HomeMy WebLinkAboutWAT Application - 10/12/2023 Exf�h w�-�--
WAT
MASON COUNTY 13G.� n
COMMUNITY DEVELOPMENT ta_:ii'nh
Permitnesimnceomar Bmidinananmry
415 N 60 Street, Bldg 8,Shelton WA 98584, W
Shelton:(360)427-9670 ext 400 4 Belfair:(360)275- 167 ext 400 4 Elme:1360)482-5269 am 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: Applicant{ Parcel Identification
Name on Applicant:Zushi, Liscwtan Date:
Mailing Address: RZ{ d✓ ,06keittiA KXV &b Phone: 360-46'3-X1y59
Parcel Number: CZ///-3Z — IQp�1I
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more 13 Building permit
connections) ❑ Division of land:
0 Individual water source(one connection), #of Parcels? SPL
S Well ❑ Boundary line adjustment
❑ Spring/surface water
❑ Other(explain) ❑ ReplacOther ement )
❑ Replacement Remodel(please indicate name
/f you have more than one residence connected of water system
below if applicable—no
to this well, check the Pubfic/Community Wafer 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 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 maybe sunned and avallable for public view altviniviii.co.mason.wa.us.
P EH Fame\DriNcine Water Revised ln5no18
Individual Water Well
JO Water well report(attached to application). Depth Soo ft.
Well capacity Test(attached to application) /0 apm_-2--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 capacity test,
a well capacity test, which provides stabilization of draw-down and recovery data, must be performed
by a licensed contractor.
.WSafisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htto://ais.co.mason.wa.us/olanning 14015= 16A 220
Water use or limitation recorded................................... N/A�Yes r-1 cA
Well Drilled ............................................................... Date �IS� 1
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)
�U Satisfactory Determination:
IThis determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the future,orguarantee compliancevnth all applicable WDOE water resource regulations.
Recommended approval indicates requirements of sanitary Code,Title 6,Chapter 6.68.040-Determinafion of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
^Rpe'vie-wer''s1 Signatures: 1 I
Environ. Health: -AV ""' " Y ,v ' Data
CSD Director: Date 2 of 2
WATER WELL REPORT CDBR6fNTWent Na. 14117 S_S'55
�y Notice o
Onpnalffi Isecopy-Pmlogy,tad copy- ,;id )�- ilSFiD A r/� /
-lam
C�wyatruationNn:ommicUon f•x in circle) unique
que P<oloRY Well ID Tag No. 7 2,0
t! al ConsWCRon APR 2 62004 WalerlUght Permit No.
O Dominnusslon ORIGINAL CONSTROC"C' Aid Q
C orieveru Number UEPPN ENt Uf ECOLOGY Property Owner N. It dV fA. /Y GLrsj/
PROPOSED SE: JSDonnestic 0listudical ❑Munrcrpal Wellall
ZZ ❑DeWater ❑Imgabw OTett Well Omhn R / w�
3 PEOFWORK: Oo sn tub rofw ll Df.meth one) CI[Y �A' / County: %/!<!Nt
Isar nnlyJlJ/Ctl m S� Twn4L RaE� circle
N New Well ❑RemnWao.d Method ❑Dug ❑RoreJ ❑Dnvca tY � llTTrr��LLL ORU oe
Deepened (]Cable ❑R-- ❑)aka
DIMENSIONS: Donaim ofwell inches dolled --ts} ft (;Lrnlll la[IvbNSec
0 Depth ofcomplekdwell�fl REQUIRED) Long Clog lung MnJSee _
C CONSTRUCTIONDETARS �p� Tax Parcel No. �.Z/I/�7�i—AOO N/J
O Cnmg ZWd&d 'Z50>�_" Dram for. VL It m1-k—R CONSTRUCTION OR DECOMMISSION PROCEDURE
IresWkd: OWver rvsWled Dram fern ftm_Fl F.mmaon Drembe by color,chvte acr,sin ofinebood unit semctum,snd We
OThmaded Dram m R fm m_ft kaul it We of We maknal:.eaeh sna in pewouted..6.1 Iran..
wq for each change of information.Indicate all water encountered.
e Perforatluss: ❑yuz, (USE ADDITIONAL SHEETS IF NECESSARY)
C Typeof pedaeamrused MATERIAL FROM TO
N SIZEof Pei by_m andno of perfs_ftomRm_R
tSA
:E ScreenJa Ta 3l4uajjrK-Pac Located- VV AV q O
L Manufaca.h Name
O Type Moded No
•O Drem Sld 9s fi.re ftm fttot
C Dram Slot Size from ft m fl
A �y
CraveVFllkr pecked: ❑ya, No O Sac of pmv&eand
I0 Materials placed from ft m fl O 44 iron
Sirfen Seal: JOYCs ❑N. To whit depth+ I $ R W
Materials useasncesl r O mow_—T n on Tfg
T Did say seem c.nmmn unusable water+ Dyes RNo Re
C Type of wavYr Dwhofamm
O Method fear saam.R _
MA PUMP: Manufacture's Name O �` 0.d< r and 'L
Typc H.P
WATERLEVELS: land.verDnelevanonabovememwelevel R
OStatmlevel �f'Z-a Rhemwmpofwell Dam STP MRQ `-k
—L Anesunpressuk Iba Pc......h Dak
N Armoire water m a. 11,il by \- y .3
es, ( ,valve,ek
V WELL TESTS: Dn o Hm wdow ao.t water level is lowered below$tube level. .A row
V Wssapumptenmade+Oyes ON. Ifyss,bywhomv
pl Ykld---- al/mm wr0 Be deawdewnafler bri a
p Yield�aI/nuv.wM ftdawdow,after m En
a Fd 1 - TQ:,Ls 37 3(--
Yield A/tun with It driewdown ante hrs
Rew.ryewan.e ml[e w«ra wAen vamp rvmed gXwom(ever mepserMfeam ' +T{ 7
W well kP ro wpeer levell
rt Tune Watertt s) Tome Wale level T:mc Wall
C
DnBvdiolm ksl 1n eel/con vnth RMwduwn aRer ZM
Ames am/mm wohneeiselat ft tie-ins,
Amen flaw e p re Dale
�I Tempennut of wakr_Wss achmud amlynr vmdcri OYes ON. S.Dne Ciao lelW Dates dC7A`:A�
WELL CONSTRUCTION CERTIFICATION: I meacJc[ed and/or amept responsibility forco.kuchon of thus well,and its enonplearlee with all
Washington well colmuuction standmds.Materia+las used and the mjommnon reported above are w tom hest knowledge and belicf.h— Driller ❑Enpv.r OTam. No=(Frim)Ll K'N C, Drilling Company V
Driller/Pngmeedpnlnee Sillii ne Address
Dn14r w'1}artke Lacuase No. u1.tt ,;.HO S V C1ly,State,lap S
igtrodelnueree,licensed diriter's Contractor's
and Licen vo No /O�MJ pgpISf
EcolagY re.Fq.l Dpp.nnany Employer ECY 050.1-1D(Rev b'Rl)
412 Lilly Rd NE
Olympia.WA 98506
360-867-2631
Ta�as[od murvrr
COLIFORM BACTERIA ANALYSIS Lan
m !
Dale Semple collected Tme Sample Canty La 1
it 1 -7 1 zoz� /Colleded 0,N
xem ore r..
A .:L=Ow 0 151�
Type of Water System(check Only one boz) ❑ Pmram���Flouuwpe�ho�6M'��
❑Group A ❑G 1PB ,�Olher 1 1
Group Aand GoupBSyaterrm-Proud ftom We Fadlitieslmanbry(WFI):
w — —
System Name:
Contact Person: ate. .111Nry ye'IGl1
Day From! 0 I4{a '�HSQ Cell Rmre:( )
Email:• y,ye Eve.Phom:I I
��weWupp ro.(PON hu.... mdapmdm«ladmea)
6Jr161>� LJIMM
14z1 W $YokomTfh Ua//ey Qo/
SAMPLE INFORMATION
Semple onueced by In.): SOAd )
Specific boetion o adtlresa Wale sample wlkcted: SpedalireWtlbnsoroomente:
4Z1 $.}oafc A), 1/4)�Py
Type of Sample(m,a deck ony one boz ot#1 throughd4liebd below)
1.0 Roultnm Distribution Sample 2.Repast Semple(aRer PneeL muBne)
Chkztnated:Yea_No ❑Dbbibutmn System
Chlor eReddual:Total—Free— Chlornaed:Yes_Na_
D.Raw Wafer Sowce Sample ChlorinResdual:Totem_Fms—
❑E.wN-GWR(A(P)
❑Foal-swo.W,arnres(Naaammt Uneatishcmry mutioe lab mdnAer
Rhmad:Ym_No_ ___ _ ___
❑Assessment Monttouirg WP) Unsatisfactory mutine wtect data:
00Ner _�_I__
S
4. Swpte C oil tacted ror lnlommOon Ony
InvesNative_ ConaWNmlRepelm X Oher_
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Dnealbbcbry Total COMM Present - o
❑EnON present ❑EwYabsent
NO debamlad
Rphcemant SmnPle Rm lubsd:
❑Sample um old(>30 hours) ❑TNTC ❑
Bachanal Density Results:Total COIMom 1100m1. EmN /t00mL
Fecal Colifo- 1lOOMI Enteromo9 /100 nJ.
MBMotl Code: SM 9V3B OSM9222D p�a�.mA lkna PxMved.
OS 9215B ❑Enteroled®
W,are TN.M.lMd Z the •L
,w� ,. 13.111— Ws d lm-w Day.
0 8 0
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