The URL can be used to link to this page

Home My WebLink AboutWAT2020-00227 - WAT Application - 8/18/2020 WAT IO U) - CV ZJZ l MASON COUNTY COMMUNITY SERVICES Building,Planning,Environmental Health,Community Health 415 N 6th Street, Bldg 8,Shelton WA 98584, Ei Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 ❖ Elma:(360)482-5269 ext 400 L FAX(360)427-7787 Application for Determination of Water Adequacy Instructions Srre,9/ 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 revi �� . 4. An approved building site plan must accompany this'application. u.N,M HEALTH Part 1: Applicant/ Parcel Identification Name on Applicant: JJWt/25 Date: Mailing Address: f,o. so`L Phone: (oO 73( 49� Parcel Number: 1 2,(b7 fLj—b 100 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more � Building permit connections) ❑ Division of land: 'l Individual water source (one connection), #of Parcels? SPL Well O Boundary line adjustment ❑ Spring/surface water O Other(explain) O Other(explain) O 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: Water Facility Inventory(WFI) Number: (write"none"for two-party) ❑ I 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)connection(s)without exceeding the limits of the water system or any limits set by state and local regulation. Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Revised 1/25/2018 Individual Water Well Water well report(attached to application). Depth '1 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 htip://gis.co.rnason.wa.us/planniriq 14_ 15 16 22 Water use or limitation recorded................................... N/AYes Well Drilled ............................................................... Date q fla Individual Spring/Surface Water O WDOE permit(attach to application) O 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. 0 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: Environ. Health: Date CSD Director: Date 2of2 ---------------------------- ------------- ------------------------------------------------------------------ 66/Z0/60 '93'9Q 1)I86oIaaDOHY 'ON uot3ez3stbaN I ON 8apsw stsATeue Tsotwayo s seM aa3sm 30 aan'ezadwal S tO3oez3uO0 I a3sa w•d 5 mou3 uetsa3zty •szt so3 '33 3s 3as wa3s /M •utw/Ts5 3sa3 zTX Z661 •0N asua0t� [QHNO2S] I 'szt 1 za33e vmopMmxp '33 OZ •utw/Tsb g 3sa3 zatteg I / / 3sa3 3o a3sQ Q xavd HaXI(M OL1 86 SSONQQX (3utzd zo adAM) (uotgezodzoo so 'wzt3 'uoszad) NI DNI'ZIHa XIQYO�IY 3WXN I Tana' za'sM away Tana' za3eM away Tana' za3eM away e3ep AzanoOag '3atTaq pus abpaTMoux 3saq Am o3 ana3 azs anogs pegaodaz uot3swzo;ut eq3 pus pasn s1stza'sw •spaspue3s uot'ona3suoo TTaM uoibutgssM I ' at za33e umopMsap •33 g3ts utw/•Teb :pTatx TTs g3tm aouerTdwoo sat pus 'TTaM sty3 30 uot3ona3s I Lwo4M Aq 'saA 3I ON dapsw 3sa3 dwnd s seM -uoo -Tog A3tTtgtsuodsaz 3daoos to/pus pa3ona3suoo I I 'TanaT ot3s3s :NOIIY023IS2I30 HOIDEIMISN00 '9'I3M I MoTaq pazamoT et TanaT aa3sm 3unows St uMopmLaa :55535 TIOM (6) 66/10/60 pa'aTdwo3 66/iZ/8O pa'zs3s xsoM Aq paTToz3uoo za3sm ustsa3.Y I I °350 tout aasnbs aad •sql aanssaza usTaegxV I 166/10/60 a'3eQ TTaM 90 do3 MoTaq '33 Ott TanaT ot'3e3S • TanaT sas usaw anoge uot3en819 ao5Jzns-pus' :S'IaA8'I 2I8StfM (8) 'd-H adA5 I I aw'N s,aazn3os;nusj :dWLld (L) 330 e3sz3s butgsas 3o pog3aW I I I '33 s3sz3s go, t3dac aza35M 3o adAl I I ON Lza35M aTgesnun uts3uoo 53sz3s Awe PTa BIINOMNES Teas ut pasn Tstza3sW I I I '33 OZ ag3dap 35LIM oS S8x :Teas aoe;zn6 II I---------------------------------------------------------- '33 03 '33 woa3 peosid Tans Tanszb 30 azTS ON :paxosd TaneaD II I---------------------------------------------------------- '33 03 33 woz3 azts 3oTs •meTa I I '33 691 03 '33 65T woz3 OZO' azts 3oTs 5 •w7TQ 'ON TaPOW a3IIO'IS adA.L NOISnOH aw1N s,aazn,os;nusW SEA :suaazo9 II I---------------------------------------------------------- I I 33 03 '33 woz3 suot3sao;zad I I 33 03 '33 woz3 suot3ezo3zad S91 I 491 I AY'I3 NMOli6 I '33 03 '33 woz3 suot3ezo3zad 691 I 291 I 2I8IXM ' 'IHAYtID I 'UT Aq •ut suot3sao;zad 30 3zIS 291 I ti I 9BAXxD U 92602W allXDXd I pasn zo3sao3aad 3o adAl LLt I 661 I H2IYM '9 Z3AYRD A'xa0 NMONS I ON :suot3sao3zad 661 I ZZ1 I I2M 43AY8D XX'IJ NMo2IS I---------------------------------------------------------- ZZ1 I 811 I '96AY9ID aNY AX'IJ 8Il'IS I '33 03 33 woa3 'sta .. 811 I SE I A?Ia xX'IO 60'IN I '33 03 '33 woz3 •stQ DNISYO a6a'IaM S£ I ZZ I 16M NYO'I aNYS a'IS I '33 Z9t O3 '33 Z+ woz3 'stc 9 :PSITs3sut butss0 ZZ I 1 I HNOISQNYS a3IN8N30 NMOHE I :S'IIYI3❑ NOIIJRNISNOD (9) 1 I 0 I 'IIOS dOI I___ ___________________________ 0I I WO .1 I Td22I3SXW I '33 691 119m pa3aTdwoo 3o g3daa '33 991 PSTTFzU ------------------------------------------—-------------------� sayout 9 TTam 30 za3awstU :SNOISN3WIQ (S) •uot3ewzo3 ut abusgo toss ao3 Aa'ua auo 3ssaT 3s LI3TM 'pa3sz3aued wn3sz3s toss UT Tstaa3ew aq3 3o aan3su pus I 8'ISYO :pog3mW T1 M MEN putt aLI3 pus saa;tnbe 30 ssauN.oIg3 togs pus 'aan3on.zs pus I (auo uet3 azow 31) Tstza3sw 30 azts 'sa3osasyo 'aoToo Aq agtaosaa :uot3ewzog I TTaM 3o zagmnN s,aauMO :)INOM 30 HdAL (6) --------------------------------------------------------------- -------------------------------------- ------ ------------ 00'I 'I'I9M (OT) I oIISBNOa :3SfI Q9SOd02Id (E) M2IAHaXUD '3AIHa S3IY8Id 16 8 (ssaapps 3sazsau a0) 'I'I9M 30 66690001 31669016 (52) NM MT 90 ''N N1Z I L 055 6/t as 911 aS - NOSXW A3uno0 :'3'93M 30 NOIIVDO'I (Z) -62596 YM 'N2'9T1 £81 XON Od ssazppl YNNOa 'xH'DINIH aweN :2I5NM0 (1) --------------------------------------------------------------------------------------------- 'ON '3P'-- d 3tSTg za3SM NOIDNIHSXM 3O 3IXIS 661621 # Q'I TTaM anbtun 96L111M ON pae0 3ae3s 190 0 d H 90 '1 '9 H M 90 6 I Y M / Diagram of well number: 57980 = Casing ( ) = Hole - - = Screen ! ! = Perforation FORMATION DESCRIPTION DEPTH COMMENTS -------------------------------------------------------------------------------- +2 TOP SOIL 1 Surface BROWN CEMENTED SANDSTONE 22 BLUE SAND LOAM WET 35 110 ( /\/\/\/ )) Static Level BLUE CLAY DRY 118 ( )) BLUE CLAY AND GRAVEL 122 • BROWN CLAY GRAVEL WET 144 BROWN CLAY GRAVEL & WATER 147 159 ( - - PACKED CEMEMTED GRAVEL 162 (( GRAVEL & WATER 164 Thurston County Environmental Health 2OOO Lakeridge Dr.SW ®Olympia,WA 985O2 36O 867-2631 THURSPON COUNTY COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County Collect Month Day Year �' O PM o� / Type of Water System(check only one box) Private Household ❑Group A ❑Group B El Other Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: Contact Person: Day Phone:( (rJ Cell Phone:( ) E-mai {f� Ev : R ) S suits o: PII namaddres an code or email address) p• �u 2-V-- 2a A q9 SAMPLE INFORMATION Sample collected by(name), Specific location or address where sample collected: Special instructions or comments: 9' A5 t Type of Sample(must check only one box of#1 through#4 listed below) 1. Routine Distribution Sample 2.Repeat Sample(after unsat.routine) hlorinated:Yes No El Distribution System Chlorine Residual:Total_Free_ Chlorinated:Yes No 3.Raw Water Source Sample Chlorine Residual:Total_Free_ El E.coli—GWR(AIP) El Fecal—Surface,GWI,springs(numeration) Unsatisfactory routine lab number: Filtered:Yes_No El Assessment Monitoring(NP) Unsatisfactory routine collect date: ElOther I / S 4.❑Sample Collected for Information Only Investigative Construction/Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and Satisfactory ❑E.coli present El Ecoli absent (No Coliform detected Replacement Sample Required: ❑Sample too old(>30 hours) El TNTC El Bacterial Density Results:Total Coliform /100ml. E.coli 1100m1. Fecal Coliform 1100m1 Enterococci /100 ml. Method Cade: SM 9223B ❑SM 9222D Date and Time Received: SM 9215B El Enterolert® AUG 26 2020 i Date and Time Analyzed. b i2(r7 Date Reported: —27-20 Sample Number(DOH number pus five digits) Lab Use Only: C? 'r 0 8 0 - 004050 0( ceilcw DOH Form#331-319(re1ed 01116) 1515 80TH STREET E TACOMA,WA 9840,4 (253)531-3121 WATER BACTER!OLC( ICAL ANALYSIS SAMPLE COLLECTION:READ INSTRUCTIONS ON BACK OF GOLDENROD COPY If instructions are not followed,sample will be rejected. DATE COLLECTED TIM OLL COUNTY NAME MONTH AY YEAR ; AM ❑ PM TYPE OF SYSTEM IF PUBLIC SYSTEM,COMPLETE: o PUBLIC I.D.No. CIRCLE GROUP INDIVIDUAL A B (serves only 1 residence) NAME OF SYSTEM 1� SPECIFIC LOCATION WHERE SAMPLE COLLECTED TELEPHONE NO. (is,kitchen tap @ school,fire station,fountainl DAY ( 360 426-3395 EVENING( •SAMPLE COL CTED BY:(Name) SYSTEM OWNER/MGR.:(Name) ARCADIA DRILLING, IN SOURCE TYPE❑ GROUND WATER UNDER SURFACE INFLUENCE ❑ SURFACE, WELL or ❑ SPRING ❑PURCHASED or ❑COMBINATION WELL FIELD INTERTIE or OTHER SEND REPORT TO:(Print Full Name,Address and Zip Code) ARCADIA DRILLING, INC SE 170 WALKER PARK ROAD SHELTON, WASHINGTON 98584 TYPE OF SAMPLE(check only one in this column) ROUTINE ❑ Chlorinated(Residual:_Total Free) DRINKING WATER check treatment ❑ Filtered ❑ Untreated or Other ❑ REPEAT SAMPLE Previous coliform presence Lab# Previous coliform presence Date E] ❑ RAW SOURCE WATER Source# mTotal Coliform ❑ NEW CONSTRUCTION or REPAIRS ®Fecal Coliform ❑ OTHER(Specify) REMARKS LABORATORY RESULTS(FOR LAB USE ONLY). METHOD USED MF MPN PA MMO RG TOTAL COLIFORM /100 ml E.COLT /100 ml FECAL COLIFORM /100 ml HETEROTROPHIC /per ml . ANOTHER SAMPLE REQUIRED SAMPLE NOT TESTED BECAUSE: TEST UNSUITABLE BECAUSE: ❑Sample too old ❑Confluent growth ❑Wrong container ❑TNTC ❑Incomplete form ❑Turbid culture ❑ ❑Excess debris DRINKING WATER SAMPLE RESULTS fi UNSATISFACTORY,Coliforms present SATISFACTORY, Coliforms absent REPEAT ❑E.Coll present ❑E.Coll absent SAMPLES REQUIRED ❑Fecal present ❑Fecal absent SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS LAB NO. DATE,TIME RECEIVED RECEIVED BY 9 -y 089 P DAT REPO D ROU E ACCT.# �004R