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HomeMy WebLinkAboutWAT2024-00080 - WAT Application - 2/11/2024 WAT 415 N.6-street MASON COUNTY Shelton,WA 99584 QD COMMUNITY SERVICES Shelton:360427-9670,Ent.400 Belfair.360-2754467,Ext.4011 ety api..,.,ar,„: ,,,,r+x xesimcemm�iyx..u, Elms: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 a 'fication Z Name on Applicant: Date: Mailing Address: Vt / hone: Z t ' Parcel Number: Type of Water System Reason for Application Public/Community Water System (2 or more Building permit 13I-DALM-00163 connections) ❑ Division of land: ❑ Individual star sou a connection), #of Parcels? SPL 7L�w Wall 2 ❑ Boundary line adjustment / ❑ Spring/;Xace 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 PubliclCommunity,Water signature required) System box. �"� Part 2: Water Connection Information p�,J'//77�l/ 1 )— DbOT� Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: 11 } Water Facility Inventory(WFI)Number: IJ (write"none"for two-parry) ❑ 1 am the manager of thistvater system.The water system has been &d for 7. services. There are presently connection(s)in use.This will be the connection. ❑ I 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 a d local regulation. '7[ Signature of Water System Manager _ Date 7- This form may be scanned and available for public view at www.co.mason.wa.us. 1?F3i Fomu\Drinlo,Water Revised 4/4/2018 /// Individual Water Well $� Water well report(attached to application). Depth lfl. Well capacity Test(attached to application) 7/0 gpm 7 VU 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 http�//gis.co.mason.wa.us/planning 14�15_16_22_ X Water use or limitation recorded................................... NIA n 1 Well Drilled ............................................................... Date L 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 Dab 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 W DOE water resource regulations. Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.66.040-Determination of Adequacy for Building Permits are sagsfied. 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: CCM Date This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 T WATER WELL REPORT CURRENT onb..at•em-sexy..r tlA-a...,.'.w-ac. nonm srl.r.tNw � ECOLOGY Cmm cflomMD mmWb.("z"M ebwa) U.igw Eralogy Wdl lD Tag No.Blil M - Ca65411.�.8 Wm Right Peron No. Dewmmissiw ORIOWALINSTALLATfON ftp"O"m Nwe'+.... Awl-g Load NtwWr FIIOSOmBDd ® Derby ❑ la.el ❑ Rex0 Wdl Sbeel Add.«el,rin N.MdsI RO 13,,w.. O xdldi. O rr wd nor (Sly sh/s.n _ County mmP YYKOFwWRe Orr.rrrdw/(see�w7__ i c U. NM14111 BEIA S.11 Twnn R2'd eve.❑ o Drrr 13/®r.r ww:d D ®Rmn o.tea (..R c Sun REQUIRED) w ■ msmaotd Orr.a.rB Lsaamrlg¢a LN/la.g Tat Deg 474Y lat MmISm 17 corglwncraonmRYAau o.b/ ® waad jr !At.jutLomg Deg l]tl3;! Long MrdSx pL 'ZC (rw� D lt.araa_ Di —L.. JI. Tm:Pecel No.(Rcq-herl)°'MlV9 9 ❑ Ixrrd .� D1i.1e /.b �6 P.MYe Y. Ne NNb'I RL--C— N ms0 NBIImImrBBDCsmI/E YyP,do.tw�.me p.mim-Debbeb.Jea..f.d •m.lrarmy6�R Raaa.x�.Br_brar.aac®JIc.—LmJ� reawr.ett ra.r.P+c4 aib..rs 1118s A� mytm'9aGRv.) Bever: ® Yn ❑ No ®XAe Iae.im,Ro _ �,�AL� �p YA..6 P11 a ASP &eaal DHaasl Firm to T1 sbwm NWNn po<Bgl.rbbrls/m]sg L..]�L 11 2B 26 o /c. •m a owft Cm//swan 79 ai rs.cNsra.ar C1 Y. ®r R.aF..d..a_ 31 m aarry.rf_am a. ao.. c.rr lrBre.b ® V. 13 w Tear &0129L bsNlmllt Byaial,Wb.a hba �[ mNSr4 A Dias rmtl wam�.oNc..rn ❑ v. ® W - 6! 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D'n wimaeLire.Ne 3a1) Cry slab,li.9B1.1TlN _ WA, 985N 1F agE:DtgkA lJmua N.: CamatuYr '- N ARCADDI.98R1 L\1a F142011 urns _ Prinl`��t�' WDrbW..Eem.a.s AOPa.r3d64wJB11. me. P.e.,rwa.�dewTare.mndn�u. Panted from Mason County DMS Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA.98594 Customer: Robert Scott Well Tag #: BHH005 Site Address; 1300 Northchff Rd, Shelton Depth: 195, Date of Test: 9/19/2011 Static: 155' Pump Set: 180' TIME GPM LEVEL RECOVERY 1 Min 20 162 TIME LEVEL 2 Min 20 162.15 1 Min 160.6' 3 Min 20 162.15 4 Min 20 162.15 5 Min 20 162.15 6 Min 20 162.15 7 Min 20 162,15 8 Min 20 162.2 9 Min 20 162.2 10 Min 30 162.2 15 Min 30 163.05 20 Min 30 163.08 25 Min 30 161.1 30 Min 30 161.1 35 Min 30 161.1 40 Min 30 161.1 45 Min 30 161.1 50 Min 30 161.1 55 Min 30 161.1 1 Hr 30 161A 1 Hr 10 Min 30 161.1 1 Hr 20 Min 30 161.1 Vanguard Laboratory 2635 Parkmont Lane SW Olympia,WA 98502 360.967.7010 VANGUARD Report of Laboratory Analysis LARORATORY iSJ/ Collected by: Seth Hodges Matrix Drinking Water 360-918-3082 tnboratory ID: V240315-8 Sampling Address: Date Sampled: 3/1524 13:00 1300 NodhdiffRil Date Received:3/1524 15:30 Shelton,WA 98584 Date Reported: 3/192024 Sampec ID: 1300 Northeliff Rd Analysis Result SDRL MCL Units OF Date Analyzed Total Coliform&E.tali by SM 92238(IDEXX) Batch ID V240315-8 Analyst:VJ Coliform,Total Negative I 1 MPN/10(lmL 1 3/152417:18 E.coli Negative 1 I MPN/100mL 1 3/1524 17:18 Notes'. MPN'.Most Probable Number ppm: neon rmillion M nond ,,t Reviewed by Robert Smalling Chemist on 03/19/M4 Na.me applicable SDRb.Slue Resection Reporting Limit Approved by Tmi Johnston.Operations Manager on 03/192024 DF:Dilution Factor aBtlaet MCL:Maximum Canmminant Level �yarm`wv Page lofl Samples were meeived in acceptable wndition.The result's)in this capon relnm only to the lamom offlm sampW,)tested.All analyses were performed consistent with the Quality Assurmce pmgmm of Vasaamd Ishoommy.Plesse cunmcuhe laboretmy ifyou should have any questions about the insults. 2635 Parkmont Ln SIN,Suite A,Olympia WA 985021 Office:360.967.70101 testing©vanguardlabomtory.com I www.vanguardlabotatory.com