HomeMy WebLinkAboutWAT Application - 7/24/2023 MASON COUNTY
I WAT
i COMMUNITY SERVICES RECEIVED
Budding,Planning,Environmental Health,Community Health
415 N 61' Street, Bldg 8, Shelton WA 98584, JUL 2 4 2023
Shelton: (360)427-9670 ext 400 ❖ Belfair: (360)275-4467 ext 400 ❖ Elma:(360) 482-5269 ext 400
FAX (360)427-7787 615 W. Alder Street
Application for Determination of Water AdemyIRON m ENTAL
Instructions HEALTH
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: eT \€, - 14 ir'=-. t
:r/Lr{,,-- Date: 9-4 %'
Mailing Address: �'Zi t N IW d:; f L t `; Phone: leb, 3. c�
Parcel Number: 22Z 30 - ?Y.1' - O
Type of Water System Reason for Application
❑ P lic/Community Water System (2 or more Building permit
onnections) CI Division of land:
Individual water source (one connection), #of Parcels? SPL
Cr Well 0 Boundary line adjustment
0 Spring/surface water
❑ Other(explain) ❑ Other (explain)
XReplacement 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. O LO R Ot —008 t , n
Part 2: Water Connection Information 1J `-�`�
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 1/25/2018
Individual Water Well
I/Water well report(attached to application). Depth i ft.
❑- Well capacity Test (attached to application) 2 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/planninq 14= 151 167122=
Water use or limitation recorded............ ............... N/A E /Yes
Well Drilled Date 4-/ �jo � s
Individual Spring/Surface Water YYY
❑ 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)
CI 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 ROW.
[� 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: Date
CSD Director: Date _ 2 oft
Start Card No. W 068273
Otment of Ecology
Flret Copy with
De VnaM par WATER WELL REPORT Uta01JE WELL LB.e ACD 870 ._
Os -
Second Copy-Owner's CAPE STATE OF WASHINGTON Water t PertmM No.
Third Copy-DAW.Copy ---
Sw
fl. (t) OWNER: None Shtdy h Four_W.S. Apda« 1 3(11 Sprit St UD]* 1r�F Seattle, WA 98104
(11
Et (2) LOCATION of WELL: coolly Macon
NW iN ;t.. tr.Sec_ 30 T ?? N.R 2(,1 W.M.
d (2a) STREET ADDRESS OF WELL(or weaadoest) E 11562 Statc Rcuitc 106_ Iininn, WA 9859?
Don,sslc (10) WELL LOG w ABANDONMENT PROCEDURE DESCRIPTION
(3) PROPOSED USE: !-jC Industrial q Municipal 0
fA ❑ irrigation Teat Wee n Crews 0 Fonr.sllon:Devote by coo charmer.see of materials ial and.t•ectur,ono show aschne of uou+.n
!1 DeWaNr end Ow Read and naive of es inalei t el each Strang.penetraioe with at Iee.m one.mry to each
- (4) TYPE OF WORK: fIh m�orte mammal. FRDN TO numb aj I I - change el INm oveon
C
O Abandoned ) New well I X Method:Dug Bored
a Driven C
o beeponReconditioned o ROWy G Jetted C Sandy brown clay . 0 10
R(s) DIMENSIONS: Dtamete,of well_ 6 inches
E vales 109 test Depth of completed wee_. 109 it Brown hardpan -- 70. 85_
2 (6) CONSTRUCTION DETAILS: •Sand & gravel...with planar 85 /09
Casing Installed: _6___- D'm hoer Q....._k.to-104---n•
w Wetted 19 ---___• Diem.from —ft.to _A.
•C '�+edned stalled I 1 _—' Diem,from_ N.a ft.
8 Pe toretlona: Yes 0 No I� — - --
15 Type or perforator used— —_ -- M --- —'— .—.
C SIZE of pemaatiOna_ in.by— --- —
(Q Otetommrr from_ _—h.to ft. ..
psAoradom from_ ft lo ft .
Q padorabom hem_ —ft.toIt
•
0) Sawa: Yes No 0 _ -
.0 Manufacturer's Name — COpk - -- --
TType ataTnl PSS.wire wrap_- SAWN No.
urn 5 Sbt s¢o 35 both-�4___h.to 109 it
C tim R .
1Ti Dam __Slot fro
t size .
Gres*pecked: Ya❑ No® Sized gravel— - -
�r Grevel placed from - -ft.to ft - -
I— Sunoco Mel: Yin® No❑ To what OWN?_ 1 A ft. _
o Material used in Seal_ Bette r.P_
Z pd any strata column unusable water, Tin 0 No bill .
H Type or water" —_ —Depth debate —__ _
—
oMethod of aeallnp strata Oa _ . — -. -- —
TJ
>, (7) PUMP: Mrhdacturera Nome- jr;)Ind f os _ ..._-__..—
Ca Type. _sub.___- -- -.-ILP.- 14--- __,_---
Co
lei WATER LEVELS: a Y,A s.,p-4JL9 _.,9 coptted 4/30J96__.-...f'—.
endue itwn sa kwM_ .
0 staac a el.___. 19_ .h.below lop d wee DIM WELL CONSTRUCTOR CERTIFICATION:
W Meson peseta* et par sawn ildl Dam —
te- ArtaN.telM e0on1n01e01N _ I constructed and/or accopt responsibility for condo Ct,01 of this well.and do
O ---ZCap.v-Ti.e.eteT�� compliance with aft Washkgton well construction Standards.Materials used end
a-+
the mformatron reported above are true to my best knwledge o end beliel
C OnWELL TESTS: D.awdown is amount water level a lowased below amtrc IeYel
E Was a pump mat made,Ya t—)X No❑ a yes,by`rtte e?.— NAME_ Dav i5 11 i no
1 _has_ a�6n.PalM ia► �i trots be PR..n
o.+ Yield: __30_gatemen.vie 16 ft.erawdO n eMr 11
R30 .. _36__ 2 •• Address
anT —
30 36 L " License No.�062
8 Iismverr data(tow a zero when puny lamed Of)fender level measuredmeasuredfran w (SWIM)ee LL
top to wafer Revel)
el Time Water Level Tins Water Level 'firm Water Lave f Contrac�tpor's
- — 55 _min.__26i— 10 min,_ 19_75� a°°atr UAVISDI1100A _Dam it — 'g 9b
F- 1 mtt. —4? 4_Ini.a._ — 30- a 19 4S Np.-- -
2_min. 30' -_5 min_ 9n 5' .1 hr. 19 (USE ADDITIONAL SHEETS IF NECESSARY)
Data of ant_
-
Barter lest gatirein.with _IL dnadown after Ise
Ecology is an Equal Opportunely and Affirmative Action employer.For spe-
Airm.t —Or men.waft stern set at— ttRC1N accommodation needs,comas the Water Resources Program at(206)
Meson flow D-0_m Oath— 407.6600.The TOO number is(206)407-6006.
Temperance of water_ _Was a dtaoktel analysts mode? Ye,IN Na❑
i ECY os0-t 20(9e31'.I
Note: Well is used for determining groundwater, and may not originate on the property.
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