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HomeMy WebLinkAboutWAT2026-00176 - WAT Application - 9/2/2026 BoldSign Document ID:8e339f72-7099-46c3-b441-b1da3dace262 WAT OO 415 N.61 Street MASON COUNTY Shelton,Nvft 98584 ' COMMUNITY SERVICES Shelton:360-427-9670,Ext.400 Belfttir: 360-275-4467,Ex(.400 Building.Manning Env'uonmental Health Community Health Ehma:360-482-5269,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/ Parcel Identification Name on Applicant: Tyrian, Charles & Sandra Date: 07/02/2026 Mailing Address: 8090 Daniel Place NW, Silverdale,WA 98383 Phone: 360-621-9795 Parcel Number: 322255100024*Reference parcel#322255100023 DPC##26-01AF#2236097 Type of Water System Reason for Application 7 ® Public/Community Water System (2 or more M Building permit '9 Z(/[5-O0 connections) * See "WEL2025-00105" ❑ Division of land: ❑ Individual water source (one connection), #of Parcels? SPL El Well O 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 Public/Community 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: Tyrian/Tyrian *See "WEL2025-00105" Water Facility Inventory (WFI) Number: none (write "none" for two-party) IN I am the manager of this water system. The water system has been approved for 2 services. There are presently 1 connection(s) in use. This will be the 2nd 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. Print Name of Water System Manag r ' Charles & Sandra Phone 360-621-9795 Signature of Water System Manager Date 07/09/2026 ca1aa300 S417-{°3a�bd2-t➢7e63f1e0ta� This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Revised 4/27/2021 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well Water well report (attached to application). Depth 5 (• ft.` ( Well capacity Test (attached to application) 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). '(ZS'(zv l5 Individual Spring/Surface Water ❑ WDOE permit (attach to application) ❑ Method of disinfection O 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. 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: 4/ p Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.gov.' Page 2 of 2 ( A MASON COUNTY 415 N 6TH STREET,SHEL-967 WA 98584 SIHELTON:360-427-3670,EXT 400 BELFAIR:360-275-0467, EXT 400 Public Health & Human Services ELMA:360-482-5269,EXT 400 FAX:360-427-7787 01/26/2026 TYRIAN CHARLES G & SANDRA J 8090 DANIEL PLACE NW SILVERDALE, WA 98383 RE: WATER SYSTEM PERMIT: TWO-PARTY WEL2025-00905 10451 E State Route 106 322255100023 The 2-party water system, Two-Party Well (SFR + ADU): Tynan (322255100023/322255100023), has been reviewed and is hereby APPROVED for 2 connections. Please continue to follow best management practices 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 iited I - rom Mason County DMS hinted from Mason Cot lily MS Water Well Report For An Existing Well Your well must be properly tagged prior to submitting this form. Asterisks(")Indicate required fields. Mail completed original form to: DEPARTMENT OF WA State Department of Ecology, PO Box 47600, Olympia,WA 98504-7600 ECOLOGY State or WashIngton Use this form if an original Water Well Report was never filed or Is missing from Ecology records. Current Use `Unique Ecology Well ID Tag Number: 8P5424 [)Domestic ❑Industrial ❑Municlpai ❑Dewater •Water Right:❑Yes(If yes,attach a copy) ❑No ❑Irrigation ❑Test Weil ❑Other. Dimensions Property Owner Name: CHARLIE TYRIAN Diameter of well G In. "Well Street Address: 10451 E STATE HWY 106 Depth of completed well 54,7 ft.(if known) "City: UNION *County: MASON Construction Details Liner installed: []Yes ENO ❑Unknown *Site Well ID: Type: ❑PVC []Steel ❑Concrete Liner `Tax Parcel Number: 32225-51-00023 ❑Unknown ❑Other: Perforations ' 'Date Well Constructed: UNK ❑Yes ❑No ©Unknown Location(Township,Range,Section) 3 Size of perforations In.by jn. An accurate location of your well is very Important, The Number of perforations from ft. to_�.ft. Section,Township,Range, and 1/4,1/can be found on your Screens tax parcel legal description or through your county o ❑Yes ❑No ©Unknovm assessor's office. Typo: ❑Stainless Steel ❑PVC ❑Other: E Diameter Slot Size from ft.to ft. Township 22N Range 3W ❑EWM or❑WWM ° GravellFflterPack Section 25 NE 114-1/4 SE 114 D'es Qio lUnknown Materials placed from ft.to ft. Comments: 3 Surface Seal a ❑Yes if known,to what depth__�ft. in ❑No Unknown e pt of SWR. Materials used if known: ❑aentonite ❑Cement 4. Pump ° ®Yes ❑No ❑Unknown a Type GRUNDFOS SQE Horse Power 1 5 LalitudelLongltude (Decimal Degrees recorded to 5 decimal places) I- Water Levels (Example 47.12345) 2 Land-surface elevation above mean sea level 1x3 n Latitude V) Casing stick-up 2' above/below land surface e Static Level 15.3 ft.below top of casing Date ntoasured:41$12•' Longitude(Example 118.12345) Artesian pressure lbs.per square In. Date measured: 123.00609 Weil head has cap? Dyes❑No Shut off valve?jYos❑No Additional Information (if available,please attach) W Well Tests: ❑Location marked on topographic map O Drawdown Is amount water level is lowered below static level, ❑Location marked on air photo 4- Was a pump test made?®Yes(attach copy)❑No O Unknown Yield: 39.4 gallmin.with 4.3 ft.drawdown after 1 hrs. ❑Consultant well report t C *Certification: The information reported above is true to the best of my knowledge and belief. d ❑Consulting Firm ❑Driller - - ❑Engineer ❑Property Owner NICHOLSON DRILLING INC ALAN MYETTE Company:Name: License Number: Address of arson completing this form: PO BOX 12 Si nature: Date SI nod: City, State,Zip:PORTORCHARD WA 98367 ECY 070.557(0912016)To request AI)A accommodation including inoterials in a format for the visually impairrd,coil Ecology\Maier Re ources i'rogrant 360-107- r'fl i v 1 6,872.99 on���11 int gird b Ieasring*may call Wasig1on Rely Seryicea at 711. Persons with speech disability may calt'fri'at 877-833.0311 ` 9 I w1 VQ .11 if f f I intu'd from lVlat:>on (;!aunty I)IVIS it NICHOLSON DRILLING INC. PUMP TEST NAME: TYRIAN,CHARLIE DATE August 26,2025 SITE: 10451 EST HWY 106 TIME 1:30 PM UNION WA 98592 WELL DEPTH i -1 Feet WELL DIAMETER f 6" llnches PUMP MAKE GRUNDFOS PUMP MODEL jSQE1220 TANK MAKE i=LI=XCQN TANK MODEL IPJR6 Time Depth Draw Rate Time Depth Draw Rate Time Depth Draw Rate ,,aava To Down gpm to Down gpm to Down gpm Water Water Water Static 15.3 0.0 40 20.0 4.7 660 0,0 N 1 19.7 4.4 39.4 45 19.9 4.6 39.4 720 0.0 2 19.7 4.4 50 19.9 4.6 780 0.0 3 10.9 4.6 39.4 60 19.9 4.6 39.4 840 0,0 Q 4 19.9 4.6 70 0.0 900 0.0 5 19.9 4.6 39.4 Sfl 0.0 960 0.0 6 19.9 4.6 90 0.0 1020 0.0 0 7 19.9 4.6 39.4 100 0.0 1080 0.0 8 19.9 4.6_ 120 0.0 1140 0.0 0 9 19.9 4.6 39.4 150 0.0 1200 0.0 00 10 19.9 4.6 180 0.0 1280 0.0 0 11 19.9 4.6 39.4 210 0.0 1320 0.0 } 12 19.9 4.6 240 0.0 1380 0.0 13 19.9 4.6 39.4 270 0.0 1440 0.0 14 19,9 4.6 300 0.4 1500 0.0 15 19.9 4.6 39.4 360 0.0 1560 0.0 20 19.9 4.6 420 0.0 1620 0.0 I' a 25 20.0 4.7 39.4 480 0.0 1680 0.0 30 20.0 4.7 540 0.0 1740 0.0 35 19.9 4.8 39.4 600 0.0 1800 0.0 z RECOVERY Time Depth Draw Time Depth Draw Time Depth Draw to Down to Down to Down p. 4• f Water Water Water 1 15,3 0.0 11 0.0 45 0,0 �, T w 2 - 0.0 12 0.0 50 0.0 3 0,0 13 0.0 60 0.0 ; +. 4 0.0 14 0.0 70 0.0 ( V) 5 0.0 15 0.0 80 0.0 6 0.0 20 0.0 a 7 0.0 25 0.0 10(? 0.0 tai 0.0 30 0.0 120 0.0 d $ 0.0 35 0.0 150 0.0 10 0.0 40 0.0 180 0.0 ' (1l _____ k f SIGNED BY: Christopher Chilton-Pump Supervisor , ti 126276 T%:ivc 4k� rt y f4 PJ ,ti° ,y` � + ►,. , Sto.C r .;S•PGC ?R;A;xti�ox a(o idsIICU u ,�� Poulsbo,WA ,.� s,iT:'k�.:� 4`livfi2/4 aCTYht"rcfti �rliirca s`e3)1i s ' 98370 r ro s u e d r,..., (360)779-5141 r;CbEIF0RMai�,9CI I;, iAIVLYSISeFORM; pale Sample Cailected Tbne Sample County Gatfectod • 1,I❑raa Typo of WoterSystem(check anlyano box) I]Group A ❑Group B Other GroupA acid Group0Systems--Prov'do horn WaterFeeittlostnventnrl(titi I): lop ( I OgSi E CT SyelemNomo: �1a L �.1wti►'`t?'r1 ConlactPerson: N CHOL ON DRILLING payPhcne: á421j _Ce_Phone: EHtaIJ: EVa,l7tIDP10: f SsroJ msuts W¢rat e9 eaq.od�e.a a�!r>R adr v er.dl.ber.ror,t.tiontc co-y of my th) _O FICF NICHO SONnptll I_ING(g�GMAII__ M ^ CCHILTON.NICHOLSONDRILLING@GMAIL.COM Semple m'ected by(name) Specl5rcloclatiartwhew amhico3ecle : SpodallnstnicBons.ofcomments: 11=/.�1Y4' BSI.t•• 4"�:l;t'L� -Jl.. V fT aof$u rlala:(c �ckaa)yona Talc) ,�',;� <<.'v r ' k',�s'•r;''�N,uk I 1.CJ Routine DfstrtbkVon Sample(Alp) 2.❑ Repeat Sample'(AlP) awnaled:Yes ❑ tlo❑ tlremdlstdbu a$)%ItMMeruzseLn;uCnel chlorineResiduakTaa tin;a5n?acleryroutinotabnumec !—.Froo. . 3.GroundVlater Rule SaurceSample —`-- L�...1..__.L....,1 Unaattitacloryrastt�ecn�ectdato: Chodnnted:Yes f`fo ❑Uggered(PIP) Chtodne Residual:Total Fiefl p Assessment(A/P) 4.5urracaorGti57RawBoufceWaterSample{Fnumorattorl) E 0 Fecal F1 Y..__rl.__ 6. Sst pia Celedrd hs lnfomutbrr Cnry: ! ( Qf OUnri}tlajactory' Total CcWnrrnt?ra'Znta'nd a tisfactory E,cn prosa7l • Q• cofehsenl Bacterial Density Results:TotalCc ifumi. mpr i00rr .lwc i nit04rr,1, . T• mp FecatColo n cltUdmt, HPC_ cirllml, • ^ Replacement Sample Required: Q TNTC ❑Sample teo old Sample Volume ❑Damaged Cootabier ❑ Da aRe _ 4bRektercoNumtor /3o0 --C2t C1 y Reco?pl Temp C: MeD odCoie: � 'Qrcourtrr srdezuo fnwryarwhx.a mytr wwd eupa~smyrmetiwyN -1 n .mrb,d3rndl,�w, .e.dwo...�rwert� 8`2.t Z2e �/2 /2 -' ttmdeStr 4nikf�sAw �IdvrtmdMMar�ath I ��f.wm7r M f4i6tr1xuLllr Y 7e}{,{jl ll Kd OOH LtbSompfo# mr�ywhoa+v:+a�. ikprn4rrdl-1 Ot/dSlO dtimtfi►1;iE rw o.jhttyC 010•. t Q �� rr,M+�,.�. ,p„,..tatlYedn0trrg� r gt4wtrosrmr.�m.drm RP�'�N-s?�tsarnles oara.attaI, ei uJ ' rite 11 `roan Mason County UM Printed from Masan County DMS