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HomeMy WebLinkAboutWAT2022-00156 - WAT Application - 6/13/2022 1ILdzO2a - b�� WAT 20 22 - OO!' 2 MASON COUNTY 415 N.6th Street G Shelton,WA 98584 (il .,1. �� COMMUNITY SERVICES Shelton:360 427-9670,Ext.5400 84 Belfair:360-275-4467,Ext.400 / Building,Planning,Environmental Health,CommunityHeahh Elma:360-482-5269,Ext.400 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. Part 1: Applicant/ Parcel Identification Name on Applicant: Lt.i r 0 b y Date: 6- 13 ,E Mailing Address: b 1OW c,t145 If,Jo. Ed. Phone: ,..3( 9. Lec.21. Parcel Number: 0001 - - c(OOI A 5hz fon WA .qE)G 4 Type of Water System Reason for Application ,Public/Community Water System (2 or more Building permit 6I<12QZZ. - 00r0t, connections) ❑ Division of land: El Individual water source(one connection), #of Parcels? SPL El Well 0 Boundary line adjustment El Spring/surface water 0 Other(explain) 0 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: �k L•Zo�2" O`-5 Public Water System Name of Water System: 4c) W rt-hydrS L i 1c...PC1 Water Facility Inventory(WFI)Number: none (write"none for two-party) ,❑'I am the manager of this water system.The water system has been approved for services.There are presently 1 connection(s)in use.This will be the .1 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. Print Name of Water System Manager 1LJcbtb , Phone 3c2o-- 44,3"`Icn Signature of Water System Manager L c Date (s- ).3 27 This form may be scanned and available for public view at www.co.mason.wa.us. I:\EH Forms\Drinking Water Revised 4/27/2021 Individual Water Well Water well report(attached to application). Depth cl L-- ft. Well capacity Test(attached to application) �-%I U 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). Cs�')szctt,i, SQ(14 cw - t;5 zx Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14 15 16 22__ Water use or limitation recorded N/A Yes)4 Well Drilled Date CA I lti I\ Individual Spring/Surface Water ❑ WDOE permit(attach to application) 0 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: Date 17 � Z This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 • - W A'TER WELL REPORT CURRENT '0a,�, -' Original&l"copy-Ecology.2,""copy-owntr..t"copy-driller Notice of Intent No. 09 i "� / 7r ""ra'"` Unique Ecology we❑1D Tag Na. J I �t ry�� Pe> n`F *+ fCOLOGY Construction/Decommission("x"in circle) q Construction Water Right Permit No. �i I M Decommission ORIGINAL INSTALLATION • Property Owner Name_— ( ���ry 4�' t Notice of Intent Number ,,. PROPOSED USE: IS Domestic ❑ Industrial 0 Municipal r Well Street Address D. ❑ DcWatcr ❑ Irrigation ❑ Test Well © Other C'ty' a ke,C sv-, county .� r--- M. • TYPE OF WORK: Owner's number of well(if more than one) Location 1/4-1/4 ,114 Sec_ Twn R--_. cusm 13/ MI0 Dewwcll 0 Reconditioned Mel,Ytul:❑ Dug 0$ Bored 0 Driven t,r Still REQUIRED) Or � 0 Occpcttcd ❑ Gab®tc � Rotary 0 ,lancet (s, w�vM 0 r= DIMENSIONS: Diameter of well inches.driilcd7� _n. tar Depth of completed wcl Z it. ',at/Long Lat Deg I at Min/Sec 5CONSTRUCTION DLTAtLS - we ca3mg Welded Diarit,from fit R.109�^R. Long Deg Lang Min/Sc O (�4 41 C)l__Z- Installed: liner installed_ " 1)ia.t,from R.to R. Tax Parcel No. (Required) S ❑ 1 hrc tied I)neon.Fran R.to ft. pcAotaliom: [ Ycx No CONSTRUCTION OR DECOMMISSION PROCEDUR C Yr. l" ofpamorr used , Formation:Describe by color.character.sizcnf material and structure.and the kind and n, apart S nature of the material in each stratum penetrated.with nt least one entry for each change SIZE _in _in.and no.of parts_front�_R.to�R. of inRxmatiat.(USE.ADDITIONAL SHEETS II,NECESSARY.) ,,., Screens: ❑ Yes It We ❑ K-Pee Location MATERIAL FROM TO orii 0 Ia a linor* ufndurces Nana /9,,,A�/, / !� 'r 0 301 TYPe Model No. /i C Vr yv`'v'[ 4/ '7 , • Dian Skirt size from R.to,. R. ,l.•e / .,�.f_ 0` to G Dian. Slotxuc front R. R. a u...1v• . • Gravel/Fitterpacked: 0 Ycs 11 No Size ofsr:wet/sand GOOGOOsd `+ Materials placed from R.to R, 16 Surf Seal; Yes ❑ No 1'g wN Ih? _ 143 Material uxcd in sail 3 I)id any strata contain unusable water? ❑ Vats El No rypx it/water" bepth of strata • method mf • scalinµ strata off ii rum I% Mannfnsurer's Nance ' gg� N.F. . r WATER t +El S 4 vd•s: tttrftcc elevation above mean sea loyal� R. l'= Static rave Id R.helnw top of well Date I—(O - t 4 t,a. ti Artesian pressure lhs.per square inch Date IS Anaian tem.valve.etc.) is controlled by tc.) —___ & wEI.E.T£i5 : Orawdown is minim water level is lowered below static lover ow was a pump test mate? 0 Yes to No if yes.by wham? w Vicki: ktt.intin,with „ft.drawdnwn atcr�..his. "' Yield. ghdltnin.with R,drawdown after__itrs. Yield. pl./Min.with a.drawrtown liner hrs. ,term•cn data Dirac taken as tern when pinup turned ofr)fwnler level weasured ftnn, hrlt inn in wnt&fort' rime water' MC] 'rime Water Level Time Water Level §t -- — — • 5 I)arcnttext _ ..... . - 4, roil.text gal./min,with tl.//dd�rawdown ancr}__hrs. Airiest 40 tall ltuin.with stela act id - a.for ` Ma. G� r()-'{Y Start Date i - 10-!`f�Completed Date . 5 Artesian Row,,,v_„g•p,tn. Date oil 'temperature of water Was n entente'analysis made? 0 Yea ® No n` WEl-I CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construclinn of this well,and ils compliance with all Washington well ill construction standards. Materials used and the info tiOn r, above arc lave to my best knowled t,and belie` • ,t � [ r �, OW k��,� �jy� j)ln Drillin E Coat t / ®Driller�Engineer Q Trainee c ri"i 0 Address r � I)ri)tcr/lingitx tell raintx Signature fit_.State.7ipil� 1?hitter rn trainee License No. ,a S ('patroller's ti�Qlc �� -WFTRAINEE Driller's License No: Rc�tisiration l>rillcr's Sig't+'ulut'C: roe tair r. ll'Y 0e0-t-11l{Rev 021101 (tying nerd this document in lot alternate,/ilr•uurl,planer mill the Weiler Resources 1§xr+;rnur at.r'Pdl.•d/!?-to p ry,r t hJt(i: fo ul ' 7,/.l nr wrot N(utr , 1gr,Srrt'kr. Pt'rs+rue with mlveer!,dislrldfy�rrtn eon 77-131.1il4!, I 'p k`t`-;?Ba_`t... '4vt, V i 2 ._ ,'.Ear .::.' P ie tt,.tes lea aat'r I t r":4 i"t m fur P)"--r •.MS I. . -*--''' ' /7865C Nide -I--- Hat Dr F . Port Orchard, ji, SPECTRA Laboratories. Kitsap , -Whirr exericiece 1111121trft : COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected 'Time Sample Conti 6 Z. tZ5 I 1_01_7, , Ccliected wee o l I I i'IS - , ___._..„.._0 ..._ _ Type of Water System(check only one box) CI Group A El°mum B AOther . Group A and Group B Systems-Provide from Water Faclfities Inventory(WP I): ---1 . System Name: ....... . ...... , contact p :: _e-z...... — , Day,,Phoir. 31x.) 501 -7 1 5-go eli Phone: say14-9- Entairvute...4 e,. ('s`).,/k6ers)-POP Eve.Phone: 5.c...0-.-% .. s.pd mut to:(NW klian p ,....ollto...o=If rlp ca co eo c,ofooll al:to:7.04r py of rottaIN _i . ..,),......c, -Pv‘0 i . SAMPLE INFORMATION • _..... . Sample collected by(iname):. k , Specific losation where sample collected: Special instructors or comments: 1410 Li R4e-d-6 LA let fit, • Type of Sample(chock only one box) i.0 Routine Distribution Sample(AP) 2 0 Repeat Sample(AP) chicorlatat Yes 0 Na 0 (frcro d,strthrtho system Slier diva.ruOthe) Unsatisfactory muftis lab nitrites Chlorine Reisittual:Total Free,__ • - 3.Ground Water Rule Source Sample —— - . Unsatisfactory routine coliect date: 1 S I Chlorinated:Yes _ No_ 0 Triggered(041P) Ch wine Reelduat Total .,Free__ • 1 (-.3 Assessment(NP) i .. 4,Surface or GWI Raw Source Water Sample(Enumeration) O E coif 0 Fecal r cored .a Ser*Collected fa Irtfonestkin Only LAB USE ONLY DRINKING WATER RESULTS LAUSE ONLY • 0 Unsatisfactory Tots,Coliforre Present and -r--atisfactory 0 Geoff present 0 E cob'absent • Bacterial Density Results:Total Cofiform _per'100m4.E cod rrpn/100m1, Fecal Califrand _ _ chit'00tre. Replacement Sample Regelredi 0 TNTC DI Sample too old a Sample Volume D Damaged Container 0 -... .../.4 , -, DahrttRrseten ,,,., i Lab Natar.NYANIIIW. 14,5t) Velrf-t-- 2.-CD i Receipt Temp C', 1 0 0 ktetoc Coda: i Sh49223110 iriCOUNTrattiV2220 . - Des Reported a te{sank r4u.i. ml la:film!vorrpr,to ' FEB 2 4 2022 Alm it k drireset.1 My tot too,c1 rt 9.1441.-dial,b;t.Nt whe.1404.p.erd ire sairaterod/yet°In rm.!'t•°,0,-,1 in mar,ple,re.naCt NI undo ...(44.0y r104 447-415 ert 0.1itq 0+,: ..1 P.114 DOH Lab-Sart** [225- -4---q Z 0 C ,....,4%?:.;.4k:;717-ZV.ZrZ:,..,,,, _____ ............_____ 104.1.,1 prser rowAssa K,rex-ixen..4 by Sport LAttolorfre CM rum At13141914.4ve tiV tlj 1-)rimed I-rorn •!,,-iason C;ou n'. .. :,:...',...4•.S Printed from Maeicn County DIMS . ,