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Home My WebLink AboutWAT2023-000085 - WAT Application - 4/25/2023 WAT ,O'oZ?j- 000E6.5 MASON COUNTY COMMUNITY DEVELOPMENT Permit Assistance Center,Building,Planning 415 N 6th Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 s• Belfair: (360)275-4467 ext 400 ❖ Elma: (360)4>2.69ext 400 FAX(360)427-7787 rL" 1J Application for Determination of Water Adequacy ApR 2 6 2C23 Instructions 615 W Alder &met 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. ENVIRONMENTAL 4. An approved building site plan must accompany this application. HEALTH Part 1: Applicant! Parcel Identification Name on Applicant: e a AtliegeTjo Date: ////23 Mailing Address: Phone: 761I-333-V5741 Parcel Number: 3Q063-42-tm(I C-MOD) (36°)43-5o52. Type of Water System Reason for Application Mg(' /I ,^ ❑ Public/Community Water System (2 or more J Building permit 6�p20p3,-j-' W ) connections) 0 Division of land: Individual water source (one connection), #of Parcels? SPL )., Well 0 Boundary line adjustment ❑ Spring/surface water 0 Other (explain) ❑ 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. Part 2: Water Connection Information Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: A.) 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 1704 / This form may be scanned and available for public view at www.co.mason.wa.us. J:\EJi Forms\Drinking Water Revised 1/25/2018 • Individual Water Well 1? Water well report(attached to application). Depth 7O ft. ml Well capacity Test (attached to application) o2C) gpm gpd. J rj .03/a:a z) 35 FPAA 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. `11, Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14(,1 15El 16E1 22F1 Water use or limitation recorded N/A It] Yes El Well Drilled Date /2/////W Individual Spring/Surface Water ❑ WDOE permit (attach to application) , "! .- ❑ Method of disinfection , I ❑ 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) `SkISatisfactory 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'svi Signatures: Environ. Health: \4-1\Q �6 v V Date 3 01 IZ CSD Director: Date 2 of 2 1.n i I. . , l / WATER WELL REPORT '� ...._.._............ bile Original and i lR�Cony with Parma tyyD Thin rtment of EcologySTATE OF WASI IN(iTON Second Copy-Owner's Copy Third COPY-Drillers Ys COPY � t(}/� �6 v.._.perl,.,0�"��!7�'�"�...'.--...9�`G -- Adar..w.c.•`-•- r� Name • GLOCATION OF WELL: County........._...... _.. ��431--- _- ._.. --_ _ caring and distance tr- °��cRO- n- °-rsubtlivlslon corner ce �10} WELL �G• ~�— Industrial ❑ municipal ❑ s ofmaterial and structure.and Domestic tor,character' e of the material in each (3) PROPOSED USE m�toatton Describe by co orrnation. Other ❑ sense of aquifers and the kind and ere o cth etn t 1 a irrigation ❑ Test Well ❑ stratum penetrated, with at lean one entry f MATERIAL 1 � --�" Owner's number 1 / <n(4) TYPE OF WORK: of m than :Dug 0 /Wed D p ��` Dee wall ID Cable a Driven D ��oaed D Rotary D Jetted D •'f+ �1 C Reconditioned _ DUtneter of well .._..... ^' - r t O(5) DIMENSIONS: of completed w+etl_.... --1G- ; .,j`- - Draped....-.^�a.._._...._.it. pep - Q w rc TAILS: - _ £ (6) CONSTRUCTION D/E D_ s<. � �v � r � - oinstalled:....._.S_.- Dtam. front -_...... - ft. �� = O Casing .fmrn-- ft to - ---~ :a - U.. Threaded❑ _ `p hero __...._.._ It to -- _- a ,�r�. IIIIII C Welded --- , r+ Perforations: yes o No ____ .. _.-w---- _ MIN Type of Perforator used....----__----_---.-.-.-- en..._ in-by t, " 'It' ''. SIZE of perforations .__.__-..__ _ 1t. s _ ft °rations!roan -ft.to . -•.--.- _ perforations -n.to ---^ -._.pertorattona from -- !t.to _._._-� -- - MUM • ► 1 i I _ - _.---- --perforations front --• _ NM - iY ■�� 1 ral Sere ens: Yea f7 No ____.�-----"'` _ 0 Tams-.....- r'a Natant "-1-- Model No------__ r . IIIIIII Cl MornType......._.. _~•Slot sire t ft. to ».•. ftt ,_ Diem. __.__._ _ -ft_ to . .►t slot site-•-•-•' —� Dram. ._____. — ----- WI —.- C Gravel packed:: Yes O NO Sire of gravet: -.-_. RS n.to___.. . _ !t. 111111 Gravel Placed morn -----•.. - -- -" _ .__-- fi [.j To at depth eti � taj' Surface seal: Yes .�2ih ---•--. + 1 R'1 plid anyi used in seal_ unusable water? Yea 0 No F„ strata contain 111111111111 --- Did Depth of strata-.-..�..-..-.... �-- - OType ofd rAat alin.._......-.-_.ft---^ --••--•-••« nrt`SAw�► �fFIC� 2 sllattlod of sealtti strata oft-------------------- il--- - "- • ��,-_ � � in Cal !7` PUMP: manufacturer'. Nnfte-_- »- . �--- _ �� ( / Zype: •_--_.. .._ ..-r L,alld-sYr2aee alevatlon � /t'�fit, 0) (8) WATER LEVELS: •bow rteao sea level. / ��'',fJ n.below top of well Date.- 1Z4fi•1- _ nite NNE O Artesian levelnp '•- L �lba-per square inch Date-.. Ul .-812 SIM O Artesian premfure ...- U/Cci3e�rr.- _ •.�-__ - U Artesian water is controlled by-- •- (Cap.+alvo,etc.) W scud !a � _-..__..19 . Completed -�,--." 1 -0 ri- Drawdow is amaountlwtw Wotia started O Wa(9) WELL TESTS: ioweredy .. WELL D�ILLEItr'S STATEMENT: Was a pump tt made? Yea 0 No it Ym it- drawdown otter Jurisdiction and this report is E Yield: al/min. with This well was drilled under my iurisd trye to the best of my knowledge and belief. r eel off) (water level o when Prune turnoOL‘gsfliri (Z, o print) NAI1dF+... t�pe r rin a Recovery a a (tune east top to level) Of co Tim. Water Letts! II1labufe a Water Lapel �. .._._.»... � Trine Waist Least m ._».»......--._.__ «...-..»........«..------ :::�:::��:::::::l . _..._...».-_.. .» ..__.• ........- (s,g,�,......... __............iw D - _ Q j� ..teat! Of test......_..._.. _ -.....�..ft drawdown afte.--.-h- 7 pate 1 ��`��_ , 19.a x Salter test..... ......... r- sn. Data.._--i. d License No....._...»--.�G-••- hntsian flow__..------r -- "•-"•"--•P mallet Yea Q No Was•chemical analysis Temperature of water__-.._...w SARY) �s (USE ADDITIONAL S8Erra lZ NECb9 EGr a -�•Za Scanned Documents 6 Lcazai---3-optv90 _______---- t Thurston County Environmental S ealth MO Lakerid&e Dr.SW S Olympia, sit 360 867.2631 COLIFORM BACTERIA ANALYSIS RECE f V a.D Da:^.Sample Col'ettcd Time Saacd ter., n 2 �rdcd 1 615APRi.',..A 02, Yri, :4•CCIv•1 1/1Ct-'5°4 \ W. 2 Al 6 der2a2 StreetJ T7paol Water System(check c yonebps) CIPiro"' (r I I Group A and Group B Systems-Provide from Water Face;le.enter!tV(il) • ID* _ - • t.IVV"IRONMENTq System Name. Comet Pe ,: -rape dr -----I ' HEALTH 7' , a CoaPtseaal a � Day Phone:t ) E. 4 — s. e '•ii Eve.Ptfono Scr4.spi 141nfine 'appose et woo aeees+)- `-�- !f .sk€ Lt_uxc)_057.-_-.___—_.__. SAMPLE INFORMATION Sarp a coreded by(ran a): . ( ,k9e �or a where sample m7ec led' Special insUXho a or tortM'titc I ". ) r-11 5 c-... Wri`i I ?r� I Type of Sample(must Cited only ono box al fit through."s Wed bean) I.O Routine Distribution Samptel 2 Repeat Sample latter mat routine) CI:'annoted:Yes___No !s 0 O outdo System 1 1 Gelatine Residual'Total_Fite_ Chama'cd Yes No____ 1.Raw Water Source Semple Chia ne Residual.Toat__Free_ Q E.coil-GWR(A'P) 0 Feral••5 cm twit red. ) UnsTNaerry touted tab minter: F:.r.W Yrs. lb ——__-- a Assessment Moberg Wit) Uosat s xtory=tne oiled date: OOther S t os 4.0 Sample CollectedCollectedbra/Rooks-__- Omer—_ lnrtieaWo--- LAS USE ONLY DRINKING WATER RESULTS LAB USE ONLY I f-1 Unsalistaetmv TWA Ce one Present and 11