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HomeMy WebLinkAboutWAT Application - 4/24/2006 MASON COUNTY DEPARTMENT OF HEALTH SERVICES !► '- Environmental Health Personal Health PO BOX 1666 SHELTON, WA 98584 LOCAL (360)427-9670 BELFAIR (360)275-4467 Application for Detennnlati on of Adequacy FAX (360)427-7798 Instructions 1. Complete Part I. No determination can be made until Part I is fully completed. 2. Complete only the portion of Pan 2 applying to the type of water system utilized. 3. Submit completed application,with attachments to the health department for review. PART I: Applicant/Parcel Identification Name of Applicant Oclan t Oral I��cc Dale HId"I�1 /a, Mailing Address ao9e0 A({'f dic?jr, (tun Telephone q( —XJw7J Assessor's Parcel Number V127500000(1 Type pf Water System (Check One): Reason for Application (Check One): Public/community water system (2 or -:kf Building permit more connections) AY New ❑ /Private Two-Party D Replace Existing Structure v.1 Individual well (one connection) ❑ Land use application, if so... Ai Well ❑ Division of land ❑ Spring/surface water . of parcels? ❑ Other(explain) SPH2 - ❑ Boundary line adjustment ❑ Other(explain) _ PART 2: Water System Information Complete the section appropriate for the type of water system being evaluated for adequacy: Public Water Spstem/Private Two-Party 'Name of Water System Water Facility Inventory (WTI)Number(enter"none"for Two-Parry): o The water purveyor has filed a lener granting blanket hookups to this watet system. • I am the manager of this-watersystem. The water system has been approved for services. Thcrc are presen:y connections in use. This will be the connection. This water system is able and willing to provide water to this(these)connectons without exceeding the limits of the water system or any limns set by state and local regulation. Signature of Water System Manager Date Mi13 r✓11wnTGr011:3 RP.DOC Uvdmk:March 22, 1999 }\iX ,-4lAL �� ( CLC, t1.i.L. c c ( !j1c. ltit LC— Individual Water Well Water well report(attach to application) Depth ft. 12/ Well capacity test(attach to application) gpm gpd Ththese well areroftenon thewsterllell acityrpo testsatlts our thee t➢ts constructed a tet I thesfater e tests canoted located by well reportResultsfromer etests wilt dos acceptedt If the water welltreport cannot be test, winch cy the vid sc tat m'if the water well reportadrec not have a must be test, a edl capacity test, wtiah provides stabilisation of drawdown and recovery data, must be performed by a licensed contraciar. Q Safsractory bacteriological test(anach to application) Individual Spring/Surface Water o WDOE WR 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 In addition to providing the above statement,the applicant will need to arrange an on-site inspection by the health department prior to determination of adequacy Departmental use only. Do not write below this line. PART 3: Health Departtnaent=Psraluation (Staff ise.Only) D SATISFACTORY DETERIGfIPiiMON Apphcatit's-water supply appears adequafo to meet the needs of its intended use: This deternnznatzon does not address adequacy of the distnbution system, guarantee an adequate supply of water indefinitely into the future, or guarantee compliance with all applicable WDOE water resource regulations 0 UNSATISFACTORY DETERMINATION: Applicant's water supply does not appear adequate to meet the needs ofits intended use for the following reason (s): REVIEWERS SIGNATL'RE DATE XdW'ELLIWATERAD3.WPDOC 'innate Marsh 22,1999 MASON COUNTY DEPARTMENT OF HEALTH SERVICES May 22, 2006 PO BOX 1666 Shelton WA 98584 Shelton (360)427-9670 Fax (360)427-8442 RHONDA RYAN Elma (360)482-5269 301 WALLACE KNEELAND BLVD S;UITE #224-324 Belfair (360)275-4487 Case No.: BLD2006-00765 Parcel No.:421275000009 Dear Applicant: Your building permit cannot be approved by Mason County Environmental Health until the following are completed and turned in: Application for Water Adequacy 4d Please see comments at the end of this letter. Please call me at (360)427-9670, ext. 554 if you have any questions. Sincerely, Trish Woolett tw@co.mason.wa.us Environmental Health Mason County Health Services Comments: NEED APPROVED TWO PARTY WELL 5/22/2006 1 of 1 8LD2006-00765 , I2 .21Z l'-''j _ Name MASON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT FEE CALCULATION W ORKSHEET VALUATION DETERMINATION SDcctfap$ffl y(3,g t ffir4Uar"e=Footage ` /�� a l r nl Total 1P 1 �s�j .x rYa4kr�1 Residence/Addition/Basement $66.35 $ Garage/Storage Building $23.95 $ Basement(sen -finished/unfinished) $32.64 $ Deck $11.60 $ Carport/Covered Deck $16.50 $ Other $ Total Valuation $ /3 7 31 q Estimated Plan Review Fee, due when the permit is submitted: $,3 (1)J)•7 Planning Dept. Review Fee ($1551$255), due when permit is submitted: $ /` S _ TOTAL DUE WHEN PERMIT IS SUBMITTED: $ "36// The estimated plan review fee is based upon information provided at the time of application and is subject to change. Planning Department fee Is a flat fee which is due when permit is submitted. Building,mechanical,and plumbing permit fees will be calculated during plan review. Environmental Health,and other fees will be collected when the permit is issued. , FIt1,t A, r:,6) Nutt.OfiFc rte +.Jib• I Building Permit Fee(see table attached to Building Permit Fee list L.B.C.,table 1-A) $ Estimated Mechanical Fees (u.MM.C.,Table 1-A) $ Estimated Plumbing Fees (U.P.C.,Table 1-1) $ Estimated Environmental Health Fees: $35.00/$75.00 $ Estimated Fire Marshal Fees(Commercial projects-50%plan review) $ State Fee $ 4.50 Address Fee $ Estimated Fees due when permit is approved: $ Total Cost: $ I:;BUILDING ESTIMATED FEES-revised 0.25-2004 MAR-21-2CC6 TUE 03:CE P'1 FAX Ni P. 02 -- 170 SE Walker Park Road PO Box 1790 Shelton,WA 98584 Phone(360)426-3395 Fax(360) 426-1455 Arcadia Drilling Inc. March 10, 2006 Owner: Site: Ryan&Rhonda Carl California Road 301 E.Wallace Kneeland Blvd Shelton,WA(Mason Co.) Suite 224, Box 324 Parcel A 421275000009 Shelton,WA 98584 To wham it may concern: The owner noted above have contracted with Arcadia Drilling Inc. to drill (1)one 6" diameter water well for single-family domestic use on the property also noted above. Estimated depths in the area range from approximately 40' to 100' depending on land surface elevations and other variables. Well productions average approximate 20 GPM (Gallons Per Minute). Some property owners do treat for minor Iron and Manganese. There are no known"dry wells"or critical water problems in the area. The foregoing information is based on supporting water well reports from the area. Copies have been provided. Arcadia Drilling, Inc. cannot however guarantee water availability or quality. If you have any questions please call. Sincerely, Connie Williams Arcadia Drilling, Inc. We Help Keep Washington Green MASON COUNTY DEPARTMENT OF HEALTH SERVICES . -,-- -r-fitirr-,1-tai _-- 426 W CEDAR ST, PO BOX 1666, SHELTON WA 98584 SHELTON (360)427-9670 ELMA (360)482-5269 BELFAIR (360)275-4467 WEB http:llwww.co.mason.wa.us FAX (360)427-7798 APPLICATION FOR WELL SITE INSPECTION Receipt Number: crjaOao-g6& WEL:: OO(o`®QCc ?- 1. Complete Part 1. Incomplete applications will not be accepted 2. Attach a detailed plot plan and vicinity map 3. Clearly stake out or flag the well site Date Received 4. Submit application and appropriate fee(s)to the Mason County Health Dept. PART 1: Applicant/ Parcel Identification Water System Name R & R Water System Site Address 1 mile down California Road Applicant Ryan & Rhonda Carl Phone 360-432-3233 Mailing Address 301 E Wallace Kneeland Blvd. Suite 224 Box 324 City Shelton State WA Zip 98584 Parcel Number plra44al7 $¢lbal • Directions to Site From Shelton travel north on HWY 101 and then turn left on California Rd about 4 miles north of town. Follow dirt rd 1 mile and look for site on right with Arcadia Drilling Inc sign, just before cell tower. Water Source is: 0 New ❑ Existing Number of System Type: 0 Well ❑ Spring Proposed Connections 2 PART 2: Health Department Review (Staff Use Only) YES NO,NA E h❑ Evidence of existing sources of contamination within 100 foot radius of water source? '7 (drainfields,tanks, buildings;indicate distance on plot plan) - / L 0 ❑ ❑ Are there roads within the W0 foot ra ius of the water source? If so,is road private/noun or State. What is distance to ROW? - 1 ❑ 0/Does the ground slope away from the water source site? (show slope on plot plan) • ❑ ❑ [v]'xts the well cap satisfactory? ❑ ❑ jC�Screened and vented? IZ e well casing extends above level ground /concrete slab? (circle one) ❑ ❑ there evidence of a surface seal? ❑ ❑/ Does the seal appear adequate? ❑ (J✓ ❑ Is a variance necessary for well site approval? RECEIVED Comments MAR 0 0 2006 • t,11� HEAL!HS� IC S, EN Pass Fail Inspector j IanUuAilnsa Date ,a ; .e1 n ' a nd determinations oft is Insecto fled obsery - con nuns as they eats: on th yof the site inspection.No claite is matl.,'^ pk `6555///olied of the sucocss or failure of this system. Well Site passage does not constitute water system approval.Water system approval is a two part process.1)Passage of the well site.2)Approval of the water system i design.Once the well site is passed the water system design may be submitted forreview te co o o 01 ken 61 | f \ 0 I \ $+ cti ) ( j \ ! = ` � § d § r( _ a 7 © • f B ! a' ; wtt Co! 0 \ { ! • ~2 ;ks({ —\2 .. E80mo / ® f: ! |o !) \ § _ I < ,§ } • 4. ) ) -§ ` a \ = (| ° }: - ° Co / \ !3 , §ƒ| ! if 0 ' ! ! / 1 f ( / ! \ . / ea \ a z , \ ! / , , / } \ ) \ a— } ) )