HomeMy WebLinkAboutWAT2023-00280 - WAT Application - 7/31/2023 FAT
415 N.6a Street
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES Shelton:360427-9670,Ext 400
Belfair:360-2754467,Ext.400
°u°4iq P1enn°'9't""10""11Ya1NiXh0a'""""��R^ro' Elma:360482-5269,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: FUTURE HOME SERVICES I I C Date: 7/3123
Mailing Address: PO BOX 2503 GIG HARBOR,WA 99335 Phone: (360)900-9777
Parcel Number: 3202942-00150
Type of Water System Reason for Application "' I
❑ Public/Community Water System(2 or more 5a Building permit-!,lc10 y2,.c Io8-7
connections) ❑ Division of land:
10 Individual water source(one connection), p of Parcels?_ SPL
® Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other exI
❑ Other(explain) (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 Wafer signature required)
System box.
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)
❑ 1 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.
❑ 1 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.
LTH
ignature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wam
Dnnki Water Revised 4l4/2018
Individual Water Well
W Water well report(attached to application). Depth wV\�'I �
® Well capacity Test(attached to application) R�L—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.
m Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA hag�l/gis.m.ma&pn.wa.us/planniing IYes—
Well15_16 22_
Water use or limitation recorded................................... N/A Drilled ............................................................... Date,
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ 1 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)
atisfactory 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 'i
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
reawn(s).
Reviewer's Signatures:
Environ. Health: (4m Date
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
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MW COLIFORM BACTERIA ANALYSIS FORM
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System Name: , )jj ^. n r
Contec Pemm: Arcadia Drilling, Inc
GYPhcw:( 3601 126-3395
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EO Box 1790
'ii..ir.in, WA
SAMPLE INFORMATION
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SpacAebntion alwra sample msecbd: _ Specal babuctiona«cpmmenb:
Type of Sample(soled oey ow type of seAple CPasl d=#Sbelow)
1.❑Radio 0lealbudoo Sample(AP) 2.❑ Rprt Sample(MP)
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'LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑UnooNtectory Total Co0o.Pmem«J Satlstsclory
❑E.tot present ❑Emfi abysm
Ow"I Depolly Results:Tote]Glilom] N0BM1. E ob 1100m1,
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❑ Sample Volume ❑Damaged OMI*w ❑
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R**0T.PC: N,Iwd Coda:
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Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA.98594
Customer: Susan Solais Well Tag#: none
Phone: (860) 758-7200 Depth: NIA
Well Site Address: 661 SE Mill Creek Rd., Shelton Pump Set: NIA
Date of Test: 31912023 Static 51.3
TIME GPM LEVEL RECOVERY
1 Min 18.0 69.0 TIME LEVEL
2 Min 18.0 71.3 1 Min 67.9
3 Min 18.0 73.0 2 Min 65.1
4 Min 18.0 74.0 3 Min 63.4
5 Min 18.0 74.4 4 Min 62.5
6 Min 18.0 74.8 5 Min 61.9
7 Min 18.0 74.9 6 Min 61.7
8 Min 18.0 75.0 7 Min 61.5
9 Min 18.0 1 75.1 8 Min 61.3
10 Min 18.0 75.1 9 Min 61.2
15 Min 18.0 75.3 10 Min 61.1
20 Min 18.0 75.5 11 Min 61.0
25 Min 18.0 75.5 12 Min 60.9
30 Min 18.0 75.6 13 Min 60.8
35 Min 18.0 75.6 14 Min 60.7
40 Min 18.0 75.6 15 Min 60.6
45 Min 18.0 75.6 16 Min 60.5
50 Min 18.0 75.6 17 Min 60.4
55 Min 18.0 75.6 18 Min 60.3
1 Hr 18.0 75.6 19 Min 60.2
20 Min 60.1
21 Min 60.0
22 Min 60.0
23 Min 59.9
24 Min 59.9
25 Min 59.8
26 Min 59.8
HOMin
.7
59.7
59.6
59.6