HomeMy WebLinkAboutWAT2021-00219 - WAT Application - 5/13/2021 ENVIRONMENTALWAT mac} l oo3I 9
HEALTH 415 N.( Sired
MASON COUNTY Shelton,WA955S4
O,, 'tF COMMUNITY SERVICES h Sn n_16oa 7vem Ext.4t,o
- - &limn 360-275-4467,het,40
6.adng 4Ynmq.Emnmmwd Neai6ramm^ryxdM Elmo:360-062-5269,Ext.400
Application for Determination of Water Adequacy
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: erte M.p&A�r PrO /DD t,: J � -I _
Mailing Address: '/ 16 71"' 5^OSCIcckQD' ISVihon�erbpr(yJl /2 S3)'1ry-70'7g
Parcel Number: 7_2±OU- 11-50O 10 C P_
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more y] Building permit iiL"50730
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ 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. ,�`,t ?C]
Part 2: Water Connection Information �C' wU'-I_ oOo`�U
rtacH
Complete the section appropriate for the type of water connection being evaluated 'd11PD
Court.
Water System
Name of Water System: Roos
WWaater Facility Inventory(WFI)Number: n OlLe (write'none"for two-party)
1 I am the manager of this water system.The water system has been approved for 2 services. There
// are presently 7 connection(s)in use.This will be the 2. 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. 9�
Print Name of Water System Manager t1 i Phone Jf 5
1
Signature of Water System Manager - Date 2)
r
This form may be scanned and available for public view at www.co.mason.wa•u4.
J.NI Pmm<.Drink ing W ate Rcviscd 4.27.2021
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) qpm 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.
D Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http.//qis.co.mason wa.us/planning 14_ 15_ 16_22
Water use or limitation recorded__.................._........... N/A Yes
Well Drilled ..._.................... ........ ................_.......... Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
O Method of disinfection
O 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
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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
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 or 2
1785 SE Mlle
Hill Dr
Port Orchard, SPECTRA Laboratories Kitsup
WA 98366 _. ...Where eipertence.ufen
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected T Time Sample Count'
Collected
b '1 3 ' it :u Pm, ✓
Type of Water System(check only one box) ��// /
0 Group A 0 Group B Other
Group A and Group B Systems-Provide from LVat liAes Inventory MFI)
IDp
System Name: 2_
Contact Person:
Day Phone`h .h!),IJ r "1 >' Cell Phone:
Email: Eve.Phone:
Send res'MS (Pmltan name.addre..and epweew email.m..forelestronleewv of mutt.)
SAMPLE INFORMATION
Sampe collected by(name)'. C; -IV
Specific location M'tlem sample collected: acial IllebllCbnn9 or comments:
puvvy(NOUSC_
)Type of Sample(died only one box)
1.0 Routine Distribution Sample(NP) 2.❑Repeal Sample(AP)
Chlorinated:Yes 0 No Brom distibsystemote)on system alter ur at.me)
Unsatisfactory routine lab number
Chlorine Residual Total_ _Free_
3.Ground Water Rule Source Sample ---
—
S I I Unsatisfactory routincollect date'.
Chlorinated Yet No 1,
❑Thggeretl (AP) Chlorine Residual:Trial_Free
❑Assessment(AIP)
d.Surface or GWl Raw Source Water Sample(Enumeration) S I
❑ E.colt 0 Fecal elsea Y.._No
?Sample Coflecttd for Information Only:
IAB USE ONLY DRINKING WATER RESULTS LAAAABB USE ONLY
❑Unsatisfactory Total Colitorm Present andSMIs6cbry
I ❑Ecoli present 0 Ecoli absent l\
Bacterial Density Results'.Total Califoml man/100mt E col rgml100m1.
Fecal Colilam, _,,, __. cfol100m1.
Replacement Sample Required: 0 TNTC 0 Sample too old
❑ Sample Volume ❑Damaged Container D
1,me Perce.ssi, C Lab Reference Number
MAY I 2021 12"20 I 0�
> > 6 ) ( C)2
Wisp
p C" Method COepi'ydypa LDUNrISUe113D
I R rwmvcmm u
Dale Reported µy.yenmwNied*Y..mte thin
NAY 1 4 2021 ape;„;e, w „^,„;o
oux Lab-Sample
`eseY"°'�"'"de
r� �r.,..**sow u.r....be.-rand.
t !. " tea nw.rerm--ry � t.:0T
2R5 ,u. m....e.h.. w Bp.eat a eta
ew WIII
0 WATER WELL REPORT CURRENT
onpul a P refry-Ember.Se ay ewen5^copy-dam Notice of Intent No.W 354045
i of
ECOlintC1Ost Construetion/Deeommlulon ("s"in circle) Unique Ecology well ID Tag No.gag in
® Construction Water Right Permit No.
LI Decommission ORIGINAL INSTALLATION Property Owner Name heRiramdem
Notice ofIntent Number _
PROPOSED USE: ® Domenic ❑ Industrial 0 Municipal Well Street Address Nycogeson ad
0 Dewaer 0 irtipia 0 Teat Well f] fiber City Sw^•nie. County Macs
TYPE OF WORK: Owner's number of well(if ems Than me)_
0 New well 0 Reconditioned Maltol:O Dig ❑ Bored 0 Driven Location gal/4-1/4 tm1/4 Sec Twn21 R a awn
O Deepened ® Cable O Ray ❑ lead (si t,r Still REQUIRED) ty.w o
DIMENSIONS: DiemFefhRP She,ddIdllle.
DIp6 of casplmd well lilt
consrarxTTON DETAILS Lat/Long Las Deg Lat Min/Sec
Casing 0Weldd 6' Dime.*Pm .lILb 1.0 E. Long Deg_ Long Min/SecIeWYd: 0 Dreji.LII d •= Dim from __0.b _II1Lbn&4 • Dim.Rm_am _II Tax Parcel No.(Required)321w-Il-smm
Perforation; LJ Yea ® No
Type of perforator uS CONSTRUCTION OR DECOMMISSION PROCEDURE
SITE of Para_ire by_in.rid n.of peers_Ins_ft.m_IL Formation:Describe by ake,cherscw,sm of material and sews,and the kind and
awes: 0 Yes ❑ No ® C-Psi lactic 165' nature dale marvel in each rtanm pearamat with et teat coo entry for melt change
b of mformedm. (USE ADDITIONAL SHEETS IF NE.CESSSARY)
Mend
Typem'sweet Nome Allay towline works MATERIAL FROM TO
Type aS Model No. Brown till O IB
DMA Isla tine jac 162fronIL fl. Sit DPNd Wld&grtvel IS 125
Diem. Slot size 6m ftto E. 125 Ili
Sand R Pavel water bearing
GravdTnw packed: O Yea ® No Size ofgneLmd_
Mamiab Wand Its ft.mn
Surface SW: C Ye. ❑ No To what depot att.
Material used in seal Smite
Did any meta stem unable w.tn? 0 Yes ® No
Type of wake Depth of oral
Medial of sealing arm off
PUMP: Mmoadmml Neme v
Type; EP.
WATER LEVELS Land-serfs derma above main eat lee R.
Static level 3220.blow top of well Date
Artesia pressure lbs.Ms Mime imb Ain
Aneaim water ea controlled by (up.vale.etc)
WELL TESTS: Drewdown is moues vista level is lowed belw sic level
Was a new tat model O Ye, ® No If yes.by Mta:1
Yield:_al/min.with_,I.deswdoem after_Jn.
Yield: galemin with er dmvdown day fie.
Yield:_yltin Wth_A Aandowo after km. .
Reany dam laws Eta a ram when pas tumdom Amcor lent mmmndMei
well tap so water Ind)
Time weer em+t Time Water Le.el Time Wan Lad
--Date of ten
Suter IS 29 galWln with Da.thaw alter Dine
hind _pllmin.with am m at_f.for In.
Meiji"tow—tpa. Dan
Tempests of Warr Wmsebmidaralyne zeds? 0 Yoe El No
WELL CONflUCDON CERTIFICATION: I oonstruaed and/or aaept Stan Date)20/� _ Completed Date SO/15
responsibility for columGionofdlis well,end its compliance with ellWdiington well
' construction sender& Materiels used and the information reported above am ram to my best lmowledge and belief.
®Driller D Enginea❑Trainee Name(Rim)Dwane Knapp Drilling Company Davin Drilling
Driller/Engke ffrainec Signature Address 340 NE Davis Farm Rd
•
Driller or neinee License No.1106 City,Sinn,Zip Eelfdr,WA,9852E
IF TRAINEE:Drilkr's Li��°°'9�No: /' �1 COnmaor's
Drillers Signature: )6(,y�� /�_/Vf/ Registration No. pAVISDI110OA Dale MgCSh3413
ECP0,114-10(Ree41-20118)) 10 Moat AIM (/ ",doe Wu":maenad In a forma for the dually OnpabM call gale WRa Regards Progrmn
-es 360.40E-0g71 hrmmwLlkLmpalalred hearing may call WaltLrgkin Reidy Servile at ill. Persons wed speed likability may call ITT at 877433-6341.
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4Ik2B27BTreMTraeal1M.SUIUC
Tw1SB POUYIM,WA BB37C
LADORATONIDS (3601779-5191
COLIFORM BACTERIA ANALYSIS
Date Stone Lolbmed are
s1* � Currey I
12 i i i 2015 0F�o I"v
Type OI Water System(dpd only one boll Pr'
❑G �
awA ❑Rap0 Cbm S ' 1J
Group A a<Goep B Sat-Provdefrom Wet nacres InventoryCM)..
ON
o Prom r E1end5 acMaSovA LFAke
Ccotad K eAv1`a
CeyfPme: )Zryl3J(I1 Cell Phone( )
L Eve.Fhonb( ) FAR:( )
' EngMan' Alavi 5 1 ra linak A@cal cow,
SS Mum In(NW NI nom nAme ntl m'rx
D4415 MMILL.Ini�
Ftf4)IRw1L 48 �2$
_ SMILE INFORIMTION •
Simple maaabyinn: S1Dfv69j DAv/5
Speck Notion*me emrple mbjged: Spinel Instructions b'.or canNet
W YVc/t�� s(�
•
Type of Semple'mat Ae&ony one box dal through Mt n)Med ban() 1
1.[/�utln GM1bAlon Sign* 2.Roma en*MR.resmy Nano
MOI 'ImYC:Yes No / 0 CMt'Ion System
CIII1fMRe♦boa:Tote`,Fee_ 0 Sou=4amMYr Ws MYR)
r I I Ranges(Sarin tlemple (Papreed no(l,Om or Is)
❑E oat-GWR source sample Un.MamryrartllW IS,'wSr.
❑Fecal Surfer.Curl some swings
DONer Unsonsfadory routine Soodsb:
Palcmai IS
+u I wrdl MI albinos]:Yes INo__
ChUNa Roost Tabl Free_
e.0 Simple COWS b Nm.Ybn Only
Ins t tin_Construction Alvah PMbe Residents Omer,.
LAB USE ONLY GRINNING WATER RESULTS LAB USE ONLY
Aneyat fynerlre: �/
❑Unsatshcbry Total COIM1 Prnenl and IySMMYbcymy
❑Emil present ❑E.aeeM I '1
❑Four colbm prowl 0 Foca aWm rifest( r
RipSnment Eereple Rennind:
❑mph bo old(s3obourn) ❑ISM
❑bWrrpa GAFNN& 0 Turbd culture
Sabel Only Raub.Pim CwrL_- _rM EccA NOW.
Total CoWm_ /fllw. Feel Cotibn_ Marl..
Ibtlrod Code: mne 1�yRecaM : /_
ISM 2y7�� rd.e_s __ . I IL- I/vs
Cab Ana nd:
Saammeepbnab.w{seep, os Lab Lb*Only.
iss7r
FIlled Imp /ST9y3ro
roxvt,anlro Immtaml�Nl