HomeMy WebLinkAboutWAT Application - 3/1/2023 • • WA"I'
*gm, MASON COUNTY
_ ) COMMUNITY SERVICES l ` /4
/ Building,Planning,Environmental Health,Community Health
415 N 6th 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. EnP/�
2. Complete only the portion of Part 2 applying to the type of water connection utilized. l� C�
3. Submit completed application, with any required attachments for review.
4. An approved building site plan must accompany this application. 41 QRUf2O23
61
Part 1: Applicant/ Parcel Identification S V ' Alder Str
Name on Applicant: &Ic..frlon5 ( 1t.J n d-j7ga,4-41/4 Date: eel
Mailing Address: 9.00 i d Phone: 21'( `105-5 t4 l
Parcel Number:
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more !is Building permit
connections) ❑ Division of land:
Individual water source (one connection), #of Parcels? SPL
Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ 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:
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\Vatcr Revised 1/25/2018
s
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) gpm gpd.
0 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://gis.co.mason.wa.us/planninq 14i 15U 160 221::
Water use or limitation recorded N/A Yes'
Well Drilled Date
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: Date
2 of
`
CSD Director: Date
1 I
1 /
tprt Care No. W('099044
DeportmentFIN Oriotrjai and First Copy with WATER WELL REPORT MOUE WELL LD.s ACY 258
saoond Copy—Ow,,.,•.Copy STATE OF WASHINGTON
Third Copy—Driller's Copy Weser Mein Powell Me.
(I) OWNER: Nan Del Gardner Ad•.aa 200 E Wilchar Blvd., Shelton, WA 98584
(2) LOCATION OF WELL: Couey Mason NW ,,. NW ,K s.. 4 T. 20 N.,R 2 W y
UL
Rio STRErr ADDRESS OF WELL(or n.aseadt►..e) E 310 Wilchar Blvd., Shelton, 98584
(3) PROPOSED USE: l Dmhelibc Industrial ❑ Muni ipr DESCRIPTION
7 (10) WELL LOG os ABANDONMENT PROCEDURE DESCITION
0 Irrigation
❑ DNNaler Tat wall 0 Other 0 Foamiest Boilers
wid the �a'� °os at Ni.materiel in soon ream erred with leas r.dweller,stas of melerial and Manse.end show Bickner d
(4) TYPE OF WORK: owners rxamber d"I chows a nlonn�oen
(i rrror..nan our) MAMMAL 191011 10
Abandoned 0 Niw wee K Method:Dup❑ Bored 0
Deepened
o Reconditioned 0 R Jetted _ Brown conglomorate 0 10
(5) DIMENSIONS: Diameter of well 6 Indies.
orie.d 78 t..,. Doh 010,9 i.ledwsn 78 it Cemented sand & gravel 10 15
(8) CONSTRUCTION DETAILS: Brown sand & gravel 15 50
Casino Instilled: 6 ' gam.from Q it to -73 tt
wiwiNd Uner Instated g Dtem. `on, nano " Sand & gravel with water 50 78
• 04m.from it.to ff.
P rla.ttian.: Yes 0 No a
Type of perlondor used .
SIZE of pertorerlors In.by in•
perforations from R.to n.
peitor tons from It.to ft a,
r Z
perforations from R.to ft. _ , ,
6eteana: era® No O
Wenuleer►rees None Cook .
let
Type stainless wire wrap Model No.
Diem. 5 sla.tz. 20 from 73 ft to 78 n.
Diem. Slot sce horn ft.to ft ,.. •o
Gravel petted: Yee ❑ No a Sirs of gravel N
Gm,placed from ft to It
Bo dace see: Yes(k No ❑ To whet depth? 18 n. MNfflgONEM
[fJMoterisiusedin.w Betonite
Did any strata contain unusable wear? Yes CINo® DECf S
Type of water? Depth of strut — n '
Method of seehrg toad of PtnMIT ASSISTANCE C>7 PUMP: Mwve.p4 Por
no n.
Goulds CtNTER
I Typo $ H.P.
.35
laawna.rvaeon n
eve worn slims 11/13/9/is. caroms 11/)3/9/ ,9
(8) WATER LEVELS: ,bone moan see I...n
stale ll 4$ h.below top of wet Date —_-_-- WELL t CCl�7Al10TOfl CERTIFICATION:
ktwian aerie. lee.per square inch Date
Ars4wn wow is controlled by I constructed and/or accept responsibility for construction of Ws well,and Its
(Cap.weave.sic.) compile/ice with all Washington well cone uclion sfatrdwds.lialarteis used and
the information reported above are true to my bat knowledge and beef.
. (9) WELL TESTS: Drawdown is amount wafer I.vei is lowered below vatic level
Wes a pump lee made?Yes❑ No® If yea.by whom? NAME Davis Drilling
id: gel./min.with ft.drawdawn alter hrs. RPM OR Co�
Ys l l q mTYPS OS"Ve l
„ „ " Address BelfairW.A 98528
" (signed) ,1 t�N is '".t90T" License No. 1884
Recovery data(tins taken as zero when pump turned off)(water Nutt measured from woe
top to water level)
Tim. Weer level Tien Water Level Tkn. water Laval Contractors
No. VISDI1100A Des Nov. 1997
(USE ADDITIONAL SHEETS IF NECESSARY)
Dais of tea
Bawer lest 20 wa✓min.Nun 10 ft drawdorrn after_____Z_—fry Ecology Is an Equal Opportunity and A1BfllaYlktt AO)i0n employer•For spa
Meg sad/min.wit}h,.�em sets R.for nn vial accommodation needs,cordsot the WierRMOWCSS Program at(206)
''- err= 3 i, b 0 fi Nff 407-0600.This TDD number is(206)407-800S.
ecwoeo.,•anrw,••1::-`''I)`pd from Mason County ptiAs
Thurston County Environmental Health
2000 Lakeridge Dr.SW Olympia,WA 98502
360867-2631 0&1 U(rI C. ^nf r ,t7
THURSTON COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected
Q 3 106 12 02 3 121 11c$O JL!
07 :30 ❑PM RECEIVED
Month Day Year
Type of Water System(check only one box) El Private Household
❑Group A ❑Group B ❑Other MAR 17 2023
Group A and Group B Systems-Provide from Water Facilities Inventory(WA):
ID# 615 W. Alder Street
System Name:
Contact Person: Cc iv/ eJe/w w..s S4
Day Phone:(2.,) p ) //O S" 4 11 I Cell Phone:(2I )t/os $2I?
E-mail:d N,rR ,,i M 2c03&yyl fo .jvghone:( )
Send results to:(Print full name,address and zip code or email address)
CGJ+iN CIeM4NJ f#
ZOOX Wrllc1,fv MVO -
SHe I r`oa wp ¶ga y
SAMPLE INFORMATION
Sample collected by(name.);
CA/,/., '•+pIiJ Sot
Specific location or address where sample collected: Special instructions or comments:
200C wrlkAir pv0
SNeLr0,4wofet5gy
Type of Sample(must check only one box of#1 through#4 listed below)
;171gRoutine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes No ❑Distribution System
Chlorine Residual:Total_Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total Free
❑E.coil-GWR(A/P)
j El Fecal-Surface,DWI,springs(numeration) Unsatisfactory routine lab number:
• ( Filtered:Yes No -
El Assessment Monitoring(A/P) Unsatisfactory routine collect date:
['Other / /
k S .
4.0 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 ❑E.coli absent f)o Iiform detected
Replacement Sample Required: •
II ❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform 1100m1. E.coli /100m1.
Fecal Coliform /100m1 Enterococci /100 ml.
Method Code:gr 9223E ❑SM 9222D Date and Time Received: 1 9215B ❑Enterolert® , 71) CY )
Date and Time Analyzed:' . -2, Date Reporte . •�• Z
Sample Number(DOH number pies five digits) - Lab Use Only:
( 0 8 0 1 ,2
DOH Form#331-319(revised 01116)
{.