HomeMy WebLinkAboutWAT2023-00324 - WAT Application - 11/14/2023 WAT 00a3
ATAMASON COUNTY
COMMUNITY SERVIQ$ECEIVED
Bolding Pbv,inq EmMnmenW HSI1F,CnmmnHy Healtl,
415 N V^Street, Bldg 8,Shelton WA 98584, NOV 14 2023
Shelton:(360)427-9670 ex1400 J Belfair:(360)275-4467 ext 400 A EI" ( 62-5269 ext 4"
FAX(360)427-7787 b�1 . Alder Street
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
' MENTAL
Part 1: Applicantl Parcel Identification HEALTH
Name on Applicant: Dale Hart Date:
Mailing Address: 1571 NE Tahuya Blacksmith RD. Phone: 253-753-7692
Parcel Number: 223305000241
Type of Water System J Reason for Application
❑ Public/Community Water System (2 or more SP Building permit gL1D0W5L?;,—C)k Z)_7i
connections) ❑ Division of land:
�a Individual water source(one connection), #of Parcels? SPL
N 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 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
L
ame of Water System:
ater Facility Inventory(WFI)Number:
(write"none'for two-party)
1 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.
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)connections)without exceeding
the limits of the water system or any limits set by state and local regulation.
ignature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
@Inldug Werer RaI... _'S'11)I8
Individual Water Well
Water well report(attached to application). Depth IV ft.
j Well capacity Test(attached to application) �]5 gpm 70000 opd.
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.
f/ Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htto://gis.m.mason.wa.us/olanninc 14 15_V 16_22
Water use or limitation recorded................................... N/A_7Yes_
Well Drilled ............................................................... Date N 00 0 6
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:
I 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 Pennits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Heafth: ��`/ �"'�1" Date
CSD Director: Date 2 of2
"WATED WELL REPORT CURRENT
�I,, , oaeeai r<ePy-P.I.o.i'nR-.tea.T"..n-anw. Notice of latest No. N 214772
L1/1�
Conatruttton/Deeummiaalon(..n'.in circle) ":::yam""�i�d ^`••"Tag"o.-i••_
A Construction Wmer Right Permit No.
O Decommission ORIGINAL INSTALLATION Norire Property Owner Name Gracll 191GRES
51AJOl� oflnlenl Number 1571 _ _........... _ __ .._
PROPOSM LBE: aaOOKRi ❑ IMWii O Multieipi Oily_Tahliva CODnLy oIm
p RWen tl WPam O Tw Well Do
WK01FwoRR: pam'sal�Raf.an(iraaealmoR) Locazion5'�I/41/4[.yLl/1 Sec�pTwn2; Rif
p papaw ••�"•••••••.• ,........_xl a Gem" o iar I Let(Long(s,1,r Let Deg_ I.m Min/Sec
rMmslons: IanmsorwnT AwAn. gim-72 IL still REOUIRED)
pas rM.FNw.+n Tp n ...ng�sLNy F1:.;,^„a:
rmnarRlRTlan aeTADE Tax Parcel No. 72110_9n AA241
uama {p wnW 6 otowepa_+_n.bfL'Lrt.
IemA&aM Tl Lm Mlb1_- ma.eun 6r rt CpNSrRUCnONORDECOMMWlMPROCWURE
ra.n mun na n Foaeliae Da[a4 ny We..aurcla.aa:oliaa.rlW.acbR Wan tiiaW
waarellel: pYn RNo MnA—A,MllaISEAneia IONALSsebMna ECER<beY fa eNaWe1M
TyR MR.faeMuaeA i.Fnnu.im fIISF.ADnITONAL SNEL131F NECERSARY.1
SI]ENRh_bay_inWw.ofPaa_flaa_a.b_n. WWRML FRW I TD
�g[raaR Tn O tb 4 gRa Lauinn (per
MrAaaa•arlm FYrn1QRa 0 2
Type AT4TNrF q Moeilb.
pion—�—ya is nan�r Rb�—ntill
GnaRPabrnaaW: O Yn RFb O a@aramsuma
raleeiala plyd fmm Ilb a Sand &9mye1WLth ater
I L.4n5u1: 6Yn O W T.
Meaia imeind ibfMihn --T�
Pi ury veaa CPWnlnmNe nebl p Ya [kNo I _�1II
TYR ofwaen Depe Rmm MeaoiafaliyaabM
PUMP: IMdraalat4w_Ia .T�_
Type: /a><l.l1Li �_RP.
wArul Bevels t.lnvsnanom.en.namxlM rt �-__
wnlew _js`.__—n.lxlon bvnrnal wb __ ��
A.Inwp.emve la.Rraauebrh 0.k
WeU.IEnY unnoow itucm r.vnw nwnvm an..a�n.0
Yiia:_yeMa aia Rbanavnn We_K
Yi e,uA,AwE nhaWnan Nn K
rna: an.n".n. A aeronal aw
b�i.my/esaanuun.nn Rnn wn.s aD hrnfewf..mb�Av nW
.en lerell
15m Wmrl/wl T. Wm Leal Tins WYa1aM . .:
YPaY_$_�I+Y4 n1n An tbneormab_�K
Avar_��IAele nln Mma.r n.lw K Y f
A..nbn Bun aPAL oa
TmiRmaeafwY_R'redsiolwlRelWal O Yr RNe .. .•-1'. , ` 11.
sm lMb 3/1/Dfi Crlarlllld Dir A/1n%ni:...-1
YwFI_I PONRTR=OAl CFQTIRTrATtnN. Im..anuaM nnMnr uvml m.5pnyibiliN(_rnnnnnlim nrlhia well,And ihrm.nlinnee wi.hnll
Wmhington well constrocfioo AwWWs. Materials used aM the information reported above are mte W my best lomwtedge and belief.
JT.svI- nc..i— nT— w,w rnwnn Mil hA Vi royria n.:114;
oiwt ,Annnrinma 5e Y, ion W. r1RVig FaIren wi
....i..,.. 7 � r,cm..,7, sIDl fai T. BID QAS?R
I(TRAWEP Canvai s
loose:.uraR4 w.
a ...,.. w DAWSDIl1O(A ry.n h,il rl(.
Iparyr•a 51pMa J - E..k,,n An 2PRl pppnMi4f opl°Yn.
Pri t d 2 TmnlariaY.�w..�alER�py�I�wamMy the Data and/or Informatbn on this Well Report
1'_ 'YLGC1 Printed from VtMason C7County DDMSSI '`7
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA.98584
Customer: Dale Hart Well Tag#: ALG406
Site Address: 1571 Blacksmith Tahuya Rd, Tahuya Depth: 72'
Date of Test: 12/20/2023 Static: 30.2
TIME GPM LEVEL RECOVERY
1 Min 7.1 35 TIME LEVEL
2 Min 7.1 37.8 1 Min 54.1
3 Min 7.1 42 2 Min 50.6
4 Min 7.1 44.9 3 Min 47
5 Min 7.1 46.9 4 Min 44.2
6 Min 7.1 48.9 5 Min 42
7 Min 6.8 50.2 6 Min 40.1
8 Min 6.8 51.6 7 Min 38.7
9 Min 6.8 53 8 Min 37.2
10 Min 6.7 53.7 9 Min 36.1
15 Min 6.7 57 10 Min 35.2
20 Min 6.7 58.5
25 Min 6.7 59.4 'Technicians pumped a total of 825 gallons`
30 Min 6.7 59.65
35 Min 6.7 59.95
40 Min 6.7 60A
45 Min 6.7 60.2
50 Min 6.7 60.3
55 Min 6.7 1 60.4
1 Hr 6.7 60.4
1 Hr 10 Min 6.7 60.65
1 Hr 20 Min 6.7 60.9
i Hr 30 Min 5.5 61.8
1 Hr 40 Min 5.5 57
1 Hr 50 Min 6.1 57.5
2 Hr 6.1 57.9
2 Hr 10 Min 6.1 58.1
p>noaoa3 -o137�y
Thurston County Envi ntal Healt
412 Lilly Rd NE
Olympia,WA 98506
.rxuRsrow�uwxr 360-867-2631 DEC 1 3
COLIFORM BACT A
Oab Sample Waddled TIM Sample
ll l ZI �2�G3 Collected
� N/ASOtiI
WNA our Y.
Type of Waler System(check only one box) ❑ Privao NouseMMl
❑GmudA ❑Group B P�psftr IAy/ 18M4Y
Group AaMGmup BSyslems-Prahahom Water FacilftMim On (WFI):
IDY
System Name:
ContactPerson: 14Ll5 — g AZT-
Day Phore:(S95) -7 q;3 -7&q CollPhpne:l )
E'��1QY`f{TOMGSIIG� ve.PMne:l 1
3ndmmem:(RMNt amsmtlrennd dp aemtlledbn
Ayary r-� oT
as�y �� rQr+uya t3r��,vSMirf-{
lfU LLJ �S �
SAMPLE INFORMATION
Sample collected by(nacre):
Specdc location or address where sample cdlected:l Special lnsoxeuns or wrmeids:
15-7 1 u6T'W"A Du CA✓S14 zd
TAN+/ A,Lt)A 4'$58'q
Type of Sample(nest check only one box of 91 through$4liated below)
1.❑Beutlne Disldbullon Sample 2.Repeat Sample(after onset routine)
Chlorinated:Yes_No a fp_buyma$psRpA /C D
Chlorine Residual:Total_Free_ Imma tl: es_ o_
3.Raw Watar Scume Sample allaai rffqj T�laj,,,"„F.
ElE.uay-GM(AR) (y��n[[m��np
❑Fecal-sm®.cm.rpimrlaamimm) Ms5s Cf 3V VV.rYA ree('
FJtere1Yn—No— __ _
❑Assessment Moniloriig(NP) Unamiafacrory mubm collect date:
❑ONer �_J_
S
4.;941sample Collected for Information Only
Investlgative_ Corded nl Repmm Other_
LAB USE ONLY DRINKING WA TER RESULTS LAB USE ONLY
❑Unsatisfactory Tool Wisdom Present and S atla Rcory
❑E.WPne"m ❑E.mp absent o Iilomi re.oted
Replaummt Sample Required:
❑Sample too old Q3O hours) ❑TNTC ❑
Bacteria Oendty Resub:Tool Caldmm 11OO 1. EMY 11O0M.
Fecal Coliform 11OOml Enlemmcd MOO ml,
Memod Onde: M9223B ❑SM9222D Gee and Time Re�alwd�p<j
❑SM9215B ❑Enleroler* 7.�'2tjLq
'Oate eM Ume Analmed Date Re -'L
Smp4Nimeer tooN nmmrgn Natlpal lab Use W..
0 8 0
gpgfsRVA713191mtNa m --