HomeMy WebLinkAboutWAT2023-00203 - WAT Application - 7/21/2023 I I WAT .01-5 - �Z
MASON COUNTY
COMMUNITY DEVELOPMENT
Fermu Assistance Gene,Buildng,Manning
415 N r Street, Bldg 8,Shelton WA 98584.
Shelton:(360)427.9670 ext 400 a Belfair:(360)275-4467 ext 400 O Elms:(360)482-5269 ext 400
FAX(360)427-7787
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: ApplicanU Parcel Identification
Name on Applicant: Yaf i n VAr�cx Date:3 1 -21 -23
aCtal
Mailing Address: 1602 ` •2 091 hone: 360-191—bq>;I
Parcel Number: HI-I Z-1 14' 0
Type of Water System Reason for Application
Public/Community Water System(2 or more I( Building permit-&Iow0 -Xq
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 PubholCommunity Water signature required)
System box. t� l 2
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: rvoAP_
(write"none"for two-party)
16 1 am the manager of thi water system. The water system has been appproved for Z services.
There are presently fa connection(s)in use. This will be the IS F 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 an i i se state and local regulation.
Signature of Water System Manager Date 0 3-Z3
This form may be scanned and available for public view at www.co.mason.wa.us.
J:TH Forme\Drinking Water Rev(ud 1'25M8
WATER WELL REPORT ODIPARTMEN1 OF NOticedlnssst No. WE471)05
ECOLOGY Unpin Ecology Well ID Tag No. IM215
TywolWwC gate al waaningmn Rib Wtll Neme dmwe thin one xell3'
IN cowewdon
❑ Reines, o Oridwl mean NO.No Water Right POMiWi if toNo.
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❑Donations, ❑Inipino OTm Wa ❑Qhr
Well Stan Address spa CMlbmla Roatl
Cwmneia TyFn IMId:
O Na.wdl ❑°bents, Oonwv ❑Mad Oc.Rk Tod City Ellakan Carty Mason
O IMpany OOdc ❑Dw w Air O mw4nwy T.Pamal No. 42127-14-91011
Dirlam:Dmnranurv°flmmR 8 m m
b 11L L W a variance approved fin this Well? O Ym 10 No
Dap°ofempkwt weu 119 R.
f embwin0.Wr: WWI Ifym,Wins,.th VafNnot fs?
L1e7 Is,Dimrmb Fmm To T lhwsw &M WC WJY1 hrrd
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❑ 1 ❑ i n. ❑ 1 ❑ ❑ 1 ❑ SW VWlofth NE Y.;Sectton 2T ToWnship 21N RRMn 4W
❑ 1 ❑ n _ n ❑ 1 ❑ O 1 0 tatitide(Example:47.12345)47.282800
L~tols(Eumple-In 12345) -123.188402
hrYrMamm: ❑Yes ®N° TypeofpvOrNud
No.WpMk+Mm_ Size°fFVBMbm_a by1116 Drillar'al.o[/ConaWetbn°r Decommission Praedom
PerSMeA Nm_am_Labw!°•avYa F.1001 Deacrih by cokr,chanln ,WO,Of mnen.I M.—sov,W WMdd
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MwuLemm'aNme Material From To
SNP emwn el Rasa and ravel 0 1e
prma®_ 9br® aRaa _!.b L
him.&_ SM.e_asm R.b_L Smwn medium Wont are growl with RR Nram 15 35
Brovn mrWJ growl,
sand era revel 35 44
RaaMFLMFtl:OYm 1No Siw Mpaekmamhi_a Mdticiloren] ravel,rrmtitm brovn send.lows 44 83
kYyriaY pYmt R®_L m_L.
tiae4w Fi M YO O No TOMm dy01 1$_L krose 010retl ravel,medium drown uM, 53
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MeiM1N olssainRswu oD
Pump: mandanurtieNaw T)R:
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Waver lewh: INwrf ekwrmtl°ro mmuwkwl 310 a,
Siickrr,pafmpofwbllmiro 1 R.aWw pine au6s
Sinicwnerkwl 75 ft hWn&KPofwcUmiq D@ 4MM
Mnian Prtrwrt_Ib.ler&Woes inch tom _
Artesian water iaeomollM by (oaA dw,m.)
Well Tna:
W..,umpi..00r,KvmM ONo OYmb bywWmo
Yidd_Wm with_R.dnwdown ear_Yes.
Yield_N:m with R.dnwMwn aflw M_ .
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linc,,bnUi—-aeru rvlwO WOV h nmMoT-wino kM rnma.A Nm&NI _
TmToros bate
w ww<r teal Tw W.lerel Time wins,lent
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Inks oat_vs, Jawdowe aaa_Is,
,Urns, M wmwMrtrm• 1W R.R& 1 Is,. hone 412L122
Mena°Mw_qxo
Tws,mmmeofawa 49 IF wonaWndml mlHk made? ❑Yee EW San Dab 4Q()M Completed Date 420/Y2
WELL CONSTRUCTION CERTIFICATION: I cwstmdd adrorascept sesponsibilay for cantrmum ofthis Well,ad its compliance with all Wadiingli n Wt11
mmtriwiw atadeas.Matmias u�and tee infmmmi0n reposed aborc art tine to my beN krbwidg and belief
O DWlkr❑Trounce 11 PE Jwh Drilling Coormy Arcadia Drilling Ise.
mtmn -Pont Name
5 !// _ Address PO Bw 1780
4cmee No 2874 City Shia Zia SMKw.WA 985M
U TRAIN�i4ame Ne. Cwtrxtm's
Sponsa'R Simmure Reginrotion No.ARCADDIMK1 Dole 412W22
ECY050-1-20(Rev MlIR) If)ma med&tls dormwm lnmalremaref tplmwcalllhe Warer Resoarms Progmmm31f0I01fi822.
Pe.with hmrag lass inn mil 111 forW ning.&toy&Mil, Penmu wbha spetth dsabiliyem w118Ad33b341.
8 Lor3
67
-7—L—COLIFORM BACTERIA ANALYSIS 'I
0.1.Sample Col(laclledd Time 6empb Cr rly 1
� 0 01Ly IIC1elle�Qle�d i
.11 W1 It. 1.:✓V �N "wlJ oil
Type of Water System(check only one box) 91 Pdvale Neareari
❑Group A Cl Group B ❑Other
—
Group A and Group B..
D11
W r Eve Phonea 1 —.
�, sane�nM Q_2ml �gmsaGJe�n:�gyeleae el _.
SAMPLE INFORMATION
'ampb cnlacled by name): V4,i
n •/ I/
alit locationar Md..Mte sample collected: Special instructors or comments
402 W [• air Orvlirn Q
Stq�f�bn 9eSF y
Type al Sample(must check only one box of kt through Nd listed habw)
1.09 Routine Distribution Sample 2.Repeat Sample(after unral.routine)
Chlorinated:Yes—N. X ❑Distribution System
y Chlorine Residual:Total_Free_,-_ Chlonnated'.Yes_No_
9.Raw Water Source Sample Chbnne Residual:Total Frea_
❑F -Surlse.G 951wrrwnbn) Junaiisfetta,mium,not nambeL I
Fllgne.Yss No _
❑Assessmeni Monitoring(A)') I rr, c1 tlnlr
LOlher
L—LLL�
a. Sample Collected for Information Only
Invearya at ConsWclionl Repairs_ Other_
LAB USE ONLY. DRINKING WATER RESULTS LAB USE ONLY
❑U jqfSaftefrii
❑Ecoli present ❑Ewli absent
harm deleded
Replacement Sample Required:
[]Sample too old(>30 hours) ❑TNTC ❑_
Bacterial Density Results'.Total Colilonn 1100m1. E.1 1100m1. t.
Fecal Leitrim, 1100od Emirrococci_...._(100rot
Method Cod SM 9223B ❑Sh192220 Dale and Time R"I'ved.
SM 921Ea ❑Bntembryb 0 r1-2 l Ori
Daoarw TMe Analrmd. O " 'Z Dale Repro - P
snrige llumlwi lAW rw�R+'du eru WNur tee Utle onlr