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HomeMy WebLinkAboutWEL2018-00030 - WEL Application, Design, Letter - 7/12/2018 MASON COUNTY 88 �UL 1 2 2018 u) COMMUNITY SERVICES aui6gPlwmie.FrrvimmemelNnitlyromnebNull6 __�'�� 415 N e SBeel,Bldg 8,Sl Itni WA 98584, Srefton(360)427-9670 eA 400 ^ Repair(360)215i467 eat 400 4 ENna:(3W)482-5266 eld 4W - F"(360)427-A81 Application for Review of a Two Party-Water System Permit Number Payment Information Instructions WEL Receipt Number 1. Complete Part 1. Incomplete applications will be reactedQjc- ❑ Cash ❑ Check 2. Make sure all required documents have been submitted (well log,water sample and recorded Eck)50 Date of Payment documents). 3. Submit application and the fee(Mason County Environmental Health Fee Schedule)to Mason County Public Health. PART 1:Applicant/Parcel I dentification Water System Name R09I nSQYI QoO-�-!'1 w.12/� Site Address (-6'-Sa 9gs.� Applicantjn& Phone 310 8 -o -L►3ci'O Mailing Address s4c•S." E 5 �[�� I�ort+P Z t�-7- City _effg 'f- State _{j_ ZIP 9 SSa� Parcel Number r ^�v't fS 'K ✓< A J o O�— Directions to Site 191y �- n Sa rxYrl, Crl't N °z 3/d � F !ii !ar pro nem and C1c�6N� '4 Akre PART 2:Health Department Review(Starr use Only) YES NO NA ❑ Water Well Report with adequate pump test on file? // y� If NO,date of capacity test -q - ( Drillegpu1 WQK/h.e/,n�GPM ❑ ❑ Received Satisfactory Bacteriological Analysis? Date of test ❑ ❑ ❑ Received Signed, Notarized,and Recorded Agreement or Notice? ❑ ❑ ❑ System appears adequate to serve two single-family residences on information provided. ❑ System Approved ❑ System Denied Comments Sanitarian signature Date This form may be scanned and available for public view on the Mason County Web site. (110)1711141 4 COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample Co0ected CourAy NW epra DYP�M ThAjD I'A Type of Water System(check only one bar) ❑Group A ❑Group B Q'Omer Group A and Grppp B%items-Provide from Weser Faciftes InvMmory(WR): Of _ SysumName: ORrr /Lo r/jB�s Gontam Person: Cosa wA;,VA ICL4Srr T Day Phone:( I Cell Phalle:(j!o )$]o- Eve.Phone: Fail 1 Email AdtlrossGact,4+MFrtdyLtu-F.`� p//0TrrA1r_ , a„ II Semtwftsand InVOIMh:(Pdntfdlmmo,Wd uaMaipcoos) CORLWAKA! 6A5L&Arrf /of It. j Awy A� /SI[lc+J6.t9roy wh gY3Tt SAMPLE INFORMATION Sample deducted by(namel: BAt— 7-ito77£ Spxmc locuun where sampu conerned SpetlallnobuLMsorconnume, D/Sll N S f RT 3o L Type M SamPhpMctdeekonty me Mentdt MmughA Initial below) 1.❑ Roullme Distribution Sample 2.Repeat Semple)AIP) Chlorinated:Yos_Na_ (tram dimbov.symem aenr unxtmugne) Unsatisfactory routine lab number: Chlorine Residual:Total - -Free-S.Ground Water Rule Source Sample UnWIWGpy routine collect doh: ¢ l Chlor med:Ya_Nu_ ❑Triggered(Alp) ChNM1M RNNmETgMI_Red_ ❑Assessmem(A/P) A.❑ Sudau MGM Rau Sw WWrSayla(Dx ratlm) I c I I I ❑EWH ❑Fecal Rased Yes—No 5.15�Sampls Collected for InWMAN OMy IMnpmVe CeneWIftr1luplR_ Pemde Rroolln. LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Colitorm Present and ys,Sallahclory ❑E.doll present ❑E.coli absent S Replacement Semple RequestedlFlapped: ❑Sample too rid(>30 hours) ❑TNTC ❑ BacNdel DensRy Results:Total Coliform /100ml. EMdF_1IOw Fecal Coliform_A00ml. HPC M col. 0` a /iye4 tab Rde MIt b ' In 5a r M sade AT9223B 0aNm e0 Incubffiur Reesepd Temp((Ne."W doll taRSampu/ RemaA3: . 010- �Q/ _ otw ammMlanpswee setae arve oa rt"'w 91w am- oeel.su o cos-ow1111 COOLWATER DRILLING, INC. 10921 HOLLY RD NW BREMERTON, WA 98312 360-830-9005 COOLWDI941QM CUSTOMER NAME DATE 6-4-18 DAN ROVINSONS CUSTOMER ADDRESS 4552 E ST RT 302 TOME STATIC GPM TUNE STATIC GPM 25 05 26 15 120 10 27 15 135 15 28 15 150 STABLIZED 15 20 28 15 165 25 STABLIZED 15 ISO 30 205 45 220 60 235 75 90 105 RECOVERY STATIC RECOVERY STATIC TIME 28 TIME 05 26 30 10 25 45 15 60 20 75 25 m To: 1�302 8 NOTICE TO FUTURE PROPERTY OWNERS OF PRIVATE TWO-PARTY WATER SYSTEM I(We)the undersigned.certify that the water source located on parcel situated in Mason County,State of Washington,herein described. OR Subdivision Division Lot Range Township Section And having the Tax Parcel Number of.L.3a-Z8-5-5--Dio n.2 Has been designated to serve a source of water to the following parcels situated in Mason County,State of Washington;herein described: (abbreviated legal description and tax parcel numbem(s)of property(iss)affected) OR 12E) _'-)a Subdivision Division Lot I VRe nM Township Section And having the Tax Parcel Number of.11�z1�}-sr2�-Q_ O _oL OR Subdivision Division Lot Range Township Section And having the Tax Parcel Number of._____-__-__—__ The system owner is res"a for keeping this system in compliance. \ p The name ofthe system is t pb This system is designed to provide for two serviceeing and design approvals must be obtained from the department prior to expanding beyond this number of services.Additionally,a water right, obtained from the Department of Ecology,is required if the water system exceeds exemption standards. This system(has/has not)been granted one or more waivers from specific provisions of the regulations. Signature Signature State of Washington ) County of Mason ) _ I,the undersigned,a Notary Public in and for the above named County and State,do hereby certify that on this day of - 20_, personally appeared before ;;;-,who is known to be signer of the above instrument,and acknowledged that he(she)(they)signed It. GrVEN undermy hand and official seal the day and year last above written. Notary Public in and for the State of Washington residing at My commission excess: Please=0111I,sign and return to the Department of Ecol 11 Water Well Report ticant N 1%hW31C odeo t In[nm No. O�ylml-Fmba,.,1•myy-mmr,T^c copy-tlNltl pTP3`t 1'Fi[•d't 4 Unique Ecology Well ID Tag No. Cau#ruc&¢n/Demmmissian QCmstruction Water Right Permit No.FXEe6Pf tYcll Dewmmissim OFJGRRL R&. 4ILATI0NNpo- property Owner None DARK IE E Oflmer¢Nitnlber Well Street Address PiCMIKGBOAD PRMSEO us: pncwnr ql) O ❑ mnwl CInumy dSoEnM dI/q4 County MSON kpee lnwa Zm'R_'Tm -wN mk TYFCOF\ : uwr'rrouecervNdes ®tasc.adi O Rumeamr>t Iarm4 U W6 ❑ems Hoe L9/Lmg(s,L i La Deg_ Lx Min/Bm �Demmm ❑oa , mrnms DrxEnslons:rnmmceraNJy�_mmm.¢MIe1x'¢ AHIMUMED ) LmgDeg_Long Mbrlec_ D�hctmmdrd w3 tm ¢ Tes PmcelND. :3d095NWV26 CDN6TRURIDN OErA1L¢ free ©weee Dim r�+�_¢aYL--n coN6TttocnorvoRnRcoaamss[orvPRocRDI!xE Dim Rm Rb R Fomsm. Dmrb MmtC rlmem.r¢eofmN¢Im[Icnxeeorv.b[¢dtlr1.5^Leor rMoradom: Y. 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