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Home My WebLink AboutWAT Application - 5/23/2023 DocuSign Envelope ID:4E477168-1A5B-4707-8846-4B9EC504495E WAT - MASON COUNTY I KECE\VED COMMUNITY DEVELOPMENT Permit Assistance Center,Building,Planning MAY 23 2023 415 N 6`h Street, Bldg 8, Shelton WA 98584, Adder Street Shelton: (360)427-9670 ext 400 Belfair: (360) 275-4467 ext 400 Elma: (360)Fd812=5269'ext 400 FAX (360)427-7787 Application for Determination of Water AdequacyvVIR01�1VIENTAL 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: DEBRA & DANIEL DEFFINBAU6Date: 5/23/2023 Mailing Address: 1510 E SPENCER LAKE RD Phone: 360-250-9258 Parcel Number: 221314400060 Type of Water System Reason for Application El Public/Community Water System (2 or more El Building permit connections) El Division of land: El Individual water source (one connection), #of Parcels? SPL El Well El Boundary line adjustment El Spring/surface water CI (explain) El Other (explain) Replacement r Remod I)please indicate name If you have more than one residence connected of water system e ow if applicable- no to this well, check the Public/Community Water signature required) System box. ��Q61)a-5'-' o Co 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) El 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 5/23/2023 This form may be scanned and available for public view at www.co.mason.wa.us. J:1EH Forms\Drinking Water Revised li25/2018 DocuSig n Envelope ID:4E477168-1A5B-4707-8846-4B9EC504495E Individual Water Well Water well report (attached to application). Depth 1� ft. Well capacity Test (attached to application) (40 gpm (?)U v 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 1 41-71 15n 161�22n Water use or limitation recorded N/A ] Yes Well Drilled Date to( 41/ Cr Individual Spring/Surface Water ❑ WDOE permit (attach to application) 0 Method of disinfection 0 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 4 • — • 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: � �� /� Date a, (Z�/Z 2 of 2 CSD Director: Date L. . File Original and First Copy with WATER WELL REPORT Start Card No a .4"t. Cl-2 -..- Osparlmem of EcobgY Second Copy-owner's Copy STATE OF WASFRNOTON `D Third Copy-Drillers Copy Water Right Permit No. gp y� / >r��Y 4.7) (1) OWNER: Nemoia 0 Dv tT'/A/LALa?2:1 . -- Address ei r rC>td!4� Ot. s19 rt I hr.: S c n./ .S ea tr v x Seer T. .,R W.M. � (2) LOCATION OF WELL: County _-- Q (2a) STREET ADDORESS OF WELL(or nearest address) ibf GI (3) PROPOSED USE: ✓4-Domestic Industrial f Municipal C (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION r Irrigation 0 DeWater Test Well ❑ Other C_I Formation: Describe by color, character, size of material and structure, and show thickness of&golfers and the kind and nature of the materiel M each stratum penetrated. N (4) TYPE OF WORK:owners number of well with st Nest one entry for each change of ilformatlon. (it more to&n OM) MATEnML fAOY TO is.1 Method: Dug Li Bored C7 - - --. _^ Abandoned i_. New well 1p f7 S 0 t!` 0 Deepened C; CaWe� Driven 0 ( ' 0 Reconditioned C Rotary E] Jetted 0 C it. M GA 3 O C C.(Ay tS.4Ai G.t (RAi. > C SG G (5) DIMENSIONS: Diameter of well inches. 5 6Z C (AY' ��k� ) �8(,v, +y O Drilled_/96 feet. Depth of completed well / RC ft. r( 1- " ..L_ +9S___ (6) CONSTRUCTION DETAILS: —_ y� o 1 _ - XJ� J4 _.------__ . 0 Casing inataMed: • Dlem.from r ft.to ft. C Welded /i')� Z • Diem.from 4_I'—h.to I V n. - r r • t _----,— 1/ b Liner installed. •. /(i O Threaded ❑ r �' Diem.from_ ft.to ff. Pertorattons: YesG No)t-1 • -( —. •• — I/` l 7S — Type of perforator used s'a ti 6 e C b I. P� 7 8 !i $G � I . 0 SIZE of perforations M.by in. Cperforations from—-_- ft.to ft. _ R pertorarions Norm h.to .ft. R per(otatroM from It.to__ ft. R Screens: YeuLJ No //�' Manufacture's Name O 0 '` - ----... /�t �G: — R Type . 5 __ ModN No / r%JlVJ� •IMI Diem. 1lr __Slot size /S from IS I tt.to / SG A. rb"//n >t Diam. Slot size from ft.to ft. v(<,O V A TT��11 �-7� By I C9Gravel pecked: Yes ll Nov]Size of gravy C� i Gravel placed from ft.to tt' (2 �i co Z To what th? � ' ft. Burled*seal: YosL�J No❑1 Matenalweed ineslU 1� --- - .—. __. __. . -��y O Did any strata contain unusable*star? Yes I._J NOL] __--. _._� Z Type of water? Depth of atfet IA Method of**annul semis on_.- - - r as ~—^(7) PUMP: Menufacture Name.re Type- . -- . __H.P. - — C9 (8) WATER LEVELS. alums elevation M - -- above mean sea level Q I C Static level / L __.._n.below top of well Dale le a9 _1k V Artesian pressure —lbs.per agwre inch Date -- •• _-._. ._--- __ --_._ W Arieaian water is controlled by (Cap.valve.etc D Wort started JO f V:- ,199Compteted /0-eta 4- .I g/ 0 (9) WELL TESTS: Drawdown is amount water level is towered below static level d•+ Was a pump test made?Yea❑ NOD Ifyes,by whom? WELL CONSTRUCTOR CERTIFICATION: C Yield: pat.Jmie.wsD n drawdOwnseer hrs. I constructed and/or accept responsibility for construction of this well. E -- — --- and its compliance with or ationWashington well are true standards. t _ Materials used and the information reported above are true to my best L _.__.._._.._-- knowledge and belief. R Recovery data(time taken a zero when pump turned off)(water level measured //� A from well top to water level) E(�a�/ ``1 /J�` /t!'7 4/� . Tama Water(ew1 Time Water Time wet«Levi NAME' y i Q _____.. ---•._-- __ /IA (PER IRM,OR CORPORATIONI (TYPE OR PRINT) a/ .. . -- _ .._ _ d / X ./ 33 Sir//t, luN 9jrs 1 - — - Address -- —:In;:5::I _ No._ y(Signed)Bolter —gal.r min.with IS —_h dra*down after Dra• C s Airiest .---,--_gal.r min.with stem set st _h.for— Me. R IO Date /O—30` ..74 • Artesian tlo*_ -g•p.m. Date (�1 Temperature ot water_.--__Was a chemical analysis made? Yes El MD (USE ADDITIONAL SHEETS IF NECESSARY) 0 (Cy oso.1 7G (*.nr) 137g ADP 3 26276 Twelve Trees Ln NW Ste.0 SPECTRA Laboratories-Kitsap Paulsbo.WA -- -.Wharf experience mows 98370 (360)779-S14r COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Smote County Off If? I2•023 Collected Ana ineq-soN Mae. UN Yea Type of Water System(check only one barn) 0 Group f$GroupB ❑Other _.__ Group A and BSyst ins-ProvdetonWaterFacilitiesInventory(WTI). L $ .2_ ? System Name: - 85i 4 )inQt- Contact Person. - / ZiEfFiutbefurnii Day Rimer Cot Pane360 ace)sin" Fmed ®-j�Mr �• poll Phone:Send ISSApilo: kA tine,&a.a AA zip axlea rWl.tore b.ekeVun�e espy of melt.) f6fo E. 5?enc 1...co 7?er- d SI.Q ft.." LN•t 9 8-5.18 SAMPLE INFORMATION $NnS�cdled°�by(na�y, yograbon where san•,ple collected: Special instruction or cameras: briJoAr t. Type of Sample(chedr clay one boo) 1..X Routine Distribution Sample(AJP) 2.❑Repeat Sample(A/P) Chlorinated:Yes 0 NOIR i (ear*erotism sys5yn after unsay muxe) Unsahstactory routine lab number • Chlorine Residual Total__ Free_ 3.Ground Water Rule Source Sample Unsatisfactory roubne collect date: r J Chlorinated:Yee_No_ ❑Triggered(AR) Chlorine Residual Total__ Free_ ❑Assessment(AM) 4.Surface or GWI Rare Source Water Sample(Enumeration) IS ; ❑ E.cob 0 Fecal ne.00 Yn en S.❑Salve Coaeaed b Information Only LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatiatectory Total Coitorm Present and ?Satisfactory Q E.cob present ❑E.cob absent r Bacterial Density Results Total Collae____-_mpn7100m1.E.cat mpnllO0nrl. FecalColifam -_tb1100na. I-PC . ---_ch,ltml Replacement Sample Required: 0 TNTC ❑Sample too old ❑ Sample Volume 0 Damaged Container 0 _ Oriel? rR7' 13oa lab Rotten*, 33 `0 Recall Temp C': MrJed Code` T-CDUNIi SN92220 Va aenursembNwadai:.+masasey.. on DO 1 91021 SEP-2 01023 m immos w«` " e. O014 W-SNIPP awn.M+sM�e.eb r......N.111.sr....an.O*•ed h••w19� ow. '33 wwas k sa.eie.+ Oaths auwnfr.e«.OW)