HomeMy WebLinkAboutBLD Water Adequacy - 2/20/1994 MASON. COUNTY DEPARTMENT OF HEALTH SERVICES
POST OFFICE BOX 1666
_ SHELTON, WA 99584
(206) 427-9670
FAX 427-8425
APPLICATION FOR DETERMINATION OF ADEQUACY
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INSTRUCTIONS
1. Complete Part 1. No determination can be made until Part 1 is fully cod-oleted.
2. Complete only the portion of Part 2 applying to the type of water systeE utilized.
3. Submit completed application, with attachments to the health department for review.
PART 1: APPLICANT/PARCEL IDENTIFICATION
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NAME OF APPLICANT _ A'® e t'-IV�i� DATE -
MAILING ADDRESS P.O. pj,�'jX /Q 2-I TELEPHONE 6
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ASSESSOR'S PARCEL NWCMM 3 110 7 -s0 ^ 00 q ►3 -
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SUBDIVISION .(If Applicable) a/ �} Lox ; �, 7. 4
TYPE OF WATER SYSTEM (Check One) REASON
FOR APPLICATION (Check Onel -
0 Public/Com2unity Water System !w Building Permit, Single family Res
13101 Individual System, Drilled Well Building Permit, Commercial
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Individual System, Dug well Building Permit, Replace/ 1
Individual System, Spring El Land Use Application
l71 Name
1� Individual System, Surface water gybe
Individual System, Other 0 Other
PART 2-A: PUBLIC WATER SYSTEM
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NAME OF WATER SYSTEM /y - wFI ID
star purveyor for t-L alsto has pr6vioeal7 flled a Certificate of -rarer adagraay With I health
district.
I an => of the above xafars=ced Tatar syat® The rater slat® bas Dce apgtmal for _ esrrity -
oannecLirea, rim m=cilo presazzly In-use. me applica-t pea approval to cco tol" rarer
syste=. eerrlce of rater to ca apPII a t for d tic perpnsea L occslatmt rite both the rarer systG
- plea and the ra rjot pe jt prpe3tl7 in effect. VatQ )i.-as are m the eppii. t: Prop"
line, or the aP911�t hss � aat.lnfactmy s ramPa=y to arta=d the lirss.
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PART 2-B: INDIVIDUAL WELL
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WELL DEPTH Ft WELL CAPACITY
Gallons/Minute - Gallons/Dap
El Well log-is attached to this application -
well capacity test results are attached to this application
BMW: Wall capacity taets ate often parfax:med by the Well dri.11ar at the rf-e, the Wall is cm-
structsd. test remits frO umme tarn are, noted "on the Wall log: P Its'fzm :bean
tsts Will be accepted by the health departst. If a Wall lag ca=ot be located by tba
appllca=, a wall capacity tear trust be perfcraad by a It.Wr-- - Balar or p=:p
tasty are acceptable, provided stabilization of draw-dwro bas been Waarse,d and recorded.
Satisfactory total coliform test is attached to this application.
PART 2-C: INDIVIDUAL SPRING OR SURFACE WATER
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❑ WDOE permit is attached to this application -
I have reason to believe the spring proposed as the water source will supply
adequate water its intended purpose. This belief is based on the following
observations:
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AUTHOR OF STATEMENT /J /c.y/J-o a&R-ri y DATE oI-0
RELATIONSHIP TO APPLICANT
SOS: In additim W providiog the above, star®mt, the applicant vill coed to artaogs a cm-nits
i`spsc ico by to bealth district prior to deteal;atloa of adegracy.
PART 3: HEALTH DISTRICT EVALUATION (Health District Use Only)
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El SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to meet :
needs of its intended use.
More: This dateaizatico Ames cot address adegac7 of tba distribution ryszc, garatae a adaq— amply
of Water lodefl-Italy into the futtua, or Tom, tse t¢plimce vita all applicable W= Water resource rego-
lat+one
UNSATISFACTORY DETERMINATION: Applicant's water supply does not appear ade-
quate to meet needs-of its intended use for-the following reason(s):
HEALTH INSPECTOR DATE
Flo- ov no cow.m s cwNo. U 097335
WATER WELL REPORT D00047Fr81ia MW 941
Acme Oopy—OmMev cap" STATE OF WASt@lGTC7N TcbaCtPr—'a="copy WarF02ftPow Iso.
M owlet N�_Brad Carey x 1021 Issaquah RA 98027
_ CD LOCIOMN OF WELL. cast' Masan w5.e �ttR 2�7 Wa1
CW STREET ADCHESSOFWELLjw t wesmwq Ne 208U North Shore Rd. Tahuva WA 98588�
(3) PROPOSED USE: a O bdrmetl O Kcal o (10) WELL LOG or ASARDOMIEW PROCM*DESCRIPTM
0 Der Te VM o OMW 0 Tens DeLa tl aatr.dsadr.sad:Wert'av aermsi.am m.aid.�aa4ilas
(t) TYPE OF WO
OwaY wept d wll �P tav d toe�,al u sstma pee�J.¢a a let ar ems/tr oa
RK: nrm ota d+al
Ababnad 0 Nm.al 0C Naft2 Doe a Bona 0 MATERIAL I FFIM To
Daapr.tl O CabeOT D&9 C- Brogan
f+ao> 0 Rotoy o jaw o
(5) oravTrd.! 6 i>deaa Blue clay &--gravel I 54 60
Dwarf 150 ra Daphd .0 150 : I
(6) CONSTRUCTDON OETAa.S: Tight sand & gravel fin FA
bnaOrt 6 D sm 0 d b' 145 el Brawn
atr:ts t :aatd0 araabm r<n el
Thsaded 0 • Disco bon—IL b 0.
T' t
Patasa>Qs rt O No p I I
Typed prtras teed
SDI d prtra5ors n by n
prtraers bm 1.b t
Pwk": mm bm 1:e - It
Brown conglanerate I -
saa.dz Yes91 Na0
178
Lbrciamwelms"aoa Gravel a same eater I 128 1
Two Stainless wire yw,
mom 5 sd stm 50 am y 145 a e 150 a
Dta_Sid she bom a.o S
GrMvMPm*g& T+a0 " No® StadQa.d Gravel & tieter
ca:.daamaem ae n I
swada.at Tat® tea 0 To.mdwag .. .1 R... e< Br04r I 141 144
IfisloOlmobsed HT BhlttlTtP am
DH r7 aTan cote duati.mR Ta.O No® Sand & Uavel w ?F D I
Type d emem7 wpaid a�trts _- I ►r,,
latlod d sesg ma o1 - - _ _ z
z w I m
m PUMP- tauwm;psrti"wee, _ I -.
Type: SIID. H.P. -
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(8) WATER LEVELS: tms"ftm mi>+ I '
4oct..r 10
0
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(/9�) .bn SesO [a RelalYe 1 I9
WELL TE�•.TS: (]�t1RCM.im,lAdli b.itl Ot�l/L'JSC 1Ad
Waapr- mmmm Trs❑ MOER 1701.br+�T WELL CONSTRUCTOR CFATU:WATSON:
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1te"sSor"aao^teynted aEas as ow to of het trw i am bdaL
ea CA:;* rt aiit when pmp mrWcq fear gang e.er<a0 boo I" " Davis
by N.a„W,4
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go,=19sd/m wm 39 It aaaT.n as 1 tea Cowaraots
Amsim. .m sto aaa eltr ea op— oaft SDI1100A Dmia,jaTlttaTyr 19—95
Taepa,a:sa d.aa,_vat s daeGl aatla cam T rat 0 No-53 (USE ADDITIONAL SHEETS T►ECES.SARY)
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