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Home My WebLink AboutWAT2023-00115 - WAT Application - 5/18/2023 _ I W A 1 in' 00115 , MASON COUNTY COMMUNITY DEVELOPMENT Permit Assistance Center,Building,Planning \,(eet 415 N 6th Street, Bldg 8, Shelton WA 98584, 615 h4 :w6O)427-9670 ext 400 •: Belfair: FAX(30) 75 446787 ext 400 :• Elma: (360)4 2-5269 ext 400 ENVIRONMENTAL Application for Determination of Water Adequacy HEALTH 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: Vi noe,--ri Shi2Ieer- (} roate: Mailing Address: -7301 mco,ibeK �jrc�ci1 2c1 Phone: 3(6o-4ctp- 1��t3 Parcel Number: (019,D`7.'�3. 9t`G01 Type of Water System Reason for Application /,, ❑ Public/Community Water System (2 or more X. Building permit 'pL-'�ab' 3""G06-WR connections) 0 Division of land: 01 Individual water source (one connection), #of Parcels? SPL gl Well 0 Boundary line adjustment 0 Spring/surface water ❑ 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: 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 125 2OIs Individual Water Well El Water well report (attached to application). Depth s g, g ft. J$ Well capacity Test (attached to application) ,�S gpm 1 00 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). i/zC/zazj Water Resource Inventory Area (WRIA) Development within which WRIA http://qis.co.mason.wa.us/planninq 14U 151 1 161 122��[1 � ` Water use or limitation recorded N/A 0 Yes Well Drilled Date 6/(5// ? �� 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 requirement may apply. Chapter 36.70A RCW. PP Unsatisfactory Determination: RO v Applicants water supply does not appear adequate to meet the needs of its intended use for the following `® reason(s). AUG 3 1 2023 MA c Reviewer's Signatures: �NUuUNryENV/�7pN,MENrq/ HFACTy Environ. Health: Date ?/3(/V Z CSD Director: Date 2 oft bu.va0a3-005(Da WATER WELL R E PORT Start Card No. W045650 Unique Well I.D. N AIJ794 STATE OF WASHINGTON Water Right Permit No. (1) OWNER: Name TAUSA, SIIILA Address N 1760 SXOIOMQSE INDIAN SNILTON, WA f8S44- (2) LOCATION OF WELL: County MASON - SW 1/4 SW 1/4 Sec s T 19 N., R 6W WM (2a) STREET ADDRESS OF WELL (or nearest address) W 7201 MATLOCK-BRADY RD., BHILTON (3) PROPOSED USE: DOMESTIC (10) WELL LOG •A (4) TYPE OF WORK: Owner's Number of well Formation: Describe by color, character, size of material (If more than one) and structure, and show thickness of aquifers and the kind NEW WILL Method: ROTARY and nature of the material in each stratum penetrated, with _= at least one entry for each change in formation. (5) DIMENSIONS: Diameter of well 6 inches Drilled 60 ft. Depth of completed well 58.6 ft. MATERIAL FROM TO BROWN LOAN GRAVID, 0 2 (6) CONSTRUCTION DETAILS: DRONE MINT= CLAY a GRAVEL 2 45 Casing installed: 6 " Dia. from 4.1 ft. to S4.8 ft. GRAVEL & WATER 45 60 WELDED " Dia. from ft. to ft. " Dia. from ft. to ft. Perforations: NO RECEIVED Type of perforator used • SIZE of perforations in. by in. perforations from ft. to ft. 2023 perforations from ft. to ft. MAY perforations from ft. to ft. Screens: NO 615 W. Alder Street Manufacturer's Name Type Model No. Diam. slot size from ft. to ft. Diam. slot size from ft. to ft. Gravel packed: NO Size of gravel ENVIRONMENTAL Gravel placed from ft. to ft. H EA LT H Surface seal: YES To what depth? 20 ft. Material used in seal BENTONITI Did any strata contain unusable water? NO Type of water? Depth of strata ft. Method of sealing strata off CASED (7) PUMP: Manufacturer's Name Type H.P. (8) WATER LEVELS: Land-surface elevation above mean sea level ... ft. Static level 30 ft. below top of well Date 06/13/94 Artesian Pressure lbs. per square inch Date Artesian water controlled by Work started 06/10/94 Completed 06/13/94 (9) WELL TESTS: Drawdown is amount water level is lowered below WELL CONSTRUCTOR CERTIFICATION: static level. I constructed and/or accept responsibility for con- Was a pump teat made? NO If yes, by whom? etruction of this well, and its compliance with all Yield: gal./min with ft. drawdown after hrs. Washington well construction standards. Materials used and the information reported above are true to my best knowledge and belief. Recovery data Time Water Level Time Water Level Time Water Level NAME ARCADIA DRILL/NO INC. (Person, firm, or corporation) (Type or print) ADDRESS SA 17 WILIER Date of test / / Bailer test gal/min. ft. drawdown after hrs. [SIGNED) License No. 2053 Air test 35 gal/min. w/ stem set at 38 ft. for 1 hrs. Artesian flow g.p.m. Date Contractor's Temperature of water Was a chemical analysis made? NO Registration No. ARCADDIOSSK1 Date 06/15/94 • Printed From Mason County DMS Pr nt.'.J 'iron! UtaS::') County OMS 6 L 12 a 3-pb (0 , Thurston County Environmental Health 2000 Lakeridge Dr.SW ♦Olympia,WA 98502 --. 360 867-2631 RECEIVED THURSTON COUNTY COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County MAY 18 2023 Collected i,A`' 1�.)3 it/ ir rl 615 W. Alder Street Mcnm Day Year Type of Water System(check only one box) 0 Private Household ❑Group A ❑Group B gOther` i G �-`I Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# ENVIRONMENTAL System Name: Contact Person: Yt nCe r cc. Day Phone:.) 71j(v— �� Cell Phone:) i iO HEALTH E-mail:Inear1Z l .elytym,(Om Eve.Phone:ak ) '0O51 Send results to:(Pant f :name,address and zip code or email address) 8EAi• (zc pa@m.3r ._CUm_ SAMPLE INFORMATION Sample collected by(name): Shtaleer C Y Specific location or address where sample collected: Special instru ns or comments: 7 C'i w MccA-taiK(Brryci c Etma-, OA 9854.1 Type of Sample(must check only one box of#1 through#4 listed below) 1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes No ❑Distribution System Chlorine Residual:Total Free Chlorinated:Yes No 3.Raw Water Source Sample Chlorine Residual:Total Free ❑E.colt-GWR(AR) ❑Fecal-Surface.GM,springs(numeraboe) Unsatisfactory routine lab number: Filtered.Yes____No ... ❑Assessment Monitonng(ANP) Unsatisfactory routine collect date: pother I / _ Sl I I —_ 4.0 Sample Collected for Information Only Investigative Construction/Repairs X Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY 0 Unsatisfactory Total Coliform Present and Satisfactory 0 E.coli present 0 E.coli absent No Colitorm detected Replacement Sample Required: ❑Sample too old(>30 hours) 0 TNTC 0 ._ Bacterial Density Results:Total Coliform___.__..-._1100m1. E.coli 1100ml. Fecal Coliform 1100m1 Enterococci /100 ml. Method Code: SM 92238 ❑SM 9222D Date and/ Time Receivei k' 0SM9215B ❑Enterolert�) �- 2 "23 t(2( . Date and Time Analyzed:t . 7 ( 2 3 Date Reported: 7 ',)/ 2,5 Sample Number(DOH number plus rive digits) Lab Use Only: 1 L f24 I DOH Form d331-319(revised 01116)