HomeMy WebLinkAboutBLD Water Adequacy - 5/18/2017 (3) i
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EMAIL TO MiKEATPOtCCONIGAST,NET
ENVIRONMEN
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Health HEALTH
Alw ys.woNr ,for a sa healthier t+ta ►c«,�ty
PO 80.1666,415 N 6h Street;Bldg 8,Sheltoo WA 98584,
SheNcn.(S80)�7-967e ext 400 4 Se(fair:(36Q).279-4d67 ext 444 4 'Elma:(;*O�482 E IV E D
FAx (30)427-7787 1
Application for Determination of Adequacy MAY 2 2 2017
Instructions 615 W. Alder Stt-Oa t
1. Complete'Part 1. No determination can be made until Part 1 Is fully cgM2.12 A
2. Complete only-the portion of Part 2 applying to the type of water system utilised.
3. SubmrtmMpieW applkwoon,,with yttachmWtts to thwhealth department for roview.
Part 1: Applicant/Parcel Identification C9�-. lU Zo t 7 - 00 y rJ 3
Name on Applicant: STEVE&DIANA LANE Date: 05/18/2017
Mailing Address:2883 NE CEDAR CREEK WAY,POUL$BO.WA 98370Phone:: 253-20$-9077
Parcel Number:: 42205-52-00042 DIVISION 19 LOT 42 !
Type of Water System Reason for Application i
W PublialCommunity Water,System.(2 or more ® Building.permit
conneotions)" ❑ Division of land:
❑ Individual water$.ource(one connection), #of Parc ts? ;3PL
❑ Well ❑ Boundary line adjustment
❑ Sprtngfsurface water ❑ Other(explain)
❑ Other(explain)
O Replacement(please indicate name of water
If,you have more than one residence connected system below if applicable—no signature
to-this well, check the Public/Community Water required)
System box.
Part Z: Water System Information
C«MpI6te the section appropriate for the type of water system being evaluated:
Public Water Sy stern
Name of Water System: LAKE CUSHMAN SYSTEM 5
Water Facility Inventory(WFI)Number: 03629 0
(write9"none"for two-party) !
❑ I am-the.manager of this water system.The water system has been approved for samiceis.
There are.presently connection(s)in use.This will be the connection.
M t am the manager of this system.This connection will be to upgrade or change the.use of an existing
connection on this system(1,e.:recreational to full time).Please Indicate on the following line the nature
of this change: RECREATIONAL TO FULL TIME
This water system is able and willing to provide water to this(these)corineetion(s)without exceeding
the limits of the water system or any limits set by state and local regulation.
Signature of Water System Manager Date i
x
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Itev w 3/um f I
Page I of2-
RECEIVED
MAY 242017
EN��RONMENTAL VATER WELL REPORT start WAIew. Alde fleet
o hair veil I.D. i AAC313
STATE OF 11A5RItiiTON _ >toter Rillt Permit No.
(I) DINER: Noel- INS, NANYEY ...Address Ills S FLOIM AVE PORT OMCNAND,-S _fp1E-_� ---
12) LOCATING OF HELL: County MASON - NN 114 NN 1/4 Sic 29~T U I., R 11 IN�
Ia) STREET ADDRESS OF 1E11 for merest address) E i1119 OFF 3, ALLYN
y (3) PROPOSED NSE: OOMSTIC ` (10) VEIL lfl6
zx =x
saasassxzsmaaaaraasssssssxasa=sass=: ss sssczsrszzss=l---»-_--------------------------------------------- ---
(4) TYPE OF wORt: is Number of yell Forestial: Describe by color cheracter 0fte of mate it
If lore tboo Coe__) I add structure, end " thicluss o agwi are and the and
O MEN HELL Nothed: AIR NOT I old nature of the materiel in each stratum Penetrated, with
C _______r________ sxx=s-=—xz it ]lest one !airy for lack ek n!! in formation.
(S DiIIENSIONt� Dieetlr of will / inches I-----__ _ __.__ _ ---_---------_---_-- -------_-_-
Drilled 90.1 ft. Depth of completed will 91.1 ft. MATERIAL FROM TO
-=azaaazssaa=aassasassa=sxazaa==a===:= PPE =TICK-iP 0 1
(1) CORSTNICIIOI TAILS: SAND I 1 14
f. Clai instal ed: i ' Dit. fro 0 ft. to 01.1 it. i so SONS NAVEL
' 4 1i
O NEEDED ' Din. fro ft. to ft. >OANR ]NAVEL NET 11 21
' tin. fro ft. to ft. I M�ON>1N liAAmNmm (NAVEL A CUT j II 33
d Perforations: NG� -- --M--~--�-�-- "' 30
1 NOW WA NAVELYI CUT SEAMS OF MITER 131 1644
Tjjpqe of perforator nod I MNM SAND GAY L NATEN ! e4 91
L SIIE of jrforationj im. by im. 1 I I
O par Orations ram ft. to ft. I I
,0 perforations from It. to ft. i 1
perforations fro -� It. to ft._
j ea Screens: YES
Nlnofacterer's Not 40MNDON j j
ea lip STAINLESS Model No. TELESWING .:.
p Dom. 1 slot size .0 fro 11.3 ft. to 11.4 ft.
Dirk slot size
--M---from-- ft. to ft:
Gravel picked: NO Site Of !!ravel
Gravel placed from w-- ft.-to t.
Surface sell: YES To shot Npthf 11 ft.
�. Material used in seal WHITE
Did Au strata contain unstable "ter? NO
Type Methodtofa�ulin! strata off Depth of strata ft.
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Q (1) POND: Nassfacterer's Nome ST 1/lE N.P. 3/4 1
Z _ _ __ __ --- ---I I
� zc— �ssszssxzssas-sszs�.-=
w, (11 WATER iiiLS: Lied-slrtace allvation I n
above Non sea lval ...
•p Static level 12.T ft. below top of will Date OI/1S/!S
Artesian Pressure lbs. per sgsers inch Date i
- Artesian utter controlled by - -� i -
work start!! O2/14/!S CaipietN 0I115/25
�zs s_z�=ssar= ---zss�sas:s:ssa:----a==asss=s -ass:.-asssaxss--=razz;: -
O t9) IELL�TESTS: 1ri�dan+ is-amosmt wetly 11wi is lowered hiss ' (ELL COISTNDCTOR CERTIFICATION:
W static level. 1 I constricted and/or wept res/omsi ility for co-
LU was a peep test Bids? NO If yes b rhom? strwction of this wi11. and its Comp iamce with W
meld: Is). oil sit% f�. �rasdosa after bus. n Nashimltoe nil construction standards. Materials used
++ n ennathilyimfor Nlon reported above ire true to my best
d Recovery data j
Time later Level Time later Level Time later Level I MANE IICMLSON DRILLING INC
1 (Person, fin, or corporation) {Type or print)
AODNESS PO 101 123
Date of test !
Diller test iS a Jsin. 20 ft. drewlora after 1 hrs. � (SINGED] �_______ Liceose No. 0519
Air test Is oil. 11 sees set it ft. for bra.
= Artesias floe J.P.B. Date 1 Contra is
Temperature of water lis a chemical analysis lids! ND ; Ngist lam No. NICINI13101 pits 01/11/11
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