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Home My WebLink AboutWAT2024-00175 - WAT Application - 3/27/2024 WAT 2D2A - 001-15 415 N.66 Street MASON COUNTY Shelton,WA 98584 COMMUNITY SERVICES Shelto.:360-427-9670,Ext400 Belfa r:360-2754467,Ent 400 amdi,Piw %Pmw,merw HeY,hCom,.mi,a M Elm.:360482-5269,Exit 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 ,I Name on Applicant m A &T4A, VP&1wk& Date: L7 14 Mailing Addrg49 krJ/ C .i)/ hl'If)✓ fNd} Phone: Parcel Number: Type of Water System Reason for Application `- .I ❑ Public/Community Water System (2 or more Building permit a�2027'(XTi�/B connections) ❑ Division of land: X,Individual water source(one connection), #of Parcels? SPL XWell ❑ 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 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- 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 an 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.ca.mason.wa.us. I1EF[Forms\Denting Water Revised 4/420r8 Individual Water Well Water well report(attached to application). Depth° CA% � _ft. Well capacity Test(attached to application)BLS apm 7 "10 0 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 drew-down and recovery data,must be performed by a licensed contractor. III)Satisfactory bacteriological test(attach to application). l Water Resource Inventory Area (WRIA) Development within which WRIA htto/Igis.co.mason.wa.us/plannina 14 15_16_22_ Water use or limitation recorded................................... N/A ,Yee1s_ /y,\/ Well Drilled ............................................................... Date 1Y C7 "t 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 Date Relationship to Applicant Part 3: Mason County Community Services Evaluation (staff use only) Satisfactory Determination: guarantee an adequate supply This determination does not address adequacy of the distribution system,g eq water indefinitely in Me future,or guarantee compliance with all applicable WDOE water resource re Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Deter Adequacy for Building permits are satisfied. Additional Growth Management requirements may ap36.70A RCW. ❑ Unsatisfactory Determination:Applicant's water supply does not appear adequate to meet the needs ofi[s intended use for the fol reason(s). Reviewer's Signatures: Environ. Health: Datel6 This form may be scanned and available for public view at wW�co.mason.wa.us. Pop 2M I Y A T P R N e L L R H P O R T St.. Ckrd No "BUSY IMlq— Nell I. X .... STASH oP MkgHII1L-IVN NStar Right Pe6it No. Ill OM . NUY SEES, Q kddxw— [SOS D.DRPI. peo VL, p 11502- ••• • • •• • •••••••v••..•••• • • •••••••••• • •• • w • v_••••• 11) LIXATION OF SHLL: Runty VA&NW - WE 1/4 WE 1/e Net 14 S 20 N.. R ] YM (lei STOHHI' ADDHHHS OP Pum for nearest addreaal 63 AOAY! IApI, sa - ... .. . .. .. ...... ......... . .. . . . ..... . --.. (3) PROPOSED ME! p MC I (In . 1N . • .I . . IO TYPE OF NORM: Owner's M:mMz of Bell Porv[San: peaerlxe by celez, o1ons. cez, afae of uterial IIf mare than eel and etrusturs. who ate a [hinessum of eyoffers an, the klod ASN NSLL Method: Rtl[YT and Nature of the wtexial in Beth stratum fenestrated. with - •••••••••••-• . at least News entry for each change in Intention. (5) DIMENSIONS: Di.—the .f Bell P theme .. _____ ______ Dtalled 13 ft. Depth of cwyleted Bell !a ft. I partne3Al Plpl TES .......... ...... ....... . .. .. . .I RSE SE San mVd I 0 a! I61 NR1ADt•IION DETAIN: I PlOg1 ttlpei W. H06 vAv6 I fS 132 Maim installed: S Dis. face a1 ft. to BY.! ft. lNp:s CONeHR man NMVp, a nkzR I a] 61 Ncm ollap • Die. I. ft. on ft. SEaY CYY u u • Di.. saw [t. to ft. I !!Gan PUT HOD I b I IP 9I:eDY ESAY FLAY 13e 1 s6 Pecfora[lf a f. ®Oil por I 56 I S! SIZE o[ Perforatio used suns COONvt Oum I Pa I o s:za of Perforations ie. by in. Pie a+* 16L el perfoesticha from ft. to ft. I PDACL D.eYR. EDDRea E.wn sm auvU I n I IS perforations frw ft. to I elra Due. . warn I n I IS perperforationsftw ft. to tN [0. I I I ................. ...........................I I I Screens: TES I I MRnpfarturer'e mm Asa srGT[SE lbdel No. .is. I I Dian. ! .lot size .Oas fca u n !a.! t. to .T t. le t Nt is. a. ---- f f c. to c. I I I _....__......._......_._ ..._.___.- ..I - I I tead, cravat el plat ed 41re of t. I I 1 gravel pl.ced [ion [c. to ft. Surface ae/al: ad Te Nun daPch> 20 ---[c.Nat -I DD I Did my wM in Seel unusable Did o Sczrta containww.Ela Depth 1D TYpa N1 f t.r? pppen of Ser,u ft. - WNud of ..a1Lg .cr.cs ol[ --• ----- -•--fact •• N n o n a 1996 (7) PISS: Mnuf.rturer'nrer'n Nee. .....—SIP- ; I .................. .................................. PT'� /. �{ � a {+.��♦{(/t`r-,,F IHI NATeR LeuHLS; ad-anrfam eleY.tiM -•i ,I�Ai { H •..' ° : - ^�""(y iO above wean Bea 1.1 .. ft. I acacia level 63 ff. Below tw of Bell Dace LO/30/!! Artesian Prea.ure use. per aguex thel: Mt. I Artesian vao— c.—I.led or I I I work at.reInd 1./s0/SS Pmplatad 1./ID/SS ................................vv...................................... • • ... • ....... .. III Naga TFST.: nrae:kwn Sa amount Be. 1ew1 is lowered teI— t eH.L cone CCNH3PgClVN B0.Tlrlg2l aa[ic 1m1. I euetad and/or a ..It ceeponalh y far c Nee a poiry Met an"? o If Yee, by Nnwl structim Of thin Be11 and it. co.p*ahm with all Yield: gal.lain with ft. dtavdwn after M1re. I Washington well conatruction standa[Ve. Noterials used who the infomacion repotted Shove ape '—w to ay me[ knowledge aM belief. Recovery data Tian Water Level Tim Weer Leval Tim Water Leval spore ANOJOI.RIIJ,SMO Fro. leer.on, fire, or t rati I Ilypa or print! jADDRESS ee v Date Of cart Pkilez cot gal/win.. s/ at. dmwtloen otter bra. lSlplSD1 uteelue Na. Spin AN cmc f3 gal/:Bin. e/ .cm set at sf [t. for 1 h[.. AzeuLn flew g.p.m. Ldte I RegisContrtration 'e T..pe[atu[e of water gas a Nhmlcal .v3y... wads? .. I ..gletra[lw No. .1Q......l1 Date 11/DS/PS Printed From Mason County DMS Printed from Mason County DMS Thurston County Environmental Health 412 Ully Rd NE 0 Olyrnpla,WA 98506 360867-2631 x1fllnnorp rnurrre COLIFORM BACTERIA ANALYSIS Dab Sample Collec4d The Semple Canty Collected 0 Oc7d. )1 Ib4 D, You ON /PF.) / [ Div Typo ofWabr System(dixkonlyone boy PMab Nqueehgtl ❑GapA ❑GIagB ❑oft Group A and Group B Sydae-Provba fm III Feobe bsnbry(NFIp . IN - - - - System Name Conted Penorc "C N y`• 1 •,. Day Phma:( , ) L+'GI OI - '; CaYphme: I sEsmwil.:y� EwftW.( ) �7l F' ��ni f'I�rel mmaawgbgs(n�,p�wl SAMPLE INFORMATION Samplle wlbtled by p; Sp,dkincannaaWwwMnurnplenobcbd: 6pedalhe4ucbonsorcomme x TYIM d8ampla(m+tdax*ody one badpi tivwpht46tetl bebw) 1.❑Routine D1.1601en Sample 1.Bepeat Semple(abler unaet,routine) onlonaled:Yea_No---,!(- ❑Nl ukn System Chlaba Reebud:Told_Free_ Chlodmincl:Yes_No-�— O.Raw Water Source Sample ChIcbe Ras mi:Tabl_Foa_ ❑Fec9-anm qM WPpeeeeered Unsatlsfadory rou1ne lab amber. Flamed Yq_No_ _ ___ _ ❑Assessment Wnlbdlp lAR) Unmliehdoryroulbacolleddab: ❑Omer —J_ S 4.❑Sample Collected forbformatbn Only ( Inveeli9ebs_ CantfidwlRadn r Otln_ LAB USE ONLY DRINNING WATER RESULTS LAB USE ONLY ❑UnaaUMactory Tebl Cdklm P nt and CSdwyoneet ❑E,wtipas'nt Ecol Bunt RaPlaummt Sample Required: ❑Sample boo1d(130 hoaa) ❑TRTC ❑ Becladel Density RuuM:Tool CONn NOOM. Ewe NOOW Fatal Colbnn I1DOml Enom000d NOD IN. Me@rod Coda: SM9N3B 0SM92221) D4eaMTma It ' ❑SM92168 ❑EnterokN C)I- ej '. DeteeNPmeANymd: '• CM I Dale 2% y.ms�ew .mbplaMeWq lal Un G19(.