HomeMy WebLinkAboutWAT2023-00207 - WAT Application - 11/1/2023 WATT 7,3 -oc)-Z-0 -7
415 N.66 Street
MASON COUNTY Shelton,WA 98594
COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
Belfair:360-275-4467,Ext.400
eme�"sa�mngfrwvmmemJ xnnhmmmwnyx«im Elon, 360492-5269,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 II
Name on Applicant: M��— T_ � Date: h
<< ( � ,
Mailing Address: 22 Phone: ^Z7�-7Z-0'6
Parcel Number: 7'?Asjo -Opp S-0 G-0 7-02-3_ 001'111
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more L Building permit
connections) ❑ Division of land:
Individual water source(one connection), #of Parcels? SPL
❑d Well ❑ Boundary line adjustment
�j 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 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. (write"none" for two-party)
❑ 1 am the manager of this water system. The water system has been approved for_services. There
are presently connections) 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.
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.
l:TH Forms\Drinking Water Revised 4=021
Individual Water Well
Water well report(attached to application). Depth (06 ft. Q
Well capacity Test(attached to application) "Z-0 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 rapacity 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/Igis.co.mason.wa.us/planning 14_)�15_16_22_
Water use or limitation recorded................................... N/A_,
,Yes_
Well Drilled ............................................................... Date v,1� OWV1
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)
Satisfactory 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
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: 1
Environ. Health: ° '" I Date
This form may be scanned and available for public view at www.co.mason.wa.usYSQ.`.mason.wa.us.
Page 2 of2
Arcadia Drilling Inc.
P.O. Box 1790
Shelton,WA. 98584
Customer: Prime Location and Solutions Well Tag#: no tag
Phone: (360) 277-7206 Depth: 66'
Well Site Address: 1161 E Mason Lake Rd., Shelton Pump Set: 60'
Date of Test: 7/2412 0 2 3 Static 45.8
TIME LEVEL GPM RECOVERY
1 Min 46.1 8.0 TIME I LEVEL
2 Min 46.1 8.0 1 Min 1 45.8
3 Min 46.1 11.0
4 Min 46.3 11.0
5 Min 46.3 11.0
6 Min 46.3 14.0
7 Min 46.7 14.0
8 Min 46.7 14.0
9 Min 46.7 14.0
10 Min 46.7 20.0
15 Min 47.1 20.0
20 Min 47.1 20.0
25 Min 47.1 20.0
30 Min 47.1 20.0
35 Min 47.1 20.0
40 Min 47.1 20.0
45 Min 47.1 20.0
50 Min 47.1 20.0
55 Min 47.1 20.0
1 Hr 47.1 20.0
Vanguard Laboratory
2635 Parkmont Lane SW,Suite A
Olympia WA 98502
pfMto*D 360-967-7010
COLIFORM BACTERIA ANALYSIS FORM
DOW Semple Wd l Time= County
07/25/2023 ,� a o.N Mason
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Srslrn Name: Robert Flath
Canted Person:AnatlW 041lrg,Inc
Dayphone'.(360 )/263385 Cell Phnne:( )
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SAMPLE INFORMATION
Sample cateued by(name):Seth
Speck loceym Mae.emo.odlectE: Spedel'mehucknaawnmenk
1101 E wsoh Lake Ra.Shelton
Typo of Smpk(eeleclmry aria rNe of sampk ham types 1 tllrmgN 5 pelow)
1.❑Routine Diddleat Semple(Am) 2_❑ Repeal Sample We)
ChbnnaWU:Yes No (lmm aevi000n system Aa unsat mdee)
Unsal¢latloryroutine lab number
ChbnraRWtlual:Tdel_Fiee_
3.GreuM Water Rule Sours Sampk — ---
lMsaWlectay roufine tolled Eala:
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Dfia aleL'.Yes_No_
❑Tiggaal(Ain) ChbMe Remjual'.rolal Free
❑Ameaemed(AR)
t SudxeecGWl WrSaume Walx Sample(Enumemfim)
❑E.pap ❑Fecal Fm.m ye`
5.®$Ynpb Cdbcletl br Nlamallm Ohl,'.
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unaaliefictery TMI Cd oon Present and Ssaalackry
❑Ecnr prmenl ❑Eonlraaaent
Bacterial DaWRy Result:ToWlColilam I1wrol. EcaP /1Dpd.
Fecal CaNWm ItOanl. IVC /tat
RplxmWnt Sample ReRulraE: ❑TNTC ❑Sampk We oB
❑ Sample Volume 0Dam,e6Cuntina ❑
IA palest.Numtia
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