HomeMy WebLinkAboutWAT2023-00294 - WAT Application - 8/22/2023 WAT �ZS� DbZ9�( I T-
415 N.3°Sheet
MASON COUNTY Shelhm,WA 98584
COMMUNITY SERVICES Sheltm:360-427-9670,Ext 400
Eelfir:360-2754"7,Ext 400
a,Idn3 WmM[iMmnmeu�NNTfmm�x,mryxuM Prm 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 aplaroved building site plan must accompany this application.
Part 1: Applicant/Parcel Identification
Name on Applicant: I 1 - GL� Date:
Mailing Address: 40 E Phone: ,,Z 53-.2-16 332-V
Parcel Number: (A)lI 1&57_ ao a3 _ 51_.qp -11,o
Type of Water System Reason for Application❑ PublielCommunity Water System(2 or more >( Building permit 23 -009qR
connections) ❑ Division of land:
XIndividual water source(one connection), #of Parcels? SPL
Well 0 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 welt, check the Public/Community Water 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. *its'none"for two-parry)
❑ 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(Le.: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.
Print Name of Water System Manager Phone
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
I:WHF®e\Dnvkin6 carte ReviuA4 7=1
a • R A T E R x B L L R E P O R T Start Card No. MO0]]30
unique Nall 1.0. B A[0s"
STATE OF WASNIfWTON Meter Right permit No.
.. .. . .. ........ .. .. . . . .. . ... ......... . .. ..... . . . . . . ......
Ill OIRi6R: Name YOUR, trCF lb
R draaa SrOE IYONOLL cynic... ..... . xA SNSs-
__ __________________ .. ... ... .. . ..... ........... . . . . ..
..
111 IAGTION DP xBLt: CwntY fPJO• - Bx 1/a WE1/0 8at ]e i ]]E N.. R TI MN
13a) STREET ADOERSE OF MB(L for vases[ ddr...) [ else xaEO• LAYS DR, x.. ®i'ma
.. . .. ........ ...a .. . .. ............ ........ . .............
.............................
131 FROPoE® USE: DRRESIC 4101 WELL LOG
.................................................„_._..._._.....I_ _--------____------_----------_----.._--------
___..
: Describe by color, cMzu[e[,
(0) Yypg OF WORK: Oeae['s Number Of wall I Formation
b el¢e Of av[siisl
IIf mole than One1 I mNI structure, and .hw thickness of pulfere aM the kint
FEES WICU method: RO'TART and nature of the material Sn ..On ....tom peee[raesd, with
.................................. ............................I at least One entry far each change in formation.
..
Oitnet.r Of well I fRcbes I
IB) DIMENSIONS; Diameter TO
Drilled al f[. Depth of ecnpletM well PO ft. I WaTSRIAL
............. ..... .... . ......... ...... ]]
O RNID YRR S.VID] ORAY6 a 1!
161 DNSTv=IW DEYAI44: LAR O. i]
Rf
G.iW installed: e " Dia. flan rl ft. t0 60.E ft. I RAN CLAY BIxO6 G. a DMA. ]] N
xpym fJPIRO • Dim. fr. ft. t0 ft. Me =Y Br1Rml ]LaCa SARR GRAVEL aT St
• Die. IF. It. to ft. sum a mNAM .1 moan. a waxes Ea 61
_____________________.___....___.________..____..______I
P.rfora iono; n I I
Type of Factor...r ...d I
size of Serf...times in. by in. I
perforation. from ft. to ft. I I
pafora[iena free It. to It. I
perforations_ ______It. to ft.
screens: LID
wwfacturer'e mama
type model No.
Dina. slot site from fc. to It. I I
Dfam. ale[ is. Iran ft. to ft. 'AZ
_ td I M I
-------------------___________ .__.______...._....____._.I
Grawel packed: ISO Site of gravel
Gravel Placed from - ft. to ft',
Surf.ce ..I YY To what depth] 20 ft.
NSlerial used in ..al EMENN'STE
Did any .crate contain emisable water] YO
type of water? Depth of c.t. it. b
I - I
Method of seal:y at. o[[ I _ Q.................................................................I — _ . . _
"I PIMP: Netuttieturer's Naas H.P.
TrPa
................ . ... .
... . . .......I
...................
18) WATER LRVF15: Land-eurfaaa elewatlen I I
seems mean sea level ... ft. I I I
Static lawl 36 ft. halo: tap of 13 Data 00/07/97 I I
.rtemiae Prosutt ihs. at spare inch Date l
Artesian water controlled by I work started 00/07/17 Completed 00/07/17
...........................................................................................
CIERTIFIC
191 xeLL reei8: DraNaw Se arounc water lawl 1s leveled below i xWL N1)a ad �/or accept
I toms respOnsibi11tY for com-
stati I10 c level. ewe[Son of this well, most
its compliance with all
Was • thin, teat made? If yes. by whom]
yield: 9e1./min rit. It. drardomn after h[s. i Muhingtrn w wall cucrucclonstandards. latarlala ua.d
and the information reported ahove are tent t0 cry bast
I kmrledge and belief.
Reipwaty data
Ties Wacer Level Tire water tweet Time Water Nvel i RANA a`mdp(persL ORr�ramED'zD lOnl Hype or print)
I
I ADDRESS SE TO WALffi PARt I
Date of test / / I Licene. N0. 1141
Bailer test gal/min. ft. drawEown after hr.. ISIGNEOI
Air test IS gal/min. w/ stow set at ST ft, for 1 hr.•l
Artesian fine 9.P.n. ORte I Contractor's
Temperatur0 of water We. a chemical analysis mad.] RO I Registration we. ARGDDIOFRI Oars O3/07/17
... . .................. ............ .. . . . ... . .. . ................. .. ... . ..........
Printed From Mason County DMS
Printed from Mason County DMS
Thurston County Environmental Health
20001akeridge Dr.SW A Olympia,WA 98502
360 867-2631
lxuasmry cosnuTv
COLIFORMBgCTERI(L_ ALYSS_
Dye SjatpIp- PTlme's:im b
dleed
le Zo aJo � , -0")
p
Type of Water Sparm(check only ore box) Private Household
❑Gm,A ❑Group B ❑Otlwr
G1olp A and Group S Systems-Provide from Water Fadkdes ervenbry(WFI):
ID# _
Syslam Name:
Canted Parson:
Day Phone I .cxil Cal Phme:(•t y..,G )), �
Emaib(� > >IEY ' +Ja fk, ' E"Yhon - )
swMm es M::(Planhenone,somas and at,code weed 0"')
SAMPLE INFORMATION
Snmpl'm9ecbd by(nwmy.
-I >iix- 1
Specific ballon or Md.xfiere sempb mlkdetl: SpeeblimembionsoramnenlN
L�/y i-E'VrttV' Lj .. ly
Type of Sample(rtuYcheck myone box of al thw9h ka litletl Dabw)
1.0 Routine Distribution Sample 2.Repeal Sample(altermet.roudm)
Chl"adrd:Yes_NoA— ❑Diambution System
Chinon Reaidual:Tory_Fme_ Chbrinamd:Yee_No
3.Raw Welar Soume Sample Chbdne ReWm:Tmi Free_
❑E.ali-GM jW)
❑Feat-scars.ay.9..l.l Unatishebryroutine lab number
FiWad Yee_No_
❑Awssreent Wmarin9(AIP) Unaatiandnryrouhnealleddele:
❑Oder
4.0 Sample Collecled for Intonation Only
InveftaWe_ ConsWctionl Repaes Oder_
LAS USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Uneadifactory Total ColDnm Pmsantend ' $atlefacmry
❑E. present ❑E.ml'ebmM No Cofibm deal
Rebeern.nt Sample Requfled:
❑Sampbl000ld(>Ml,ma) ❑TNTC ❑
Swam Density Reeubs:ToW Colilmm I100ml. E.ali 1100mL
Fecal CoNmm 1100mI - Enbrocuod NOD 4..,
Merme Cade: W238 ❑SM9020 proemial u3 Redeeel0 S
SM 9215B ❑E .e a lu 7�
pale aM line NWynad - 1 F 4-I mbRapeM�. f' )-S �
sroN mimed oau,µnmvayel tabusay i�N`t�
0 8 0 �— Classy
MXfmmiy4a19(mie]01n8 J1151 y"1