HomeMy WebLinkAboutWAT Application - 5/10/2023 • J:.c:•
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R 415 N 6th Street, Bldg 8, Shelton WA 98584, F p I D
-Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 Elma: ( e Quv
FAX(360)427-7787
Application for Determination of Water Adequa Y 10 2023
615 W. Alder Street
Instructions
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: Jer -rry ()rip! "Ivy wlP•(i'e I Date: ;-7-/ L 5- /2- S
Mailing Address: 51 U e L�c��` 124,-0( Phone: C /2 ` ?oa ' L
Parcel Number: 320 i3 - 31 " 3C)
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more , Building permit
connections) 0 Division of land:
15 Individual water source (one connection), #of Parcels? SPL
le Well 0 Boundary line adjustment
0 Spring/surface water ❑ Other explain)
❑ Other(explain)
Re. - emenr or Remodel (please indicate name
If you have more than one residence connected o water system below if applicable—no
to this well, check the Public/Community Water signature required)
System box. 7L O U c — 00�
Part 2: Water Connection Information IJ
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)
0 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.
0 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:A H Forms\Drinking Water Revised 1/25/2018
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test (attached to application) 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/planning 141 150160220
Water use or limitation recorded N/A) IYes1
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: Ft-----&-/-0Date
2of`
CSD Director:
Date
'Inc. LQRoa: - odsal
Davie ilunps,3409UE Davis'Farm lid RECEIVED
1'3er?fair,`Wa 98528
(360)801-6107
MAY 10 2023
Project 510 Lonesome Creek 615 W. Alder Street
Capacity Test TAG:NA
Date 3/21/2023
Pump 1 - �r=hp ENVIRONMENTAL
Well Depth +178 HEALTH
Static Water Level 167
Draw Down Recovery
Time Water Level GPM Time Water Lever
0 min 167 0 0 178
5 min 176.8 14 1 min 171.1
10 min 178 14 2 169.2
15 min 178 14 3 168.1
30 min 178 14 4 167.8
1 hr 178 14 5 167.3
2 hr 178 14 10 167
3 hr 178 14 15
4 hr 178 14 20
Capacity Notes:
Well seal with catch rope - unable to take well depth measurement with obstructions
I
I
jLvaL)a- b05 at
i ENVIRONMENTAL 26276 Twelve Trees Ln NW Ste.C
HEALTH Poulsbo,WA 98370
SPECTRA Laboratories - Kitsap (3601 ECEIVED
...Where experience matters MAY 10 2023
IOC TEST PANEL 615 W. Alder Street
Complete or Selected Inorganics
System ID No: System Group Type: Private
- — --_-__.. -- -----------_..---
Sample Number: 010-74202 System Name: 510 Lonesome Creek Rd
Sample Location: Source County: Mason
Sampler. Marisa
Source Number(s): Sampler Phone No:
Sample Purpose: Other Date Collected: 03/15/2023 14:05
Sample Composition: Single Source Date Received: 03/16/2023 1 1:00
Sample Type: Drinking Water Date Reported: 3/23/2023
Send Report to: Bill to:
Davis Pumps Davis Pumps
340 NE Davis Farm Road 340 NE Davis Farm Road
Belfair,WA 98528 Belfair,WA 98528
DOH# Analyte Results Qual. Units SDRL PQL Trigger MCL Exceed Method Analyst Analysis
MCL Date
0020 Nitrate-N ND — mg/L 0.5 0.0330 5 10 EPA 300.0 NV 03/17/23 3:20
NOTES:
'Confirmation Include the original lab number,sample number,and collection date of original sample in either lab or sampler comments section.
SDRL: (State Detection Reporting Limit)The minimum reportable detection of an analyte as established by the department..
Trigger Level: DOH drinking water response level.Systems with compounds detected at concentrations in excess of this level may be required to take
additional samples or monitor more frequently.Please contact your DOH drinking water regional office for further information.
MCL: (Maximum Contaminant Level)If the contaminant amount exceeds the MCL,please contact your regional DOH office to determine follow-up actions.
NA: (Not Analyzed)In the results column,indicates this compound was not included in the current analysis.
ND: (Not Detected)In the results column,indicates this compound was analyzed and not detected at a level greater than or equal to the SDRL.
<(O.00x): The compound was not detected in the sample at or above the concentration indicated(usually the lab method reporting limit).
mglL: milligrams per liter or parts per million.
NTU: nephelometric turbidity units(a measure of water clarity).
Nmhoslcm: Micro ohms per centimeter(a measure of the ability of the water to conduct electricity).One micro ohm per centimeter is equivalent to one micro
siemen per centimeter(uSfcm).
No existing trigger or MCL value.
1: Secondary MCL(Established for aesthetic purposes,not health based).
224742-02 Page 1 of 2
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SPECTRA Laboratories—Kitsap, LLC
DRINKING WATER SAMPLE INFORMATION(WSI) FOR
INORGANIC CHEMICAL ANALYSIS
See Sampling Instructions on back of page
1.System ID No: 2.System Name: n 3.Group(circle) -�.,
_ SID Lo c 3-cC eci A B Private
4.Sample Location: 5044 5. Date/Time Collected: AMt6 Lab Number Lab pie only
►pc_ a05' Q 3/-is, 3 \ Zq-74 '7,--- 102
6.Sample Collected By: 7.Sampler Phone Number: 8.Sample Type:(Circle one)
AUtA,S C,c g&O PO( (o(O 7 Untreated (raw) Treated Unknown
9.County:(circle one) 10. Sample Purpose: 11.Sample Composition 12. Source No(s):
Kitsap Clallam Jefferson D Single Source __ _ ,
(4 ason Pierce Thurston ❑ Routine Compliance CI Blended -->
Island King Grays Harbor El Composite
—
Other: Other,Investigative 0 Distribution ----' —
13.Send Report To:(Print Name,Address,Zip Code) 14.Phone No.:
D U\ 2..L a,\,(N
�iuls(��P P
fir(, c6I .0 15.Fax No.:
La to c- 16. Email:
17.Special Instructions:
Analysis OPrimary IOC
❑Inorganic Chemicals,IOC O Kitsap 5(No3-ti,Fe,Mn CI',Cond) (Sh,As,Ba,Be,Cd,Cr,CN,F,
Requested (Group A&B systems) lig,Ni,Se,TI,NOs-N,N01-N,
(Sb,As,Ba,Be,Cd,CgCN-,F,tlg,NI,Se,TI, OPierce County IOC Na,Turb,Pb,Cu)
Check a NO3N,NO:-N,C1'Fe,Mn,Ag,SO4,Zo,Na, (Sb,As,Ba,Be,Cd,Cr,CN,F,11g,Ni,Se,TI,
group bard,cond,turb,color,Pb,Cu) NOS-N,NO2-N,Fe,111n,Na,turb,Pb,Cn) El Other(circle
or circle individual
individual kig,1,4itrate only 0.1efferson County(No,-N,Co) test or write in new test
tests below
below)
-
EPA EPA REGULATED EPA REGULATED STATE UNREGULATED
REGULATED (Secondary) REGULATED
Antimony(Sb) Nitrate-N(NO3-N) Chloride(Cl-) Sodium(Na) Alkalinity
+Arsenic(As) Nitrite-N(NO2-N) iron(Fe) Hardness Calcium(Ca)
Barium(Ba) Total Nitrate/Nitrite Manganese(Mn) Conductivity Magnesium(Mg)
Beryllium(Be) Nickel(Ni) Silver(Ag) Turbidity Potassium(K)
y Cadmium(Cd) Selenium(Se) Sulfate(SO4-2) Color pH
Chromium(Cr) Thallium(TI) Zinc(Zn) Other: (list) Chlorine Residual (circle)
Free and/or Total
Cyanide(CN) STATE Total Organic Carbon Orthophosphate-P
UNREGULATED (TOC) _ __ (PO4-P)
Fluoride(F-) Lead(Pb) Total Dissolved Soi'ids Sulfide(HzS)
Mercury(Hg) Copper(Cu) Bromate(BrO3) Tannin
Sample Signature — �— — Date FTlme: — —
Relinquished By:
Sample Received Signature Date I ime: Condition and'temperature on Receipt:
11 By: 3 II b f 2-3 /l o
26276 Twelve Trees Lane,Suite C. ♦Poulsbo,WA 98370A (360)779-5 141 ♦Fax:(360)779-5150 A wwr'w.Spectra-lab.com
S.\Administrative\Forms and Templates\Templates\Sample Management\Current WSI Form,st1OC loon Rev 6.2 052021.doe Revision date 081619
26276 Twelve
Trees 12,NW •
Ste.0 ' SPECTRA Laboratories - Kitsap
Poulson,WA ...Where experience loaners
98370
(360)779-5141 COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Tune Sample County
3 '15' a 3 Collected
o AM
Mont Day Yew 415 GPM11(t J! 1
•
Type of Water System(check only one bar)
❑Group A 0 Group B 1J utner- LLidi+L
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID# ---
System Name:5/O 1c���Jj'}��e cr e— I2ct
Contact Person:4 1A S --
Day Phone: Cell Phone:
EmalUbja Cttivkp reps lr v .1) �'j( 6 tor
Send resits 10:(Pitiful name,address ad it cede ail above for.19dM114c copy of results)
Dcw t 5 Pc,i-" s
SAMPLE INFORMATION
Sample collected by(name):
Specific location where sample collected: Special instructions a comments:
Type of Sample(check only one box)
1.❑Routine Distribution Sample(AIP) 2.❑ Repeat Sample(AIP)
Chlorinated:Yes ❑ No❑ (from distribution system after unsat.routine)
Unsatisfactory routine lab number
Chlorine Residual:Total_Free_
3.Ground Water Rule Source Sample •
Unsatisfactory routine collect date:
IS I
Chlorinated:Yes No
❑Triggered(A/P) Chlorine Residual:Total_Free
El Assessment(AR)
4.Surface or GWI Raw Source Water Sample(Enumeration) I S I I I
❑ E.cot ❑Fecal Filtered Yes No
5.I6arrple Collected for Information Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Cotiifonn Present and atistactory
0 E.cob present ❑EcoQ absent
Bacterial Density Results:Total Callum mpnl100m1.E.coli _ mpn/100m1.
Fecal Coliform cfu1100m1. HPC cfullml.
Replacement Sample Required: ❑TNTC ❑Sample too old
❑ SamplpleVolume ❑Damaged Container ❑ ___ /_ `
Recaps Temp C: Method CodeT COUNTI SM9222D
paten: Date Out then:ne...d,drrkreru.de.peeonnn.p.Wyep
���1kf23 3111%2,3 "nder.dtrwdMw.dCyobv.r.o..aeur eon VI,rk0 M
fn.d.d reagent n.rthau.d M ry l.w no.w.8141 n
enn,pieeenoW a.eerdr enmedrMy r 36ptnatsl srd
a.aq a:,norm port"
DOH tab-Sample##�"
7 ! 10 I Them molts Mattony canes wed sod tre,ndels)
010 -- re►.dbrawlsb.Wy TM fecal net re be rceoduwd wept
n U.•in.s price acne rose,gene el by Spectre Lsbor.fr
DOH Form 1:111Jf9 Wed.DM 7)
26276 Twelve Trees Ln NW Ste.C
Poulsbo,WA 98370
SPECTRA Laboratories - Kitsap (360)779-5141
...Where experience matters
Final Page of Report
Lab Qualifiers Comments:
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
i unauthorized.If you have received this report in error,please notify the sender immediately at 360443-7845 and destroy this report promptly.
I These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not he reproduced except in full,without prior express written
approval by Spectra Laboratories.
� y
Approved By
Angela Kaelin
Laboratory Manager
224742-02 Page 2 of 2