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Home My WebLink AboutWAT2022-00159 - WAT Application - 6/13/2022 ..0. p;\ WAT 2� 001 Dc1 �121h� MASON COUNTY ( 7.,` COMMUNITY SERVICES Building,Planning,Environmental Health,Community Health 415 N 6ih 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. L 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. )' '`) 1 5 r street Part 1: Applicant/ Parcel Identification Name on Applicant: ,O -rh ' J j 5 Date: Mailing Address: 7.50 t f E 't ruj e4j, ) P cA Phone: •3-6 27-5691 Parcel Number: 23O2-3%-90i Type of Water System Reason for Application Cat Public/Community Water System (2 or more it Building permit connections) 0 Division of land: ❑ Individual water source (one connection), #of Parcels? SPL ❑ Well 0 Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) 0 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. 'S`r`►'J P�`'` ,� e'° °No ENVIRONMENTAL Part 2: Water Connection Information a o23.ao HEALTH Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: T L-' --I Water Facility Inventory(WFI) Number: G (write"none"for two-party) ❑ I am the manager of this water system. The water system has been aeproved for services. There are presently I 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 I/25/2018 Individual Water Well 4h Water well report (attached to application). Depth -3—(-1 \ ft. i (Well capacity Test(attached to application) i 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://qis.co.mason.wa.us/planninq 14n 15416Q 22= Water use or limitation recorded N/A EJ Yes Well Drilled Date 1 I 1 10o D 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: 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. 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: V--)C.Ihrl Date 1 I-1 1--2 -- CSD Director: Date 2 of 2 , . •ii-i a.. 0 0.. 0 Ct VVATER VVELL ItEPORT State Card No.WI20817 UNIQUE WELL IDA APE 762 ..... CV STATE OF WASHTNGTON 0 41 €54 u2. Water Right Permit No E 4, (i) OWNER: Name JOANNE eERURYON Admit 751 TRIM/EAU MT TI.D,W IIELFAIR WA C 0 (2) LOCATIONOF WELL: County.MASON NE 1/4 $18 I/4 sec 2 T 71N N R 2W Ve NI C (2a) S'CREET ADDRESS OF WELL(0,marest Mamas)751 MOTIF-AU MT RD BEI r AIR AY A 0 .....0 CV (3) PROPOSED USE: Domcgc,.13 industrial G rinnictrL 0 (10) %vpi".inc ar A BANDOMMLN I FRO ICS DESCRIP FION E Irrigation ii - DeWater L') Trot Wel o Ma LA MATERIAL FROM TO 1.i . C (4) TYPE OF WORK:osv.-c,number of wen(lf more than one) CLAY&G1tAVEL HP BLUE 0 65 4) Nos-Well & Method Dug ij Herod :1., CLAY&GRAVEL F1P BROWN 65 186 r Aboodorted 0 Doepeoed 1-1 Cable 0 OfiVell 0 SAND&GRAVEL 1120 BROWN 186 201 li.ea R mooch:wand E..,' Romey to 1eno4 0 I-. 0 ...., -0 —(5) DIMENSIONS: Viemetercfoe11 6 ascnes C Drilled 201 feet Depth of Grannie:oil well :01 R. TV r3 ....a, (6) CONSTRUCTION I)ETAILS: ci3 CI Canna Ina tailed: 6 Diem from r I ft fct 146 il. RECEIVED , - welded K Laam froin ft to II Clii) liner bundled 0 - .0 Threaded r,:i Balm from fl,ro ft ...... JUN 1 9 2006 p ..,..: Yes 0 Na KI -11.0 C iy pc of perfbrslor umd DEPT. OF ECOLOGY ra sLZE of perTormons in.by in %... 1... praforaturos horn ft to h M; pantomime horn ft to ft perronnfons from ft.to ft a `Semiotic Yes E No 0 Z Manufacturer's Kane WENTCO SEP 2 Type STAbILESS Model No V) Dant 6 got Wry 13 from 1'1.6 &to 201 ft Cl.) Dram Slot size front i's k, II 0 "CI Department u Lcoicgy Ceravel piscluat Yea Li No X Sine 01 graoel CPGravel placed from II to tt — 0 Wort Slatted 111-204tO Com plood 9.1-03 ....... Sorfeee mall Yea FJ No El Tu what depth,' 20 ft IATTL CONSTRUCTOR c:LarivicAnum: C.) U..1 Mauer&used in vial BUM:PATE Luna:roe...1 and/or accept respoosibRny for ccostrucrion of this writ,and ft ram pliancr with all Wulltn Attell.t.11 corttartoulaco..........ds NULOArlda,l I•PI d...1 tl,..4.1"...... '..-,ton,...,..A.....t.,,..rt -- 4— Cad my so'-'coriatn unorabk woe? Fes 0 No XI true to my best knowledge and belief Type t)(.the Depth ot slaw, C Method a sealing strata off Name Coolwater 1.)rilling al E (7) PrIwie.z. Mama fresurre i Same GOLS-DS BillItlgtOft Wilthutglor. l_romsse No 1773 IV fypt St 113Pall SIBLE H P„ 1 1/7 04.0 ...0.4046€ CL ,. i 0 (8) WATER LICVILS: larodysof(ere elevation a above mean ma Icvel n Cur:tractor's RestanaPon Sate its61 PO ft below top nf wr.11 OILS 9-140 Na."COOLWD*044DN CV ..0 Antlizo proasure Hos per square inch Date DATE 9-5-00 II. . Aromilarl` smite is irootroSed by (Cap,tam rtr..) (9) WEILL TESTS: drawdown IS 311104211 Weer tr.tti It Itnyaed WO.:wk.level Date of tell 9-1-60 Was a pump trot made'Yea(31 No 0 if yes,by whore Bailee text la gal halo with 17 It drairdoom after A hrs Yell& lb salAnia with 17 ft dravedowai ay 4 bra — _.-._—— Aintree lealfaiin,wrIN stem sex at Iv ro, h,s — Artesian now 6 p m DAIC — — Temperature of oaten W.,4 chemical.14161 made' Yea 0 No [;) 2 ka o „.- 6 son County D Printed from Mason Gouray OM'S 4 • • • • • • 4 • tF� n a 1 2k S. • • S 4 r iF. PrintedFrom Mason County DMA Panted from Mason County DAtl a