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Home My WebLink AboutWAT Application - 3/3/1995 MASON COUNTY DEPARTMENT OF HEALTH SERVICES - POST OFFICE BOX 1666 ' SHELTON, WA 98584 (206) 427-9670 FAX 427-8425 APPLICATION FOR DETERMINATION OF ADEQUACY Revised 09/01/92 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 system utilized. 3. Submit completed application, with attachments to the health department for review. PART 1: APPLICANT/PARCEL IDENTIFICATION r.nr'.'.r:r:-- - - - - ---In:L,.n..J i.i::rruuuufpmafniln Oi::€i,•i.e NAME OF APPLICANT 00N a iS/3 Ly 5'i y DATE 3/4/y -- MAILING ADDRESS /2// Sifmic.is 02 S. /AWnA / (UA TELEPHONE ( 2 ) 5 €/2- 93H6S City abet v. zip ASSESSOR'S PARCEL NUMBER 326c2-/7 -- 7o/27 ZUT.m' - nq ce/Y AE4 e SUBDIVISION (If Applicable) LOT Vol 5rMa,C/'4Ji `j/C2O TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Check One) �Tr/� Public/Community Water System � Building Permit, Single Family Res y� Individual System, Drilled Well IEl' Building Permit, Commercial El IndividualSystem, Dug Well u Building Permit, Replace/Remodel ❑ Individual System, Spring El Land Use Application Name ElIndividual System, Surface Water Type ❑ Individual System, other El Other PART 2-A: PUBLIC WATER SYSTEM 1„,„;NNi❑Imum,•,r..u:u.................911”.•:............'-'n:...,.....DiiiiiiiiiniiiiIMMIinaiii ::n:L:.: -Iuuuni.niii"""" NAME OF WATER SYSTEM WFI ID 0 The water purveyor for this system has previously filed a certificate of water adequacy with the health district. ❑ I am manager of the above referenced water system. The water system has DOB approval for service connections, with connections presently in use. The applicant has approval to connect to this water system. Service of water to the applicant for domestic purposes is consistent with both the water system plan and the water right permit presently in effect. Water lines are available to the applicant's property line, or the applicant has made satisfactory arrangements to extend the lines. SIGNATOXE OF SYSTEM MANAGER DATE )\.1- / PART 2-B: INDIVIDUAL WELL WELL DEPTH Ft WELL rnPACITY Gallons/Minute Gallons/Day ❑ Well log is attached to this application rI Well capacity test results are attached to this application NOTES: well capacity tests are often performed by the well driller at the time the well is con- structed. Test results from these tests are noted on the well log. Results from these tests will be accepted by the health department. If a well log cannot be located by the applicant, a well capacity test must be performed by a licensed contractor. Baler or pump tests are acceptable, provided stabilization of draw-down has been measured and recorded. Satisfactory total coliform test is attached to this application. PART 2-C: INDIVIDUAL SPRING OR SURFACE WATER WDOE permit is attached to this application I have reason to believe the spring proposed as the water source will supply adequate water its intended purpose. This belief is based on the following observations: AUTHOR OF STATEMENT DATE RELATIONSHIP TO APPLICANT NOTE: In addition to providing the above statement, the applicant will need to arrange an on-site inspection by the health district prior to determination of adequacy. PART 3: HEALTH DISTRICT EVALUATION (Health District Use Only) • SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to meet needs of its intended use. ate Nate: This determination does not address adequacy of the distribution system, rantee an eeanradequateesup�y of water indefinitely into the future, or guarantee compliance with all applicable lations. 111 UNSATISFACTORY DETERMINATION: Applicant's water supply does not appear ade- quate to meet needs of its intended use for the following reason(s) : DATE "- • �P HEALTH INSPECTOR �h I_ - > Rue a:m roe 515 [: 1 1TACO THR1A-WA.B24Q4 B L/ (2118)5313121 WATER BACTERIOLOGICAL ANALYSIS SAMPLE COLLECTION:BEAD INSTRUCTIONS ON BACK OF GOLDENROD COPY IF baea9lorr w nos 1elkand..made a to recent 11 e, rWUNIY NAME l4/r,_1 W Fr TT�HyE COl0 PM ir'akYOl1 TYPE OF SYSTEM IF PUBLIC SYSTEM.COMPLETE ❑ PUBLIC teal ry4 V.Y4 j 5 .;e C}3y CIRCLE GROUP INDIVIDUAL a nal I�h1 3°✓,�¢( V'�d ti '`r, A B ( nos 1 resistance) Fiil:C4. )Lk .� .. .. NAME OF SYBTEM b2,S -5 SPECIFIC 0E n mace. COLLECTED TELEPHONE NO kitchen lJeli EVENING( ) SAMP175 COLLECTED BY:(Na e) SYSTEM OWNER/MGR:(Name) Fti55 SOURCE TYPE M❑I GROUND WATER UNDER SURFACE INFLUENCE ❑SURFACE ✓L WELL or FIELD D SPRING 0 INTERTIE PURCHASED or I:[COMBINATION OTHERTION WESEND REPOR TO (Print Full a Address d➢p Code) za2ll N ;ti D� and ync, SE I7//0 f Aker Pork P1 pG 5ke`TiIT') WASHINGTON /n Siri f TYPE OF SAMPLE(cbckofN one In Na column) ROUTINE ❑ Chlolated(FL&Wu4L__ToW---EIb) , DRINKING WATER Mack treatment -> 0 Altered Al.) ('' e,'.R.',-An. '�' Untreated or Other ( ❑ REPEAT SAMPLE 1 Previous conform presence Lab• Previous conform presence Date ❑. RAW SOURCE WATER Source II ® ®III: 0 Total Ccltorm 0-NEW CONSTRUCTION or REPAIRS ,. 0 Fecal Cabral .: .0 OTHER(Specify) wet) CJelj :. _ LA0011ATDBY-ryF.81FLn ooB W EkEaEan I ,::_";,;}.".3 MLIn00 USED MF I MPN I PA I MMO I ... .,.. TOTAL COUFORM_ J100 ml E.COI 1 1100'mI FECAL COLIFORM__J100 ml HETEROTROPHIC—_JP1r ml ANOTHER SAMPLE REQUIRED . EST UNSUITABLE BECAUSE:T SAMPLE NOT TESTED BECAUSE: ❑ Confluent growth 0 Sao too old ❑Wrong container `❑TNTC ❑ Incomplete lolm 0 Excels culturee 0 0 Excess stable DRINKING WATER SAMPLE RESULTS ❑UNSATISFACTORY,CoMosms present K SATISFACTORY, Gain absent REPEAT 0 E Can present 0 E.Cc.absent SAMPLES REQUIRED ❑Fecal present ❑ Fecal absent I SEE REVERSE SIDE OF GREEN COPY FOR EXPLANATION OF RESULTS BY LAB NO. •}aj E'�'/T DATE.MAE RECEIVED j 89-3 ID )LJ . l (1 V.,i1i1J` AGCT DATE REPORTED II I ' (c a-9—°ia-1 ) WATER WELL REPORT Start Card Mo. a 086428 STATE OF WARRINGTON Water Right Permit No. . an mean ••••••• (1) OWNER: Name PETERS, LES Address 1700 COOPER POINT RD OLYMPIA, WA 98502- 1 LOCATION OF WELL: Canty MASON - SE 1/4 ME 1/4 See 22 T 20M M., R 30 W a) STREET ADDRESS OF WELL (or nearest address) LEEDS DRIVE m (3) PROPOSED USE: DOMESTIC (10) WELL LOG (4) TYPE OF WORK: Owner's Number of well formation: Describe by color, character, size of materiel (If more than one) mad structure, and show thickness of aquifers and the kind NEW WELL Method: ROTARY and nature of the material In each stratae penetrated, with at least one entry for each change In formation. (5) DIMENSIONS: Diameter of well 6 inches FROM TO Drilled 78 ft. Depth of completed well 78 ft. MATERIAL an TOP SOIL GRAVEL 0 3.5 (6) CONSTRUCTION DETAILS: BROW CLAY GRAVEL 3.3 16 Casing Installed: 6 • Dia. from el ft. to 75 ft. GRAY CLAY B GRAVEL 16 29 WELDED • Dia. from ft. to ft. BLACK GRAVEL 29 62 • Dia. from ft. to ft GRAY CLAY 62 73 SLACK GRAVEL WATER 73 80 Perforations: NO Type of perforator used SIIE of perforations In. by in. perforations from ft. to ft. perforations from ft. to ft. perforation free ft. to ft. Screens: YES Manufacturer's Name HOIUST0N Type PERFORATED Model No. Diem- slot size from ft. to ft. Diem, slot size from ft. to ft. Gravel pecked: NO Size of gravel Gravel placed from ft. to ft. Surface seal: YES To what depth) 20 ft. Material used In seal BENTONITE Did any strata contain unusable water? NO Type of water? Depth of strata ft. Method of sealing strata off (7) PUMP: Manufacturer's Nemo Type N.P. szzzseme====e======z.z=:e=..=.zsersersz=s===.zzeessn ===== (B) WATER LEVELS: Land-surface elevation above mean sea level ... ft. Static level 32 ft. below top of well Date 12/10/92 Artesian Pressure lbs. per severe inch Date Artesian water controlled by Work started 12/10/92 Completed 12/10/92 (9) WELL TESTS: Drawdowm is amount water level is lowered below WELL CONSTRUCTOR CERTIFICATION: static level. I constructed and/or accept reaponsibil ity for con- Was a pomp test made? NO If yes, by whom? struction 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 ere true to my best knowledge and belief. Recovery data Tire Water Level Time Water Level Time Water Level NAME ARCADIA DRILLING INC. (Person, firm, or corporation) (Type or print) ADDRESS ' 7 PARK RD Date of test / / Boller test gel/min- ft. drawdown after hrs. [SIGNED)' ir'llCh/ License No. 0950 Air test 60 gal/mIn. w/ stem set at 55 ft. for 1 hrs. Artesianflow 9.p.m. Date Contractor's Temperature of water Was a chemical analysis made? NO Registration No. ARCAD0109BK1 Date 12/11/92