HomeMy WebLinkAboutWAT Application - 2/7/2023 4\1141.4
a N-�'`\'_ WAT -
r �0\-' '''-, MASON COUNTY
', 4'1 p,\ ' -: .1 COMMUNITY SERVICES
`. Building,Planning Environmental Health,Community Health
..,w rur<;s
415 N 6th Street, Bldg 8, Shelton WA 98584, ---9 11•-•rs,
Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 Elma: (360)482` 69 ex�401L,LI
FAX(360)427-7787
Application for Determination of Water AdequacyB - 7 2023
Instructions 615W. Alder Street
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.
ll 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: \'�la„d,, c Sao LI\-,,n< n Date: f)._-c\- 22 _
Mailing Address: q2.0 L a_ , .A . Phone: p•
831 L/O 2. - d O l 0
Parcel Number: 2,ZZ 2-2_Z 0`7 0 Pa.c>t t t✓ v ro v C,, C,rt . 5'3 9 5 D
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more ® Building permit
connections) 0 Division of land:
'k Individual water source (one connection), #of Parcels? SPL
® Well 0 Boundary line adjustment
0 Spring/surface water 0 Other(explain)
❑ Other(explain)
X 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. LO ao�3 001 0
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.
,C\Ell Forms'Drinking W ttcr Revised 1/25/2018
1
mommiewer
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v111-
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Individual Water Well (/)
d Water well report(attached to application). Depth 70 ft.
II
❑' Well capacity Test (attached to application) 2 r) 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://gis.co.mason.wa.us/planninq 14y I15E 1n 16 221-1
Water use or limitation recorded N/A I V I`Yes I—I
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)
7 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: /7
Environ. Health: -,�1 � Date 3/ L V 7zl'z.
,°12
CSD Director: Date
6t.A9 20.95 -00 09
1 Spectra Labs - Kitsap, LLC (Port Orchard)
SPECTRA Laboratories -Kitsap 1786 SE Mile Hill Dr.
—__, Port Orchard,WA 98366
...Where experience matters r c'
,,,; Phone: (360)443-7845
ENVIRONMENTAL� .� JessicaD@spectra-lab.com
HEALTH i_s�2?, www.spectra-lab.com
��g - 1
645
W• Alder Street
Spectra Labs- Kitsap, LLC (Port Orchard) received samples for Craig Stanley on Friday, December 30,
2022 at 10:06 am. Unless otherwise noted, all samples were received in good condition and were tested in
accordance with the laboratory's quality control procedures. A summary of the samples received are
outlined below.
Sample No. Description Location Sampled
136464-01 Private 14601 E St Route 106,belfair,WA 98528 12/30/2022 9:20
This report package contains laboratory sample results and any attachments listed below. If you have any
questions please call (360)443-7845 or email us at JessicaD@spectra-lab.com.
1
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91
This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other
than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at
11 360-443-7845 and destroy this report promptly.
These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced
except in full,without prior express written approval by Spectra Laboratories.
01/04/2023 Page 1 of 1
I'
r 1786 SE Mile
Hill Dr,Port
Orchard,WA " SPECTRA Laboratories Kitsap
98366 .-a711rre eAper,ace alerrero
(360)4 13 7sa5 COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Tina Sample County
Collected
BMA
^ y\c�
►blel -0+/ yew ,: 2O D Pry C S A'\,
Type of Water System(died(only one box)
�Grow A ❑GrcupB erotherW5.4.0 rtiUa�2
croup A and Group B System-Provide from Water FecAbee Inventory(N'F f):
IDR
System Name:
CoflladPemon: tarc`,ricS'\ ...\e��_
Day Phone 1 i� -I 3\ 3}11 Cell Mono So�.c
Em81t i-L\` c�n�t..;.•\v*T�{ .111r be.PhOfle.
Sendremat Ptal wee,rakes edr¢me►awWeereke dotes*bib elMI
SAMPLE INFORMATION
Semple coiectsd by(nave).
Specific location wfhere\sample calecfed: special instructions or comments:
E.Si-.Roa;te- \Die Qr.dacc. Vl e I I
%MI Ac c •
.>>,W n• j
Type of Sample(check only one box)
1.❑Routine Distribution Savople(AMP) 1 2.❑ Repeat Sample(AlP)
Chlorinated:Yes 0 No 8' I (fra('ctsetistion system slier ku cal mine)
:lnsetistaci7lyroutine s.):center.CM —
Waite Residual:
S.Ground Water Rule Source Semple
S
I I tlnse�%collect J date:
Chlainaied:Yes No
❑Triggered(NP) Chlorine Residua(Tota_Free._
❑Assesernent(A1P)
4.Surface or OWI Raw Source Water Sample(Enustuslkn) ISI I 1
❑ E.col ❑Fecal rune'MI--11r_
5.( ample Cabcted to Information Only.
LAB USE ONLY DRIN)c7NG WATER LTS LAB USE UN-L17-'')
❑Unsatisfactory Total Coform Present and 3atlafadery
❑Ecot present ❑Earl t
Bacterial Density Results:Total Colionn 100m1.Eco8 mpW100ml.
FecalCorrform - -- .ctJ100m1. HPC cfuliml.
Replacement Sample Required: ❑TNTC ❑Sam old
❑Sample Volume ❑Damaged Container 0
tat *nag WM*
lids ' 'tat i • `(.44..A I-0
Rroyp Temp C; Method Code:S1.192238!aT-COUNT!S119222D
ryat.e.rcnay wi r=VWb
Dab Repd1ed lore eengy.Ki,��oeiwa.. dWmmattyh
rr
ence.prr.n torn lr re. 10617A0/11 eta
lOHLvw..M# I i • a gotoo. rower.
Thws wsf HYb`'AJ b b�rn.far Mdto mow is
1 r. eIOYMObr N Ifatsy.1lb mai eel it Mbp r'�edct
..—._.. aKreroUPbaper�neridlrW.taaa�rte.
imommormilogliMw
1786 SE Mile Hill Dr.
Port Orchard,WA 98366
SPECTRA Laboratories - Kitsap (360)443-7845
...Where experience matters
Lab Number 136464 Entered By Lona
Client Craig Stanley Date Received 12/30/22 10:06
Due Date 1/4/2023
The following samples have been recieved,they have been scheduled for the tests listed below.If this information is incorrect,
please contact the lab.Thank you for using Spectra Laboratories-Kitsap,LLC.
136464-01 Private 14601 E St Route 106,belfair,WA 98528 12/30/2022 9:20
E.coli-P/A Total Coliform-P/A
•
12/30/2022 Page 1 of 1
L..-O5JO23-- 00309
From: Mark&Sue
Sent:Thursday, October 27, 2022 8:59 AM
To: craigandcarolyn@q.com
Cc: Mark Johnson
Subject: Mark and Sue Johnson—well information
Hi Craig:
Our well at 14601 E. State Route 106 in Belfair is approximately 70 feet deep; it has been pump tested at
20 gallons per minute; in 2020 we changed out the pump in the well and also the tank so that we now
have a 13 gallon tank attached to a Constant pressure system.
We are unable to locate any recent water quality tests, so I would ask you to please use your resource to
get a bacteria water test conducted.
Please let us know if you need more data or documentation regarding the well.
Mark
Sent from my iPhone
Te1 : 13/3 / z0zz
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Davis Drilling, Inc.
NE 3410' Davis Farm Rd.
Belfaih, WA 98528
275.5367
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Thank You:
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