HomeMy WebLinkAboutWAT2023-00191 - WAT Application - 7/27/2023 I
MASON COUNTY l IVED
COMMUNITY DEVELORk6R
Permit AulstaMe Center,Building,Planning �UL 27 2023
415 N 611'Street, Bldg 8, Shelton WA 98584,
Shelton:(360)427-9670 ext 400 % Belfair:(360)275-4467 ext 400 t TFIT"86a11#31?R,,11�x�0o
FAx(360)427-7787 ENVIRONMENTAL
Application for Determination of Water Adequacy HEALTH
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: V664 Vair
V Date: 07 -277"2
Mailing Address: 102 Ndf H ul X, We4 0 Phone: 3(oa- 98q -6981
98S/3
Parcel Number: 117191-)1/-%V!111
Type of Water System Reason for Application �t�
e( Public/Community Water System (2 or more ❑ Building permit JLOQoZ-ob8B2 J
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 PubliclCommuntty Water signature required)
System box. L
0 av2s--
Part 2: Water Connection Information v)ZZ�
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: -VN0 �Ay/f ' 1
Water Facility Inventory(WFI) Number:
(write"none"for two-party)
0 1 am the manager of this water system.The water system has been approved for Z services.
There are presently I connection(s)in use. This will be the 2 H d 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 a i N� set by state and local regulation.
Signature of Water System Manager Date
This form may be scanned and available for public view atwww.co.mascn.wa.us.
PAEH Fmms\Drinking Water Revised 1/25/2018
/ Individual Water Well
C Water well report(attached to application). Depth 1111 ft.
® Well capacity Test(attached to application) %0 gpm 246 oOgpd.
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.
Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htto://ciis.co.mason.wa.us/)lanninci 14= 1501(*220
Water use or limitation recorded................................... N/A_�;(Ves F-1
Well Drilled ............................................................... Date i
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 Dale
Relationship to Applicant
Part 3: Mason County Community Services Evaluation (staff use only
'SvfSatisfactory 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,Tire 6,Chapter 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
C Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
('n1 � Q/�( Reviewer's Signatures: /
Environ. Health: 1 \�3 ' '"�1�✓) Date l d I(7 n—
CSD Director: Date 2°f 2
I
RECEIVED b'flx0--5�ag3
ENVIRONMENTAL
JUL 27 2023 HEALTH
WATER WELL REPOltTj IES� tic
Skpef Noeofhnelu Na. W£45540
rrp•rwmk s�t�evr Wemlagmn Unique adogy Well m Tag No. BNX214
F Cnaaulbn Site Well Name(ifmae than we wxll):
❑ mcommiwimO New nomination NO[No. Winer Right vWea lfitab No.
Proposed No a Nowak ❑howe dt ❑""'and
Prop"OwTla Name Hpdon Vadia and Deve oOmeN LLC
❑M,oacti,y ❑inipetion ❑Tea Well ❑OLL•er
Wall Street Address CMS(rtlie Rd
Ce type: Merbod:
l9 New N-11 well ❑AkrYbn ❑Davin ❑Jmed ❑Obb Tool Cily Slln9arl COUMy 1A090n
O Dwpeniea O N ❑Ws a ow- ❑Md-Retry Tm Noel No. 42127-1494014
abow.iem: Tinewrofbming 5 o:.,w 119 R. WasavmianteamrovedfarthiswdlT ❑Yu O• Ne
IXghofoompklWwel1119 R.
Cammwdoeweak: wYl 1(yq wMtwv the variance fMl
cam., Lber Diameter Frown To Twomen Shal PVCWeal Nand
0 ,
❑ 6 in. 0 119 .025 in. 0 1 ❑ 9 1 ❑ I tian Ns,inatmctims on Page 2): GWWMor❑EWM
❑ 1 ❑ in is ❑ 1 ❑ ❑ ❑ SW Ye-/.OftM NE '%;Swaim V Tsmlwhp 21N Range 4W
❑ 1 ❑ n — _ _ a. ❑ 1 ❑ ❑ I ❑
❑ 1 ❑ — _ _m ❑ 1 ❑ ❑ 1 ❑ I ilude(F mple:4712345) 47.251059
Inngiwde(Gemple:-120.12345) -lM.157571
Perrwadm� ❑Yw ONo Ttteofpn!wwd
Unller a LaWCen aslra5vn as Decommission Proeedpn
No.ofaafo im_ gveafpvbnwaa_rt.hy_n Pmbmedn Lkbw 0om _ Fowe,aeaofn
Svem: Oyes ON. ❑K-packor — Death I. eUs.n iM[ie biitytii e cinoelol ra,yc—lur apicetmawee,eenaNry4 o fwnituM1u ev:Iwlen:do mu wm.tauym f,oanrwtl NcM1e e4M1iv,tl,gWe of Menufumeie Name MYerid Ffom To
Tliw a1NM No.
D—wr Slur nse k.firm L b L BiNem sl mod and Ransil 0 9
DYwowl Saske_uawn _Lb_R. Boiem silly sand and grand,UAK 9 15
Saed/Fharpeek❑Yea Who 5ne Mpdmebrsl_ha Broam m¢tllwrl sBM aril onewill With at binder 15 24
M.mriak Fkxd amn_n.b_n. SMT ondlkobmd grawel.brown medum sand 24 W
Surf¢e.1: mYw ❑No Tools,dephi 18 A. Brahm menlurn eased,pea 18VN .38 41
maerial and k NY Bentorde Chips MUNwImeO vet,medium brawn nerd, oax 41 ]B
Did my.1.ro.m mamble wwe ❑Y. 0 No MYIlicoloned grah,el,million to coarse brgM 79
Tsleaf-1.0 Dwtot. send,latest,ket 91
Mdmilwic.li::pamlaolf MuRwolmed grawal.mndium to whose brown 91
sand,loose.water 119
pomp: Momm.. er'a Name Tya:
HP._ 1'mW waste depth:_it OmVadflawme:_g:m
Wabr4elm L•M-amkeak-ousabo.—scalond 310 n.
Stick-upofaw.fwellc m, 1_5 a_akvepwNwalwe
Stukwaerkwl 67 h.belowmwofwellouwa DYe 42522
Amount pews_M.per apatoian Doe
Merin ostar a verstrollel by loan,wlre,ek.)
Well Tn.:
Was a summit,we perbmWt E No ❑YesC by whwm+
YeLd_ppm with_0 dewelown after_M.
Yind_pxn wind_0 dnw it M wdn sn _
Ykld_ape wit_n,dmvdown akr_M.
Rrtwery&a own me when Punpv name R-.'ant memwed fiem well
bpbwaak+e0
Ttee Wwwri—I Time weer level Time Want lwwl
DusorpammR sal
hadelnl_..ini hdnwbweakr hn
Aiteu fl ppmw aaemana 100 R.krt nn. Dam 42B22
Mnwasnnw_ppm
Temprenw efwm 49 sF wmadwmiwlm.hnumad.t ❑vm nrvo Smn Date 42822 Completed Dale 4/2Bv12
WELL CONSTRUCTION CERTIFICATION: I mnshuated andforaccept respwaiMliry f«colltlmmim of Nis Well,and ilscompliame with all We bosom veil
amtlruction sNndads Malwials used tld Ih[infamnion rcpaned above art true to my but krmwldge and btlief
E]DnIlar❑Tmhree❑PE-Pmlt N oah Km DrillinLComeany Arcadia Oailarg Inc.
Sig. Addy®PO Box 1790
License No.2574 // City,Slain Zip Shallon WA985B4
IF TRAINEE:Spapw's Licmx No. Conmctor's
SwllaalsSl®wWre R,,emman No.ARCADDWSK1 Ude 42B22
ECYRS0.1.20(Rav09/19) UYm:nadrbiddocunlmrmmattenmre/anmtpla wlileWafer Remurna Program,n3m.407fi872.
Permm with hcorfng/oal mil 711jbr Washington Beiay Bervfce Pers=lvilhaspe hd'.wbilify=w118124334341.
Thin.ton courity Y vbo -otal Hee1t6...t
E000LFerdg O.SW !011 i WASai
.V 36086E-2631
j COLIFORM BACTERIA ANALYSIS
Dal sample couectee Time Sampe county
IP i Pi� (7023 SowAY
D a
ay �L.�1Z MRS /l
Type of Water System tNeck only ene bi Private Housebeld
( Some ❑Group B Clot
Group Amd Gm,B Systems-Prei from Watm Foci Inveneory pwi
IN
wvPlb ea�CI $Y�FFTFB een Peon., )
s^"'t r,4 R/ "aQ Rv (on,; Eve.Pbare 1 --
sw.,®yIg fRMM . .r emi.eer n.laefnat
a./ � -- — - -
�4ceyIiAI98s SAMPLE INFORMATION
Sample collected by Inane):
KTnUQhel
S ufe location or�Qress v)M esa�nple cpllenetl: Special instructions or[ammenl.
She 1�-n , Wh gs§a5
Type pf Sample(must check only one box o(M1 Ihmugh W lined Eebw)
]..e Routine Denotation Sample 2.Repeat Sample(after ui routine)
Chbnnaed:Yes_No_,,_,f_ ❑DlsNbuoon System
Chlerine Residual:Toll_Free_ Chlorinated:Yes-_No_
3.Raw Water Source Sample Chlorine Residual'.Toll_Free_
E.ea,-GWR Si
❑Fecal-semi Ge.amea feu—) Unsatleferl,mubne lab number
F1.0 YeY_Ao_ _
❑Assessment lot ibdrg(P/P) Unpatisfedo
plIOmCCer I ry moune pppena ate
:
d.p Sample Colledtlfor Information Only
Investigative_ Corsi on/Repairs_ Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatislctorp Toll Coldome Present antl Sathifachry
❑E toff present ❑Porte absent o 1hrormdetected
Replacement Sample Required:
❑Sample too old 00 hours) ❑TNTC El
BaUenal Density Results.Toll Co[utarr I rl Eou,__1100m1.
Fecal Calsamr 1100ml Enterocoai q00 m1.
Wood Cod . SM 9223B ❑S1d 9222D Oele aM�,Trma peam
❑SM 9215B ❑EnlrolelEFi
Due and Time lmolned - �Z. Cale Repphed'.
wenummrlocx.mee,"w,.naa onml 0 7
0 B D lab Uae drly.
b
i e eYlrire...�0lnlll