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Home My WebLink AboutWAT Application - 1/24/2023 t J�tnG•nLtN�! WAT MASON COUNTY ENV ,R r � MENTA ` _ ; COMMUNITY SERVICES \� no" y Building.Planning,Environmental Health.Community Health 415 N 6th Street, Bldg 8, Shelton WA 98584, T r 1it Shelton: (360)427-9670 ext 400 •:• Belfair: (360)275-4467 ext 400 ❖ Elma: (360)482i52, v FAX(360)427-7787 AN 4 Znu23 Application for Determination of Water Adequacy G Instructions 615 W. 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. 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: Regina Lange Date: I/16/ 102.3 Mailing Address: 1703 NW 201 st St. Shoreline, A Phone: 206-303-0908 Parcel Number: 222145000004 WA 9s i-77 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more C Building permit connections) 0 Division of land: ❑ Individual water source (one connection), #of Parcels? SPL El Well 0 Boundary line adjustment 0 Spring/surface water 0 Other(explain) 0 Other(explain) Z51 —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) 6L--0 System box. R-0 R:10 —D cq 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. JAI I Forms`.Drinking Water Revised 1/25/2018 Individual Water Well ❑ Water well report (attached to application). Depth ft. E Well capacity Test (attached to application) 12 gpm 840 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 14I 15(] 16=22= Water use or limitation recorded N/A Yes 0 Well Drilled Date B / 7 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: Applicants 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 2 of era 1786 SE Mile Hill Drive Port Orchard,WA 98366 SPECTRA Laboratories-Kiwi) www.spectra-1ab.com .9NOP''"a•waw` (360)443-7845 COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected lime Sample County 02 I 05 / 20 Co lected 02 00 DAM Mason Web Day ...--- Yes -EOM Type of Water System(check only one box) ❑Group A ❑Group B ❑i OBux Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# System Name:Jeanne Ballot 16561 WA 106,Belfalr Contact Person:Arleta Eisele/Arcadia Drilling Day Phone: 380-426-3398 Gel Phone: Emal: arietagarcadladrilling.com Eve.Phone: Send results to:(Print full name,address and zip code or e•mal) arleta@arcadiadrilling.com Arcadia Drilling,Inc SAMPLE INFORMATION sample collected by(name):Dan Specific location where sample oolected: Special instructions or comments: 'Hose Bib Type of Sample(check only one box) 1.Q Routine Distribution Sample 2.Repeat Sample(after unset routine) Chlorinated:Yes❑ No❑ ❑Distribution System Chlorine Residual:Total_Free_ Unsatisfactory routine lab number. 3.Source Ground Water Rule Sample S 1 I I I Unsatisfactory routine colect date: i l I CI Triggered Chlorinated:Yes❑ No El ❑Assessment Chlorine Residual:Total Free 4. Enumeration Source Water Sample I I I ❑E soli ❑Fecal-surface.GWI,springs:Filtered Yea❑ No❑ 5.Q Sample collected for bicemalon Only:Investigative LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Colifonn Present and 'Satisfactory ❑Ecollpresent ❑E.colabsent Replacement Sample Required: 0 Sample too old(>30 hours) ❑TNTC ❑ Bacterial Density Results:Total Col'iform _/100m1. Ecol _HOOml. Fecal Caiiform /100mi HPC Il mil. Lab IDNumberf`�C(�i{ (� q `e�1 V V `V ` Date l �LQ \IlA' Method Code: Date and Time[nabbed: SM 9223 B E E B 0 5 202)0 Date Analyzed: Dale Reported FEB 0 6 2020 FEB 0 6 2020 DOH Lab-Sam 225 - pl at) U` Lab Use only. DOHForm R331219 teaxie we).N1ea need WaD acaen l7 n d1rnahe knot col 0,1525.0127 gram(d 714 71W nd other publications re aisleNe sl rw.631 agpv/trneirpNr. Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA. 98584 Customer: Jeanne Ballot Phone: 206-291-5528 Well Site Address: 16561 WA 106, Belfair Date of Test: 2/5/20 TIME GPM Technician ran the well at 12 gallons per minute for 1 Min 12 70 minutes and pumped 840-gallons of water. 2 Min 12 During this test the water performance maintained 3 Min 12 this flow rate for the entire test period. 4 Min 12 5 Min 12 6 Min 12 7 Min 12 8 Min 12 9 Min 12 10 Min 12 15 Min 12 20 Min 12 25 Min 12 30 Min 12 35 Min 12 40 Min 12 45 Min 12 50 Min 12 55 Min 12 1 Hr 12 1 Hr 10 Min 12