The URL can be used to link to this page

Home My WebLink AboutWAT2023-00289 - WAT Application - 8/2/2023 WAT go,-�,3--_OD,-O9 415 N.6-Street MASON COUNTY Sheltory WA 98584 COMMUNITY SERVICES Shelton:360427-9670,Fxt 400 Belfair:360-2754"7,Ext 400 wuyw,n.yr,m�m.r.�w.xn.ce..,..�ryw.M Elm.:360-482-5269,Fad.400 Application for Determination of Water Adequacy Instructions 1. Complete Part 1. No detemlination 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 a2proved building site plan must accompany this application. Part 1: Applicant/ Parcel Identific tion Name on Applicant: -�r`r...tt 7, I Date: 8 3"t3 Mailing Address: Z13 $V Lew t- Phone: gt-o LZS f37S Parcel Number. 319 I Type of Water System Reason for Application❑ Public/Community Water System(2 or more Building permit BLMC93-OIX41 connections) ❑ Division of land: III( Individual water source(one connection), #of Parcels? SPL IX 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 it applicable—no to this well, check the PubliclCommuntly Water signature required) System box. Part 2: Water Connection Infortnation 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. Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. 79EH Fom, Ddntin8 Watu R ie 4'4/2018 Individual Water Well ❑ Water well report(attached to application). Depth QZ k. ❑ Well capacity Test(attached to application) 30 apm OO pd. 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 hfto://ois.m.masQn.wa.us/olaft[nN QS45_16_22_ Water use or limitation recorded................................... N/A_�Y11es Well Drilled ............................................................... Date rr'/7�wo 1 Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection ❑ 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 Part 3: Mason County Community Services Evaluation staff use on/ Satisfactory Determination: This determination does not address adequacy of the distribution system,guarantee an adequate supply of water indefinitely m the future,or guarantee compliance with all applicable W DOE 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: Applicants 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 of 2 rub Otlglnal•n..nt Co9r Maim AV9Uro.n NQ ............... Dr,omeeolb(h.]a WATER WELL REPORT - Aroma Coff—owYmr.obey Taal copy—Dnaers Copy STATR OF WABRZKG ON Frady No r (1) OWNER; Q.wu4L� Oe�weRat �aa�_dl lQex�K� JLllrw .4/�se� O (2) LOCATION OF WELL: c.cony_...Af4b"X_......_....................__._....._...._—S!✓..t: .S.AG.V. az<_LL..... T..LLx..B.,J.._.WAl. dSo," •nd d0dooce from meson w.9eatvbdon ..-ol (3) PROPOSED USE: n m bmLe mamrw ❑ awmp•e❑ (10) WELL LOG: 3 Ifnpaae ❑ Tort Well ❑ purr ❑ rpmamn:Dlsc l e ey rotor,Morprr .0 sumMst n.d rtemrs.ma .lure thick....1 aqu err,eN IM kind m eOYn of the materul in pbn ..eves penormted,wh at tout w. turn for exh elmp..1)wmmmn. N (g) TYPE OF WORK: uwer•a number or wall _.._.... mwa L naY Ta New waU Wmod:Dar ❑ Boost ❑ y Deep®.d ❑ caw HNsoo C R[maamned ❑ Rot•w❑ yeNad p O C (S) DIMENSIONS: ntomew ae weu _.._..__�Yaer. { ,1'a.✓ � � . 0 Malea......_RG�r Dee._._-A. m a rompleted weN._.._ _-1L E (6) CONSTRUCTION DETAILS: �- Cuing imtalled:.,-.-1.Dun. .rem -14 R to _r.a. r F I { u 3 C Th[erE.d❑ _^ coon.from ._.—R to —n. Welaedfr -rases.from..._...__R so Ol Perthratlome: Yes❑--NaAf — Type a p.mnmr rW..__...._— p SIM of fa by Ar[aestlw haY —.—._._a. C .._._...........9etex•a®Lam A _.__......_..._..psrmtNroW teem___...___a.Y_—_.._R AScreens: Yu❑ No gf p sn9maetmar.N.ae._....._ 9M tiv_..__.._.from__._._n.to R MAY 'IG AI CGravel parked: Y..p ere W N 1'l�"ECBL9__�a'n`.lnvr ` Oeevel DLeM from..... ....A.Y 3 W Surface Sea[: Yes(Y No O�To.t�m�s{t��}�y.�q Lsted'd used In tpl_.._.._. r./fl•_._.------ _• "I a0y Nato eenYY 9apYLa sat., YY❑ ne0 --- OTY%o[wet r}..._..._.._____._dpm pf Z Nomad of nanny.hNa (7) PUMP: ' 9a (0) WATER LEVELS: r..ee.a.ta«.weNon •ha w too war... — x am leret......__.._..lj['-.._n bemw.mp . weu D to—.-. 8 uY •n p Ymn .. .__ . _fib.. o M. InN ONe _._._..._..._. _ A.YYsa mtee L eon4anm aY_...._.. ...._...Fee__._....._. W (can. wow, l mwn h•vmM.'met Iml Is 's (0) WELL TESTS: Drswmwmea b.. elahc level CWY a Damp tat Mader Ye.❑ NO Of N yes.by ammr__- _. ....._._._ 01 Ytola: - ea/ado.'Ad, do dn..army h.. WELL DRILLE R'S STATEMENT. This well was drilled under my jurisdiction and Mis report is ^ true to the beet of my knowledge and belief. tg Am°wm�rymad pees we up w o.Hr Mwll�9 [.reed en) (watt' Yv.e l� NA1dE_afll.a'_4..XI/A'I. or pus _.___..... Trw Mawr roost Tmu Nwr Leo.l T1N Mawr Gwl IP/etasba,arm.ore amn R'+YM a�'nN9u t __......._..__._..._..........�..._............._....._.._..... AdrLeY.Jh...._L.R.�4 a �e�51,9....,.Q .._.._..........._-_...._ naa YLa..._.._._..__..----....__.. II (gigaed). ....rY...'l._✓ ......__......__._...__.. Ayiar wt.y.y_..asl. . wM.�fit.<.awdew9 afrar_�1......Fn. (W,� Artesian m..__.._.--_saes Hain.._. .____—_._.._.._.__. Sbmperamn Y water.._.—Mar a d1Mal�aoalyN mods[YY❑ N.R IUR ADHRgori L aentF[g II NZOESSART) `a er,.1. Thurston County Environmental Health 2000 Lakeridge Dr.SW #Olympia,WA 88502 T 360867-2631 COLIFORM BACTERIA ANALYSIS Dab Semplm Culbcbd T'ure SempIs cstmyy y� 119,1 13 Dwbwd NmN M Y. ys MG'S J7 TYFaolWabr Syabm(dtecl;onyore box) Pdyata Househad ❑Group A ❑Group B El Other Group A antl Group B Systems_Pml*bar Water Fadtias nwar II)'D# System Name: Corbel Penn: r Day Phone:( ) El Ce9Phona -mai aeMresmb N:IPINM a /o.UM Eve.Phmy:( ) ✓VV ! 'adRem wd apoxe«anal edbwel r to 3 At SAMPLE INFORMATION SenVte Odeded by(namel: SW&location or address ,hem sat"w16e : SPKWnsbuctionsacommmnb: Type o(Sampb(muslcherk onyone box of#1lhrough#4 fisted below) d.❑Rm111M Ybb�Mdon Sampb 2.Repeat Sampb('dW umaL roWIM) Chorine Chbrie Re:Yes_No ❑Disbibu0on System sbual:Total_Free_ Chkanased:Yes_No 3.Raw Weser sourte Sample Chorine Reabuy:Total_Free ❑E.co#-GWR(AP) ❑Facet-swan,M aro^wt�l Urearwac gY roubm lob number. Filtered.Ym_Nm_. ❑Assuarrast Wnioing(AIP) — ————— . 001har UnselbsecmryroulM colbmdeb: 4.0 Sampb Colbcsed for Infommflon Only Investigatire_ COnsWOyon/Repeim_ Ogg_ LAB USE ONLY DRINIQNG WATER RESULTS LAS USE ONLY 0Umatbbg1VTotal ColifomtPmaentand usfapfory ❑E. ipiesent ❑Ecobasew I�'ftanndetected Replacement SamPb Required: ❑Sample boob(>301xbm) ❑TNTC Bacterial Density Resub:To' ICONmn n90m1. Ew# /fOpN. Fecal Colifmm /100m1 EnlBrocepj W m. fdenod Cotla: SM 92236 11Sh19222D Dpeb alai SM 9215B ❑Enorolxh0 I-�Q Z3 l $ Date aro tone Nnayred; Z � . samnu mam.ryw a>ra«lens..auml tm '2 }