HomeMy WebLinkAboutWAT2023-00011 - WAT Application - 1/23/2023 RECEIVED
WAT2023 — ono I
JAN 2 3 2023 ' ""k MASON COUNTY
jam' 7.
615 W. Alder Street ' COMMUNITY SERVICES
r r
ryj tiY Building,Planning,Environmental Health,Community Health
415 N 6th 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: Michael Johnson Date: 1-11-23
Mailing Address: 9735 NW Skyline Blvd. Portland, OR 97231Dhone: 360-989-4862
Parcel Number: 22009-12-90012
Type of Water System Reason for Application
�
Public/Community Water System (2 or more lk Building permit -?a1� ZU 3 -uOD 3�
�-
connections) 0 Division of land:
O Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
O Spring/surface water ❑ 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
Complete the section appropriate for the type of water connection being evaluated.
Public Water System
Name of Water System: GREAT GRAPE
Water Facility Inventory(WFI) Number: 45291
(write"none"for two-party)
I am the manager of this water system. The water system has been appr ed for e services.
• There are presently /7 connection(s) in use.This will be the connection.
•
❑ 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 Managed�^ • - Dgr/1 it_-r Date /J1,„ 03
This form may be scanned and available for public view at www.co.mason,wa.us.
1\FH Forms\Drinking Water Revised
a ' I.: r
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 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.us/planninq 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
❑ 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:fMason County Community Services Evaluation (staff use only)
V 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: II �'L:�O
Environ. Health. Date (% /0 Zi
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
•
2000 Lakeridge Dr. SW t Olympia,WA 98502
- 360 867-2631
ntottgroN COUNTY
• 11111111
. . COLIFORM BACTERIA ANALYSIS
•
Date Sample Collected jTirse Sample County
Collected
1 I DAM
. P..
1,1,,,,rr YEzr
Type of Water System(check only one box) LI Private Household
Group A 0 Group B Dcther
GroupA and GroupB Systems-Provide from Water Facilities InventoryFI):
NV
IDg
System Name:
Contact Person:
Day Phone:( Cell Phone:
E-mail: . Eve.Phone:(
Send results 0P"it fil rare.adcress and zip code or email address)
SAMPLE INFORMATION
Sample collected by(name):
Specific location or address where sample collected: Special instructions or comments:
Type of Sample(must Cried(only one box of gl through g4 listed below)
i.EJ Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes No 0 Distribution System
Chlorine Residual:Total Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residua'.Total Free
0 E. -GWR(AiP)
0 Fecal-Sslace,GWI,springs(numeiatvi Unsatisfactory routine lab number:
ziltered:Yes No
0 Assessment Monitoring(AP)
Unsatisfactory routine collect date:
Othe.
4.0 Sample Collected for Information Only
Investigative construction I Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
0 Unsatisfactory Total Coliform Present and 0 Satisfactory
LI E.cofipresert 0 E.coli absent No'Coliform detected
Replacement Sample Required:
0 Sample too old(>30 hours) El TNTC LI
Bacterial Density Results:Total Coliform 1100m1. E.coli /100ml.
Fecal Coliform 1100m1 Enterococci /100 ml.
Method Code:El SM 92238 EISM 9222D Date and T•rne Received:
LI SM 921513 CD Enteroler*
Date am:Time Analyzed Date Reperted:
Sa-ve Number MO,4 ripme•cl.ts`.ve cLqcsi Lac Use Only
0 8 0
DO 4;or—:1331-315(rev.sed 01/16)
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PICKERING ROAD i`"~
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N '' I f OLD WINERY RD
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1 /I PUMP TANK
EXISTING CONNECTION POINT FOR
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APPROX. EXISTING _ \1 'CAUTION OTHER UTILITIES NEARBY
WATERLINE. SLEEVE
TRANSPORT LINE I I PROPOSED SHOP/RESIDENCE
IF W/IN 10FT i I
r1 I PROPOSEDSEPTI TANKS W/ NEW
CONNECTION TO I I
COMMUNITY L 1 j Ay tiVeb
PRAINFIELD LOCATED L_1 I
ON PARCEL N I r I MAR 0 3 2023
22009-12-90180 &
22009-12-90190 v N MASON COUNTY ENVIRONMENTAL H _ TP
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APPROX. SHORELINE I ♦if., fps
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PICKERING PASSAGE EXPR S
AN ASBUILT/INSTALL SIGNOFF FEE WILL
BE CHARGED AT TIME OF INSTALLATION 1 CUSTOMER.: MICHAEL JOHNSON NO TEST HOLES NEEDED/TANK ONLY
PIONEER DICCINC, INC. PARCEL=:22009-12-90012
SEPTIC DESIGNS ADDRESS: 50 E OLD WINERY RD
30331.:MASON BENS`N RD. GRAP 'IEN',WA 085I6 DESIGNER: ROBERT H.PAYSSE RATSSURVEYS FIELD TIES IS MOT"SIEASUREYP-j TS REFERENCES
DENGN T INCLUDE E OEDFONTY UR PROVIDED
FfiCL 3bi)#Lfi I8i)3 FAQ 3 1T I>_%2353 n PURPOSES ONLY PROPOSED 'EVE_CPMSNT MAY BE SUBJECT TO OTNER
SHEET: SITE PLAN SCALE: I =mu DEPARTMENTIAGENCY REVIEW DESIGNER NOT RESPOSIBLE FOR SETBACKS UNRELATED TO
SEPTIC COMPONENTS
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,./. ' I '‘ AN ASBUILT/INSTALL SIGNOFF FEE WILL
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EXISTING STUB OUT/ I
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. EXISTING STUBOUT AND CONNECTION
TO EXISTING FORCEMAIN. INSTALL
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SERVICEABLE 2" BALL & CHECK VALVE
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IF NONE ALREADY EXISTS.
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PROPOSED BALL VALVE
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PROPOSED NLIkA,'.-1‘TER. BN R500
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PIONL.1.7:1‘. I.J1k_xk...111 N la) liNl..... PAR.CEL 22009-12-90012
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'.11TIC: DESIGNS ADDRESS: 50 E OLD WINERY RD
. . 3083 E xiA,..s.,\3EN...,zoN R.D. GRApariEw.‘‘A 08546 DESIGNER.: ROBER.T H.PAYSSE C4SCIJUMER THIS IS NOT A SURVEY.RVER'is+CES.I..O.....JE APPL.CAICWOUNTY PROVIDED
PLATS OR&AVM FiELOVEAS.ASN'Ll A.P.:...0....7:WS DESiON NTEROE0 FOR SEPTIC
1 ' •-.)FFNa .:;0-4261803 F.AX-3ôO4272353 SHEET: DF DETAIL SCALE r=20' i>67itrigrZficy REPvil.:vM;s.T'ti'it;')!ifitrE Frli SES,tfgtilirfLATIErg
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USE RVBBER
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/�. AND ELECTRICAL
! F‘ ON RISERS. MAKE
. 1 '. _. SURE ALL HOLES
P,`,'' .- — ARE WATER-TIGHT
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. u _.. _ i a - a FINISHED GRADE
- TRANSPORT ORT LINE
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' .HIGH , TER. FLOAT .
..__._ __ C, --- SE TANKS FITTED
' ON/OFF FLOAT 1,,,jluiiiijr1
_ ' .7 CAST I '::ATER
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:i� '— '" ENSURE�1�A ER1 i.. z2-.4,',.1...1,....•;;;,..;:ii,. , :' - TIGHTNESS tI
EXPtf
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, CUSTOMER: ,MICHAEL JOHNSON SCALE:N:x 1
4 '_ PI' EE-? DIGGI �G, NU. PARC>I.=:zlno°a oo>z INSTALL TANKS O ORIGINAL OR
j ,L DESIGNS ADDRESS: 50 E OLDOBERT H.WITiERYPAYSSE RD COh1PACTEP LEVEL SOILS. RUN CROSS ki
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' 3083 E.�+ ",d RD. R MEL`IGW,WA98516 DESIGNER: R CONNECTIONS:NTO ORIGINAL NAL SOILS TO
O FF C E• 36042&O3 FAX 36 42:2 53 DESIGN PAGE TANKS DETAIL
I AVOID SEITLI N .