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HomeMy WebLinkAboutWAT2025-00163 - WAT Application - 9/22/2025 r WAT 2025-00163 MASON COUNTY< r*: Shelton:360-427-9670,Ext.400 : r Public Health & Human Services Belfair:360-275-4467,Ext.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! reel Identification /1 r� .r Name on Applicant: I 1")I,YtC Li , ,�1{l;� I`1>C: " :{ L�:') Date: 1"r�-262,`7 Mailing Address: i 1 p L�?24,-1- �,�i �t �lt�-t ,, Phone: l '7.2IJC' '7W ' 690 Parcel Number: VL) ' `y .1.t YL lt. .l_� C�i),-c-,! ‘2, •-i - `'{'f - &-) Type of Water System Reason for Application Public/Community Water System (2 or more ❑ Building permit ,��(.G[il - i ' connections) ❑ Division of land: ❑ Individual water source (one connection), #of Parcels? SPL ❑ Well 0 Boundary line adjustment ❑ Spring/surface water 0 Other(explain) 0 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 See WEL2025-00028 Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: /.i)Lkk.'.t7. "J44t6(2' ' IVY-) t71. I))Le • - Ckk c.ix) . 22,12to 'L f- Oal x. 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 tom.. connection. 0 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. 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 J:\EH Forms\Drinking Water Revised 05/08/2024 Page 1 at 2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well ® Water well report(attached to application). Depth unknown ft. 11 l Well capacity Test(attached to application) gpm >400 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. l Satisfactory bacteriological test within last year (attach to application). 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: 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. CI Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). 'R Reviewer's Signatures: Environ. Health: Date 9/22/25 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 Water Well Report For An Existing Well JoN?3 .. Your well must be properly tagged prior to submitting this form. Rec 25 Asterisks(")indicate required fields. Mail completed original form to: �Fjj DEPACCTMENT OF WA State Department of Ecology, PO Box 47600, Olympia,WA 98504-7600 ECOLOGY State of washingtoo ------- Use this form if an original Water Well Report was never filed or is missing from Ecology records. L�`\ *Current Use "Unique Ecology Well ID Tag Number: -)Q C VL\ IAODmestic ©Industrial ❑tvlunicipal ❑Dewater 'Water Right: QYes (if yes, attach a copy) QNo ❑Irrigation DTest Well ❑Other. `Property Owner Name: Tara Parker Dimensions Diameter of welt 6 in. 'Well Street Address: 3261 E Harstine IsInd Rd N Depth of completed well__ ft.(if known) 'City: Shelton — `County: Mason Construction Details 'Site Well ID: NA Liner installed: Dyes ENo ❑Unknown Type: DPVC ®Steel ❑Concrete Liner Tax Parcel Number: 22126.44-00080 k DUnknown Dottier: 'Daly:Well Constructed: Na. Perforations Oyes ONo QUnknown 'Location (Township, Range, Section) Size of perforations in.by_ _in. An accurate location of your well is very important. The Number of perforations_ from—�ft.to Section,Township, Range,and Y.,%can be found on your E Screens tax parcel legal description or through your county Dyes QNo ®Unknown assessor's office. E Type: ❑Stainless Steel ❑PVC pother: __ il E Diameter Slot Size from ft.to_ ft. Township 21N Range 2W DEW M or I]WWM 6 Gravel/Filter Pack Section 26 SE 1/4-1 J4 SE 114 c QYes 0'10 ®Unknown 1, AC."6 Materials placed from ft.to ft. Comments: .�r� Mah'1\4 - )ok4 7-n-3r g Surface Seal ,4�2.�51 1!� o Oyes If known,to what depth ft. ttff V 3 f)U tvt.C]�l1GS 5 ❑No ®Unknown :lff"rOlrto/ Materials used if known:_- — Co I- r QBentonite ❑Cement O ? , lcvy � f({Pump J `�Z� Yes ONo ❑Unknown LatltudelLongitude , Type sub Horse Power?a • >R (Decimal Degrees recorded to 5 decimal'plaarditas PAD Water Levels ` Latitude{Gxa le 47.122345) 9 iStin Land-surface elevation above mean sea level )` rt. �ud �� 471� T n Casing stick-up +.05 above/below land surface o _ Static Level 95.5' ft.below top of casing Date measurod:5/9i2t Lon iti$le xa m lNiCe_118 345 Artesian pressure no _lbs. per square in.Date measured: :� ` i_(E r u LI [) Well heed has cap? yes❑No Shut off valve?OYes®No o Additional Information(if available, please attach) uu Well Tests: [_)Location marked on topographic map o Drawdown is amount water level is lowered below static level. Location marked on air photo Was a pump test made?®Yes(attach copy)❑No 0 Unknown g Yield: 11 gal/min.with 12 ft.drawdown after 3 ______hrs. `(]Consultant well report 's *Certification: The information reported above is true to the best of my knowledge and belief. w ❑Consu Ling Firm [Driller ❑Engineer ❑Property Owner c —•-r------ Name:Mlke Davis cA c- t- Company:Davis Pumps Inc License Numb : 7 7 ( Address of person completing this form: -- 340 NE Davis Farm Rd Signature: -— [Date Signed: +1 "n L City, State,Zip:gelfair,Wa 98528 Printed -roan Mason CountyDMS 11 1'11'I1•.iST ft)•)•'tllhl Iar1,a.•.I:11.1h.t•:.N11nh iti•�et1,pNC1111i111t •t.1at.'risl•11 a 1.611,111 tot 11,. %1 .1.,11, t1lq.:n1.',I ,.u•I.•.t'kn tk1i1.•t lt.:o.wx;l'o4Tr.'t. tr,u.•1117• �te,At7itl�fi fi1.+61b1.fiittCliVia.1t•n:v,,t:rLn `:.•t%it'r>.I :1I 1'.n..,, ••.,d,.p.•rihd1 ..1.d't•. 1,..,. , ,.1iI'. atl 'lt.t.tII F Vavia 1'wn a, Inc. i 340 M Dcwia'Fcu7n 1141 ?3ef fair,`Wu 98528 . (360)329-2399 ' +.110 n(of .co/o9Y Project: JUN 0 3 2025 Capacity Test TAG: nta, none 3261 E Harstine Island Rd. N h 'As p�� rain Shelton, Wa V Date 5/9/25 Pump 1 H.P. Well Depth Unknown i _ Static Water Level 95.5 _Y Draw Down Recovery { Time Water Level GPM 0 107.5' 0. c g 0 min 95.5' 0 1min 102.3' e 5 min 106.1' 11 2 100' d o +`1 `- 10 min 106.4' 11 3 99' L a 5 15 min 106.4' 11 4 98.4' O 30 min 107.2' 11 5 98' _ . c 1 hr 107.4' 11 10 97' aL 2 hr 107.5' 11 20 96.5' L ..._/ a 3 hr 107.5' 11 30 _ 96.1' __ _� �, .� 40 95.5' 6 U U o Capacity Notes: c L L a a R Printed From Mason County DMS Printed from Mason County DMS Vanguard Laboratory 2635 Parkmont Lane SW . 0' Olympia,WA 98502 �;'•* 360.967.7010 VANGUAR Report of Laboratory Analysis LABORATf)K1 L Collected by: 1-Pro Home Inspections Matrix Drinking Watts aprowa(a)comcast.nct Laboratory ID: V241216-3 Sampling Address: Date Sampled: 12/16/24 9:110 3261 E liarstinc Island Road North Date Received: 12/16/24 9:58 Shelton,WA 98584 Date Reported: 12/19/2024 Sample 1D: 3261 E Harstine Island Road North Analysis Result SDRL MCI. Units DF Date Analyzed Total Coliform&l .coil by SM 9223B(1DEXX) Batch 1D:V241216-3 Analyst:AF COI iform,Total Negative I I MPN.100 mL I 12/16/24 18:00 E. colt Negative 1 1 MPN/100 rnL 1 12'16/24 18:00 Nitrate by Hach Method 10206 Hatch ID:V241216-3 Analyst:KS Nitrate(us NI ND n.50 I 0.fi(1 mg/I. 1 12/16 24 14:55 Notes: MPN:Most Probable Number ppm:parts per million rid.non-detect Reviewed by Dustin Newman,Laboratory Director on 12/19/2024 ma.not applicable SDR I. State Detection Reporting,limit Approved by Ton Johnson,Operations Manager on 12192024 Db.Dilution 1•avtie �s, Tyr• 11e25:2117 MCI:Macimum Contaminant I ccel !` S ACUEK ov a :4, Samples were mecived in acceplahk condition.The tesaltts)in this tepurt relate only to the portion of the samples)tested.All analyses were pertonacd consistent 11 with the Quality Acsttrance program of Vanguard Laboratory.Please contact the laboratory if you should have any questions about the results 2635 P t Ln SW,Suits A,Olympia W 98 0 I •- •c:360.967.7010 i testing(a;vanguardlaboratory.com l Printed From anon Count ..1.::lxtratorycom 1 of 1 Printed from Mason County DMS