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Home My WebLink AboutWAT2023-00054 - WAT Application - 4/20/2023 •L `��rr. r NL WAT aO 9-3- WD6 " \ MASON COUNTY �+ �� '' ' I" . COMMUNITY SERVICES t -w► R — $ 2023 \�, / Building,Planning Env,ronmental Health,Community Health E IAAig•IIL,V3N� NJ VIR0 N M E N TAL SASeSt 415 N 6'h Street, Bldg 8,Shelton WA 98584, 991 r fl A 1 .r� 615 W. rSh�iton: (360)427-9670 ext 400 ❖ Belfair: (360)275-4467 ext 400 •:• Elma: (360)482-52 �Zt I FAX(360)427-7787 Application for Determination of Water Adequacy LEGL7 Instructions APR 2 0 2023 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. RECE VED 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: Martha & Tom Fontaine Date: 02/01/23 Mailing Address: 105 SE Arcadia Point Rd Shelton Phone: 541-990-1976 Parcel Number: 22028-50-04001 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more ❑ Building permit eL.i22023--OCR�� connections) 0 Division of land: E Individual water source (one connection), #of Parcels? SPL I!dw Well 0 Boundary line adjustment 0 Spring/surface water 0 Other(explain) 0 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: NA 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 Water Revised 1/25/201 t ivarrissommor Individual Water Well E Water well report (attached to application). Depth unknown ft. ❑ Well capacity Test(attached to application) 10 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. 0 Satisfactory bacteriological test(attach to application). 9 Water Resource Inventory Area (WRIA) Development within which WRIA http-//ciis.co.mason.waus/planninq 1411,V/ 15E7 161— 122E1 Water use or limitation recorded N/A MI Yes 1 1 Well Drilled ... Date Individual Spring/Surface Water 4,JOE 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) XSatisfactory 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. on: Unsatisfactory watuppp y does not appear adequate to meet the needs of its inter P5e PROM E D reason(s). MAY 0 2 2023 Reviewer's Signatures: MAS?4,CQU 2e ••NMENTAL HEALTH Environ. Health: Date -, I C 6 J CSD Director: Date 242 OLJOROR3 - DeD,9_,7 Arcadia Drilling Inc. P.O. Box 1790 Shelton, WA. 98584 Customer: Tom & Martha Fontaine Well Tag #: None II %L-1/4./c...1 t..:. Phone: MAR - 8 262 Well Site Address: 105 Arcadia Point, Shelton 615 W. Alder Street Date of Test: 4/4/2023 Static 33 TIME GPM LEVEL RECOVERY 1 Min 11.7 39.0 TIME LEVEL 2 Min 11.7 40.7 1 Min 36.2 3 Min 11.7 41.4 2 Min 35.7 4 Min 11.7 41.5 3 Min 34.8 5 Min 11.7 41.7 4 Min 34.6 6 Min 11.7 41.7 5 Min 34.5 7 Min 11.7 41.7 6 Min 34.3 8 Min 11.7 41.7 7 Min 34.2 9 Min 11.7 41.7 8 Min 34.1 10 Min 18.75 41.7 9 Min 34.05 15 Min 18.75 43.6 10 Min 34.0 20 Min 18.75 43.9 25 Min 18.75 44.1 30Min 18.75 44.1 E A1RONMENTAL 35 Min 18.75 44.1 40Min 18.75 44.1 HEALTH 45 Min 18.75 44.1 50 Min 18.0 44.1 55 Min 18.0 44.2 I1 Hr 18.0 44.2 il d 0 0 1786 SE Mile Hill Drive c6 V O R3 OO R:7 5 Port Orchard,WA 98366 SPECTRA Laboratories-Kitsap www.spectra-lab.com • expolowe `-t1" (360)443-7845 E N`✓I F O N M E N TA L ^ COLIFORM BACTERIA ANALYSIS FORM H EA LT H r1��,J Date Sample CollectedTime Sample County 44.• Collected U Ji$ � 01 / 02 / ICI Collected Mason �jPit\ Mom Dry Yew p PM `r3 vN1 P' Type of Water System(died(only one box) O Group A ❑Group B ['Other Group A and Group B Systems-Provide from Water Fealties Inventory(WA). ID# System Name: Tom Fontaine 105 Arcadia Point Rd,Shelton Contact Person:Arleta Eisele/Arcadia Drilling Day Phone:360-426-3395 Cel Pie Emai adeta@arcadiadrilirg.com Eve.Phone: Send results to(Print full name,address aria zip code or o-man arleta@a read iad rill ing.com Arcadia Drilling,Inc Sample collected by(name): Dan Specific location where sample collected. Special instructions or comments: Hose Bib 1.0 Routine Distribution Sample 2 Repeat Sample(after unsat routine) Chlorinated:Yes❑ No❑ 0 Distribution System Chlorine Residuak Total--Free_ Unsatisfactory routine lab number. 3.Sauce Ground Water Rule Sample —-- ---- ——— • ISI I I Unsatisfactory routine collect date: 1 I I Triggered Chlorinated:Yes❑ No❑ El Assessment Chlorine Residual:Total Free 4. Enumeration Source Water Sample ISI I I ❑E.col/ ['Fecal-sr,am.n. i.spring(Fired Y.c NoD 5.❑� Sample Coleded for Information Or Investigative 15k6t� �� 6.471 = '4 • .ohs,:. �+ �:E�. 06 .. ❑Unsatisfactory Total Cofiform Preterit and .' tisfactory E.colipresent O EoariiiIrtt: . • ❑Sample too old.( oils)>50 b .0 TNTC- 0 • Bacterial Density Results Total Coliform /100m1,E.cohIs. • _11100r ill. : Fecal Collofrn - I100m1. •HPC : .•/1 ml. :• • Lab ID Number Date and Tdne Received itethodcam:. . • . - - SM92238 . •:ate Analyzed: Dehl ftepoited . JAN 01019 .- .. JAN •0 .32019 oo►f tabSampi�t tati'use ordr 225 •_o t°\ x r..,00aia+a(.n.a..anal-era,•..drop,ercalomh.nae.n.rwiernatdef453aorn(rourrrd»t) Ton and err per.sr,..AM,R move ddl.vaipachn nwa.r.