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Home My WebLink AboutWAT Application MASON COUNTY COMMUNITY DEVELOPMENT P efusl#arc r.. ,,9NIEInr.Plamft 415 N 61°Street,Bldg 8,Shelton WA 98584, Shelton: (360)427-9670 ext 400 4• Belfair (360)27SA487 ext 400 P Elms: (360)482-6269 ext 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: Dan Williams Date: Mailing Address: 121M SE 2g4m Sven,Auburn WA 99092 Phone: 206-713-0984 Parcel Number. 122294400020 Type of Water System Reason four�Appplication ❑ Public/Community Water System (2 or more O Building permit Bi-DPt3-01503 connections) ❑ Division of land: El Individual water source(one connection), #of Parcels? SPL l 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 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 on this system (i.e.: recreational to full lime). 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.wam 11EB Forms\Dni ng W&W Revises IM=8 Individual Water Well El Water well report(attached to application). Depth Sg k. El Well capacity Test(attached to application) gpm gpd. Tyler Pump& Drilling Co.Allyn, WA 8-9-1975 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 rapacity test, which provides stabilization of draw-down and recovery data, must be performed by a licensed contractor. El Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://pis.m.mason.wa.us/olannina 14E::]1501fi022=] Water use or limitation recorded................................... N/AQ Yeses Well Drilled ............................................................... Date 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 only) fl 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: Environ. Health: / tom ' 'fg Date CSD Director: Date 2.f2 Thurston County Environmental Health 2000 Lakeridge Dr.SW O Olympia,WA 98502 360$67-2631 - 'INuas-mN cowry COLIFORM BACTERIA ANALYSIS Dab Sample Colleaeo Time Sampte:, Coutty Colle w Type of Water Statem(uhd only one box) .11 PMeb Household ' 0GroupA ❑Group B f. 1300*( Group A and Gmip 8 Sye ems-Proviie from Water FaGlit as MaanWy(WFI): ID# System Nare:— — — CunteutPeson: _IJI`y:/ �/A {f `> 'Day Phana:(,7:i.1..).7 �. .�5'S"-f Cell Phore:(3?q +� Emel:O/,V�tiLW it/n-f G:we7.j•,, ,Hre.Pham:(nc�.)7/ •�5 Sutdtwuar ex(fiwY�n,m� �aO/troatlxlDwasamWamra) . �r•„v' ate— �(in na 3 - , 2tat - SAMPLE INFORMATION +Sample vatlected by(nacre} .. '. Speck location oraMrew xere semplecolecbE: Speoalinabustionsormmente 152rf` 7 /t h� 3?! T eot 9ampls(muel clmdcontyom boxof Ml Mtagh#4kledbNow) i. oulire Olemlbutlon Sample 2.Repeal Samphletter unit routine) Chbrinaled:Yea_No_ ❑DiWMw System Chlorine Residual:Tolat _Free Chlodnahad:Yes_No 3.Raw Water Source Sample Chlorine ResHoal:Total_Free_ ❑E wg-GWR(AF ❑Feoef-S.W.Gan.aTMmlan ,) (Jnealtsfe"rouble teb rettbm: Fexed:Ya_No_ � ' ❑Assessment MonibMg(A/P). Unwtlahaoryrou6mwleadeb: podw S 4.0 Sample Collected to,In"nallon Only lowsfigabw— Conebuctionl Repdm_ Olwr_ LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Umtifactay Total Wellman Prewnt and ry ❑E.mNprewnt ❑E.coh'abeam Colleme debcNd Replacement Sample Requited: . ❑SamplebooH(13111,oum) ❑TNTC 0 Bacedal Density Result:Total CQflofm HM, E.uW /10pc. Fecal Conlon It0Dml Entmcaa"i NOO W. Mam:aJQDdo:VI,SM92Z3B ❑SM9222D aDaaaro Taroaauime: ❑SM9215E En**rg 1-[7-2'5 (1I5 Dn.nd Ttineaaar+aa'. '+ 13. 2 taaa 1 Z Svawtxuwetlocuaamergaewsyaq WtNe Otap romsvlafl lmaeaotnR •yrU�a� F .0 i,�Copy with WATER WELL REPORT MWM3 Cop copy STATE OF WASHMGTON permit No. (1) OWNEIL Adgm,w_-P_G_--aax (2) LOCATION OF WELL, t7ason ------- ........... n.e% s I, ,o 2 9 T22N,R Seuln, and dJmmm hom sedloo or subdiviWan comer (3) PROPOSED USE: Dmnwal. R IWdwAzU1 0 M—Idpal 0 (10) WELL LAM: I,,adom 0 rwi Well 0 Odbw, 0 Vnoaflcm:Deere color.dch Cto��a)material M-.4 dhow thbknea 1. fg.. 'Zo. z 11== . Z9 (4) TYPE OF WORK-' —zwr•s number of WWI MnO000 moobWgd� man at leas000 �M jo,ewh some 0 �1tion. mom uum FROM TO New WWI Ig Method: Dog 0 Q Deepened 13 C.ble P9 Doll. 0 Inp Soil I E mlftlmmd 0 R-W,0 JWUd 13 rLwy eallylufflurate 1 Z4 (5) DIMENSIONS: Djanotm of WWI M...Hy Sands DHIIWI, U_ - ft, Depth of mMPIam WWI z3and Men (6) CONSTRUCTION DETAILS: Casing installed: ...E, .-- riono. from _12-- a. w--61L m ThrWwwi[) .. 11-2.Dien,had, ft.to ft, WWded C9 !-blab.Imn, M.to R. Perforations: ym 0 No 0 Type 0 cermmwr Sco' of "W', ...one N. b, mforadom fromfL to ft. A pmf—LI.from -*—,--a" ---ft, pmimd.from to dp Screens: Y.Ig No 0 'doodn'" es S—e _1911M%0D.......... bto6d No-- vuoo. sio, bow, ft to ft —M a lot Wowfromtd...........Gravel packed: Y.o No w 91Y a vW,,: 0'.1 pheod from ft.W Surface seal: Y. R No 0 To what ch,dhl a fadunw onod in Wedi...Boatani.ta Did Wo, M—ft c mbdn omm ble Imb,0 Y.0 MA3 Type a watm?. Depth 02 MMIWd W!YamH fflOft a------ '11 PUMP: 1K&mdWAm'a (8) WATER LEVELS: 1,md-W m lw_lo. .�.. :. I.1... iMaH. level below top of well DMM�— "ma,m IoWdum per wImoe Web AftoW. w.mr Is omoomIled mdm 75___o,_(9) WELL TESTS: lowD �d below rNotio IIwd Wk Ww a pump bon model Yes 0 No M If w.by 11.1d, 'a./oom.with n.d—wdown h.. WELL DRILLMS STATEMENT@. This well was drilled under n,y jurisdiction and flois report is "d to the beg of my knowledge and belief. Mod'"' WwdW` W" (W� bwe=Vodl) Co.___Inc_....__._....... �I V. wan renI wono,�f NAME...Jf�� or""nQ Time Waln 0; or i ................. ............. ........................... ... ... ..................... P.O. Box 3 Allyn, Wash. ....... . . . .... .................. Add,.- .* .................... IE - ------ (Signed]........... 8� bn (WM Coale!) . ................. w.•.adodwi ambda eb~va o NO [i U.nse No........_._0 ..............Date....._ ................ 1911 (USE ADDMONAL SHEM M NEC831JRV) UN.4PG.n