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Home My WebLink AboutWAT2023-00138 - WAT Application - 6/20/2023 ` WATX33---_()_0138 ..Q. MASON COUNTY COMMUNITY DEVELOPM> CEIVED .ni1rA,. Permit Assistance Center,Building,Planning 415 N 6th Street, Bldg 8, Shelton WA 98584, JUN 2 0 2023 Shelton: (360)427-9670 ext 400 ❖ Belfair: (360)275-4467 ext 400 • Elrr:)(6W82-526eexx t,4�00 H FAX(360)427-7787 Application for Determination of Water Adequacy. 7N"MENTAL 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 II / Name on Applicant: La -A deb- k StA i iEl.ty �y�Date: w! Rd/aaa3 Mailing Address: 29011 "�(} bo Wl \ �!II I to Phone: 3(p0-fn�1"73°) ) Parcel Number: 1,4 CG'Sb - 00031 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more '9 Building permit 1 ,L 2ad a33 OO( 8 1 connections) 0 Division of land: tiEl Individual water source (one connection), #of Parcels? SPL ® Well 0 Boundary line adjustment O 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: Water Facility Inventory(WFI) Number: (write "none"for two-party) O 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. O 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. ]:\EH Forms\Drinking Water Revised 1/25/2018 Individual Water Well �a Water well report(attached to application). Depth ft. Well capacity Test (attached to application) Jl I 7 9PmvO 9Pd 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). sasm73 Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planninq 14'151 I 161-1 22= Water use or limitation recorded N/A E Yes 0 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: A , This determination does not address adequacy of the distribution system,guarantee an ade dat. •`•t,,-.• water indefinitely in the future,or guarantee compliance with all applicable WDOE water resource reg+l. iM Vol 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 may4661y2 chapter 36.70A RCW. l'+gSONCOUIt J 20Z, Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the fc NAignENr1 reason(s). J.4 11e41 rn Reviewer's Signatures: / oZ Environ. Health: P Date ('/ 25 l 2 of 2 CSD Director: Date ,e)L0 a,023 OO(9S`# Thurston County Environmental Health RECEIVED 2000 Lakeridge Dr. SW t Olympia,WA 98502 360 867-2631 THUR.STON COUNTY JUN 2 0 2023 COLIFORM BACTERIA ANALYSIS 615 W. Alder Street Date Sample Collected Time Sample Collected Ccunty 143 1a3 Lda ),PM inadv7'Ll Month Day Year Type of Water System(check only one box) El Private Household 0 Group A ❑Group B El Other ENVIRONMENTAL Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# HEALTH System Name: / Contact Person: Ted 1ecIL1.1— Day Phone:(30) �Li y- ' q 11 Cell Phone:( �av)(p'i�' � E-mail: C/r J Ji') i,_(') J'-t hone.( ) Send results to:(Print di name,address and z.19code pr Iliai��resk) r i` III/ I __ 6. 1'�)�k1i- Ihll L cr;I IArI/db--6 j kiit 14'3,0 SAMPLE INFORMATION • Sample collected by(name): / ai-i `{�C��Y Specific location or address wheerreessample collected:( Special instructions or comments: 9.3/ Fr 10.0 Gakt-Av ALIgC✓tea)/ W`1 18S-Y.� 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.coli-GWR(A/P) ❑Fecal-Surface,GWI,springs(numeration) Unsatisfactory routine lab number: Filtered:Yes No ❑Assessment Monitoring(A/P) Unsatisfactory routine collect date: ❑Other / / S 4.1' I Sample Collected for Information Only Investigative Construction/Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY El Unsatisfactory Total Coliform Present and Satisfactory ❑E.coli present El E.coli absent o liform detected • Replacement Sample Required: El Sample too old(>30 hours) El TNTC ❑ Bacterial Density Results:Total Coliform /100m1. E.coli /100m1. Fecal Coliform /100m1 Enterococci /100 ml. Method Code: I SM 9223E ❑SM 9222D Date and Time Received:Iti)>7 b SM 9215B El Enterolert® J ;1 oit- - Date and Time Analyzed: Date Reporiet'-j-1 •13 dT�c Sample Number(DOH number plus five digits) Lab Use Only: 0 8 0 c�D f DOH Form it331-319(revseaL1p.(;r r3 3 AUG 2 3 2023 MIN Arcadia Drilling Inc. P.O. Box 1790 RECEIVED Shelton, WA. 98584 Customer: Joseph Builders Well Tag #: No Tag Phone: (360) 649-7391 Well Site Address: 931 E Mason Lake Dr E, Shelton Date of Test: 7/25/2023 Static 78.1 TIME GPM LEVEL RECOVERY 1 Min 8.0 79.3 TIME LEVEL 2 Min 8.0 79.9 1 Min 81.2 3 Min 8.0 79.9 2 Min 79.3 4 Min 8.0 81.4 5 Min 8.0 81.5 6 Min 8.0 81.6 7 Min 8.0 81.6 8 Min 8.0 81.6 9 Min 8.0 81.7 10 Min 8.0 81.7 15 Min 8.0 81.7 20 Min 8.0 81.7 25 Min 8.0 81.7 30 Min 8.0 81.7 35 Min 8.0 81.7 40 Min 8.0 81.7 45 Min 8.0 81.8 50 Min 8.0 81.8 55 Min 8.0 81.8 1 Hr 8.0 81.8