HomeMy WebLinkAboutWAT2024-00117 - WAT Application - 7/29/2025 WA I ZoL�- OO /f7-
MASON COUNTY
'111rinF '~) COMMUNITY SERVICES
Building,Flanning.Environmental Health,Community Health
415 N 6"'Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 Belfair: (360) 275-4467 ext 400 Elma: (360)482-5269 ext 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: I,cLi Ill o j)ciple iA Date: 22iJ,,.(y 20 7 5
Mailing Address: 15431 L1Cc-c t;d N ; r�.1IsN_Phone: (831)2157- 53 i/
4, 9E370
Parcel Number: ,0c 33QyQq¢
Type of Water System Reason for Application
rNi Public/Community Water System (2 or more ® Building permit
connections) 0 Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water 0 Other(explain)
❑ Other(explain)
0 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 L7DZC-00003
Complete the section appropriate for the type of water connection being evaluated: {�f
Public Water System
Name of Water System: ' `'` -^_- """ "� 733 737 ( 12_3643:30g tl'2- /(2.3 0,-.1 33o10,42)
Water Facility Inventory (WFI) Number: J.IGNE
•
(write "none"for two-party)
O I am the manager of this water system. The water system has been approved for 2.• services
There are presently connection(s) in use. This will be the connection.
O I 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 Brg
c� R� �L Date 6 1
This form may be scanned and available for public view at www.co.mason.wa.us.
11G11 Fomu\Drinkin_Watcr Retie l Ih l20l�
Individual Water Well
Water well report(attached to application). Depth Mg 5‘ ft ! (Zp iq
iti
4 Well capacity Test(attached to application)_ if c1� gpm ?$DO gpd. Rf
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.
XSatisfactory bacteriological test (attach to application). (3 /7n it(
Water Resource Inventory Area (WRIA)
-I
Developmen— t�tttrit WRfA http.Ugis.co mason.wa.us/planninq 14_ 15_ 16 22___ �y
Water use or limitation recorded ..... ... . .. N/A __Yes �TFI`22v767l
Well Drilled .................. ... ... . ........ ....... ....... ..... Date 5/Z?1 f l .7
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: ason 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.
1 l UnsatisfactoryDetermination: s. �;.
ct:. ,,
Applicants water supply does not appear adequate to meet the needs of its intended use for the`'fo)Yoci gL .,,
reason(s). _
_1. & >
• as�yc 4 'c . rp
• •
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Reviewer's Signatures: 0 ; 8�%
r k7S
Environ. Health: Date 5/704'.1‘.,6T
CSD Director: Date _ �`yFglTy -"' '
MASON COUNTY 415 N 6TH STREET,SHELTON,WA 98584
SHELTON:360-427-9670,EXT 400
BELFAIR:360-275-4467,EXT 400
Public Health & Human Services ELMA:360-482-5269,EXT 400
FAX:360-427-7787
YATES ET AL ALLISON NICOLE
733 NE BEAR CREEK DEWATTO RD
BELFAIR, WA 98528
ARE WATER SYSTEM PERMIT: TWO-PARTY
WEL2025-00003
7' ek Dewatto Rd
123093304020
The 2-party water system, 733737 (123093304020/123093304040 , viewed and is
N hereby APPROVED for 2 connections. Please continue to follow best management prac Ic -with
maintaining your water system including regular water analysis, landscaping, keeping wellhead area
free of contaminants, and stormwater management around the water source.
If you have any questions, please contact me at 360-427-9670 Ext.353 or email at
danderson@masoncountywa.gov
Sincerely,
David Anderson ' -
Environmental Health Specialist
Mason County Environmental Health
'7(7)( ?o7f
Application No. -
or,�,,.I and First Copy with WATER WELL REPORT
rsla r411"of LeewaydTON Permit
urea Owners Copy
�y OftNees Copy STATE OlR W
TurdBn Q ._.Balfai�
None__ �t� hano - , a T.23-N.. R.1 -W.M.
. . .... -,��-+: -S..u1..: see.-�
• (2) LOCATION OF WELL: cour,tr_... . __._..O1IP.9U ..._.
fa. Bearing and dLtance tram section or subdivision corner WELL LOG
Municipal❑ (10) material an3 afr»etttre,and
(3) PROPOSED USE: Domuac [g Industrial ❑ to cage
Test Well 0 Other ❑ Tormation: Deacrtba by1 Bolo+,elteracin ttze o
Irritation 0sAor,t►ttckneas of o0�4A et lrwtuont rry for earl. champ, of rl formation.
Ql meaty-=rpted. IrRom TO
MATERIAL ERIAL
pwner's number at well •.-.- ,
(4) TYPE OF WORA: itt more then anal..-• _..........__Bo 0 --
N New well ] Method: Dun 0Bra�_tapsniL-- - - r
Deepened ❑ Cable ja Driven 0 : • • a • e • • : . - a
D Rotary Q Jetted ❑ -
o Itecondltioned 0 rtat•.]ced-__- --
(5) DIMENSIONS: Diameter of well inehH• • a
6
i.
rt. Depth of completed well. ........ -
o Drtlled...___36.. -----
h (ti) CONSTRUCTION DETAILS: — -.___
�- Casing installed:. . G....2,Diarn. from .......0... ft. to ..31-_f. -
O -?ham. tram . ........._ ri. to -_.._....ft.
Threaded❑ ... ._.__ - -
ft. to __._._... .
= welded Q .._.._._-•• Diem. tram ....___...... � �
t Perforations: Yet 0 No __.-. !
y Type of perforator used._... _._._.._._......_.....-.--
>v tn. by ..._._.__......._.__ ter. o
Q SIZE of perforations is._...__._�_.__... �^_.-...- �. - _
-__ --_-perforations from -...•.--_ ft.to -
,� -.ft. -
! C pertoraaooa from __.- ft.to.. 111111"1°."..-. NI _ -
nw. - ft.
� _ _perforations from --._ - '—
Al
4+ Screens. Yef No 0 _
= Manufacturer's NameUPO -Z "`.n-._...._________• --
lk* co 4ypc.5 i2 3-e-as.-Set - Maatl xa...._-----.-..__.
it _Slot size QZ from . 31-ft.to - ft.
Dlam--... -
from .._ T _
D1am -- Slat size -
Gravel packed Yea a No]C site of gravel:._._..._._.__.......... ______ . iim
C
- _,43 Gravel placed from._..------...._.-ft.to....._...._........---__..ft. / -
Surface seal: Yes a No 0 To what depth, ._..... .8.•--._ ft. - _ JUN ) , `
_.-_-.. t� QV
Mtezfal ,,seal sa seal...-Bt311t41I..t•-..""` V No❑ ____ — _.-i-7----_--------
D/d arty ,,rats eontafn utlsable water} Yes❑ __.._.Depth of strata..,.._...... _e of watery..-----� _._ _..._.._....16ethod °t aeallna atria off---....-.-._.- -(7) PUMP: Manufacturers Nameof lneristal-li-T H. -.._..._....T - ... _._._....... _---.__...+ (8) WATER LEVELS: Land menace elevaaan
COabove mean sea level.... .. ....._......a.
Q Static level 21 rt. below top of well Date..5./29/79
O ..._...lb•. per square Inch Date ___..........
Artesian Dzessute..___..... _..-.
O Artesian water is controlled by (Cap, vale), ate.) -- - ------
LU
M-
p (9) WELL TESTS: Dray/clown is amount water level 1s .1 }��lowered below static level Work started- J...._...... 1A__7.9 Completed...NR j...29 it...
t, Was a pump test made? Yes 0 NiMita If yes, by whom?.
at Yield: gal./min. with ft. drawdown after hrs. WELL DRILLER'S STATEMENT:
This well was drilled under my jurisdiction and this report is
„ - true to the best of my knowledge and belief.
Q Recovery data (time taken as zero when pomp turned off) (water level
0.1 measured from well top to water level)
NAME jt�ra,�-t�Lg... el•�.... .- 1•-Il , . . . . .. .....
3 Tune Water Level Time Water Level I Time Water Level "(ire n, rm, o ra on g (Type or print)
_... . M. .._ Star OU a 2, ox 79
a� __
C t
Addreta...BY!emer.tnn, UBsh-.....9.a31Q•�- ---_
•
I.
•
Date of test ..... ,. ,
-,_ --.. -. _- ----_..... [Signed]......... 11rr�Bailer testgal./min.... gal./min. with.--. ..7 tt+
... .lt, drawdoo after...... her. swell Driller)
Artesian Sow...-._ _ __ ..... _._..._x.pin. Date _.._...._.._ _,........
Temperature of water..............was a chemical analysts made/ Yes D No D Ldeenae No........�? D•tt.....5/3p . l9. '�•
1USfE ADDITIONAL SHEETS IF NECESSARY) .�► i
P.No.tli/-O5--)Rev,/-71).
COOLWATER DRILLING, INC.
10921 HOLLY RD NW
BREMERTON, WA 98312
360-830-9005
COOLWDI941QM
CUSTOMER NAME DATE: 30 August 2024
Davies Construction
CUSTOMER ADDRESS
737 NE BearCreek Dewato RD
TIME STATIC GPM TIME STATIC GPM
22
05 25 8 120
10 32 8 135
15 35 8 150
20 35 8 165
25 35 8 180
30 35 8 205
1 45 35 8 220
60 35 8 235
75 35 8
90 35 8
i 105
RECOVERY STATIC RECOVERY STATIC
TIME TIME
05 32 30
i 10 28 45
15 25 60
20 22 75
25 90
•
26276 Twelve
Trees Ln NW .
Ste.0 It SPECTRA Laboratories - Kitsap
15oulsbo,WA _ ^` ,,Where exntrienct raarreer
98370 —
(360}779-5141 COLIFORM BACTERIA ANALYSIS FORM
,
Date Sample Collected Time Sample ( County
Collected
jj dra 4
North Day Year L • a 774 s of
Type of Water System(check only one box)
❑Group A ❑Group B grOther •
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
System Name:
Contact Person: coot, R. 6 p-et�CL�
Day Phone: 3 c O $j D• $'pi c Cell Phone:
! Email: Eve.Phone:
(
.Send resutts to:(Pint fo41 name,arOress and zip cede or urea above for Cectroniu copy of renufl)
{
el,sLW!~r ttAt at G e /461,4/ddE. 041_
•
SAMPLE INFORMATION
Sample collected by(name): vo
Specific location where sample collected: f Special instructions or comments:
737 c2“f
Type of Sample(check only one box)
1.❑Routino Distribution Sample(AlP) 2.❑Repeat Sample(A/P)
Chlorinated:Yes ❑ No❑ (from distribution system after unsat.routine)
Unsatisfactory routine lab number
Chlorine Residual:Total Free
3.Ground Water Rule Source Sample
S 1 ( Unsatisfactory routine collect date:
i / !
Chlorinated:Yes No
El Triggered (ANP)
Chlorine Residual:Total_Free
❑Assessment(A/P)
4.Surface or GWI Raw Source Water Sample(Enumeration) S f
0 E.coil ❑Fecal Fit'ured Yes_No
5. Sample Collected for Information Only.
LAB USE ONLY..:: DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Colfcnm Present and �Satisfastory
❑E.coli present ❑E.coliabsent
Bacterial Density Results:Total Colifoern mpni100m1.Ecoli mpnll00ml.
Fecal Coliform cfu/l00ml. HPC.__ cfu/tml.
Replacement Sample Required: ❑TNTC ❑Sample too old
❑ Sample Volume ❑Damaged Container ❑
Da!e/Tirne Received: \`5 Lab Reference Number
Receipt Temp e't—IS3 Method s M922 B QT COUNTI SM9222D
TRf ropai,lamed softly r7to use or to pawn orcca rryto
Date In: Date Out Wren a is seamed rly UM.copying crdidoun eor dun braa
mrx,Mono nosy It*an*Irttrottak*at X0-77a-5141 end
DOH Lab-Sample# dO >rxl P
onv
These natWMa crty btho Kan'baled ant to=Naga)K
010- =Wed Who bbe.'ay.IAsr pat 3trall mcc.rwodrAa.aaa
4n all tlCcu pier egmaarbn6WCk lbfSped{letorabries-
ooN Form t331Jt9(oaocav cell7)
RECEIVED
MAR 28 2024 2209074 MASON CO IAA
03/26/2024 10:17 AM NOTCE
KRITLIN DUPLECHIN ti196173 Rec Fee: 304.60 Pages: 2
615 W. Alder Street IIIIIIilllliii ill�Illllliai IIIIl riiiiiil1Ill!lill1 i'°tiiiiI1IIII
Return To
15h'31 RAC. h1vv'
Pru 1,6-19 , WA $
Grantor(s):(1) >vcl i.1-1)*'2 Jup1-th)k - '(2) - _Grantee(s): (1)PUBLIC
Legal Description (1) 6`/k ( �/2_ (,t1 I 01-0 L LL 444/!et tP
(Abbreviated form:i.e.lot, block,plat or section, township, range)
Assessor's Tax Parcel: (1) 1 . 9, 3 ,0 9 - 3 - D Li T)
Pi
TITLE NOTIFICATION OF WATER RESOURCE INVENTORY AREA(WRIA)
I (We), the undersigned grantor(s), hereby place this notice on record that the described 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: +l
Maximum Annual Average Gallons Per Day: ci'510 gallons
Dated on this ) L/411 day of Arr.], , 20 2VI .
•
Signature of
Grantor(s):
(1) :��rr , (2)
State of Washington
,County of-Masao`)
Page 1 of 2
11.11711111.1.11111111.11111.11.1.11111111.11111111"
I,the undersigned, a Notary Public in and for the above na ed County and State, do hereby
certify that on this I(� day of NkC.k(()+A , 20 ZL ,
:-.Gk l t 14 VQ cL11(\ 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 itten.
,N.N. ••. "\" '\1•.. Nota ublic in and for the State of Washington,
SYDNEY HERNANDEZ
NOTARY PUBLIC#22022901 I) residing ata�
STATE OF WASHINGTON j My commission expires: 0 91 i /)ty .ce
COMMISSION EXPIRES
FEBRUARY 17, 2026 '
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