: speObl eubuctioreaammlte: 4251 E SR-302 Belfair Typeofsampb(setal onel of seeme a ham Win t Wpgb 5 below) i.❑Routine Dbbibuson&mpb(NP) Z.O Repeal Sampb(AIPj Cbbdnabc.Yes—No— Chemins Ixom durteuem system dbruma.muonel Unsalbfu nory muting tab number Residual:Tool_Fnb_ 3.Ground Wear Rub Some Semple — — — — — S I I � Uesatabctory routine cdkctdate. Cnbmated:Yes_Nu_ 0T (ASP) CbbM1re Res"..Total_Free_ ❑Assessment(AN) I. Surber«laall Raw Bwrce Walar SampN lEnumemeonl ❑E pl4 ❑Feral raeao rn w___ 5.®Semple CdIe fix Inbmaeon Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY 0 Umaesfac ory Total ColOomi Preset and ®Sathhclory ❑E wh lament OEcaeeibent lb«ebal Density Fill TOW OAkxm It00ml. Ecoli 1100dt Feral Colilorm J100st NPC M M. Rmpbcement Semple Required: ❑TNTC ❑Sampb too ow ❑ sempus Volume ❑Damaged ConbMr 0 = ttl Reberca veneer S Rx TmpC `te"otlCo°°: SM9223B Dile Repodedb OOH tebusioniy 0011 L49npN 285- 20515