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Home My WebLink AboutWAT2024-00281 - WAT Application - 6/4/2024 WAT MASON COUNTY RECEIVED 415 N.0 Street Shelton,WA 98594 COMMUNITY SERVICES Shelton:360-427-9670,Ext 400 JUL 19 2024 Belfav:360-275-4467,Ext.400 a,aaayP�i� rev, —.1 H.Ift wm1We Elm:360482-5269,Ext.400 - 615 W. Alder Street fRiOWRANUENAWnination of Water Adequacy Instructions HEALTH 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: 4iW'1/1V (4/C Xy'1Zzlwt Date: 6-Y-9�Z,/ Mailing Address: 83 /2uff£GG r?cf. 0.41r✓i 11G Phone: 316 117u -9'3 c b Parcel Number: 6200 7UV 0 o u u o Type of Water System Reason for Ap�p'1lric'l�a,tio)n� aa��rr ^ ❑ Public/Community Water System (2 or more �Building pemlit bL-V W-�2`{-00Bbll,l connections) ❑ Division of land: B' Individual water source (one connection), #of Parcels? SPL gr 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 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.co.mason.wa.us. 1:tEH Forms\Drinking Water Revised 4/4 018 Individual Water Well Mr/Water well report(attached to application). Depth 30 ft. @/ W/ ell capacity Test(attached to application) 190 apm 7 4 0 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 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�t/gis.co.mason.wa.us/planninti 14_15_16_22_ Water use or limitation recorded................................... N/A_Yes_ 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 Dale Relationship to Applicant Part 3: Mason County Community Services Evaluation staff use on/ Satisfactory Determination: This deteminadon does not address adequacy of the distribution system,guarantee an adequate supply of water indefinitely in the future,or guarantee mmpliance with all applicable WDOE water resource regulations. Recommended approval indicates requirements of Sanitary Code,Ttie 6,Chapter 6.68.D40-Determination 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). Reviewer's Signatures: 1 , Environ. Health: ` Date This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 rue OripnalaM rltr Cnmwah V✓C!/�`"� wtVWt<�m.+. ..._... nrp.nm.nt al Drpwo WATER WELL REPORT 'Tamed rnor°°�un�Dtatfi1,Zlpy STATE OF WAZIfGTON FrbN Ne. .. (1) OWNER (2) LOCATION OF WELL: y' sea I end tlmtanca !Tara radon or aubdl<alon corner ! 10 WELL LOG: (3) PROPOSED USE: nomwc YJ bay.vl.l ❑ Ntmmlp.l❑ ( ) lmiaatloo ❑ Teat well ❑ Other ❑ rormatba:Dreslaa aeV/mb<,enaoonr eW o1 rnate<1o1 sad rtrvamn.aM i °Cr�Y.w°Mepn<taid�re(tn attleosee fAs �/or..hoewe1°0to/°�/ammb. (4) TYPE OF WORE:: t°it v°<or.ia:nnnr 0.R°__. Ne...0 M detnod: Dag ❑ HOM O Gbis V Drl.0 a 9O1 Deepened ❑ -' r a`m°'"t"ppeQ° N`m°i° resod ❑ ravel 3 uauer � (5) DIMENSIONS: Diamatm of wall ...... meet. Tama&...._ Q...........Jl. Goole ad awapblast well--N R C (6) CONSTRUCTION DETAILS Casing installed:__b......:• Dram. nuoo 11.-- X.as _1fl h rwba.d❑ .._......... nab.tram _..._— h b_r.h welsea y =• users. . Aldpr Perforations: Ym❑_--No B Type a! °erto<ebr we1..__..._.....___.__.�__--- --- 81rZ of parbraaeu __...____..___.. is,2, parinratwo, horn ...____.—.. perlorsdom hors ____..._._X.as h g ..—_....-.___ "oese ohms fears 0 Screens: Yee❑ No LA ManYleelV[aia Nana mom No--- = OWn. ....___.. skd Yb X.to Dlrea _..._._.- a r,alw emm >1 Gravel packed: Yea❑ wag 6 Gravel plattd :1 L7Vtt 0 Surface seal: Yea ? No p To gran deptm —IL— -- iMaterial used I.aw_........89a.toni.c0.___ Dtd avy strata eontaae amaaaNa wal s? Yr O No[1t afrtaod Massing unison------ — y (7) PUMP: Manwaaemar. w (4) WATER LEVELS: �"e<"em.o d w. osoo. level 1 z..._.._.._..._...._x.nabw ay al wW Dab_. RO artertaa preaere a .._._._ . _Jan aer aenaes bM arterial, webe to emballad by-..------l;+_p.valve.Z.1•_— (S) WELL TESTS: lowao,rel mina, 1.1 twel r W rk aurted_.1111.i Gi: ceeaeiteia-1.111A- Was a pomp tM mast[ Yes❑ NO 10 N 1s,ny wMmf_ .._.._. Yt.W en.loom. with X. dr o elawn slat nn. WELL DRILLERS STATEMENT: This well was drilled under my jurisdiction and this report is .'� true W the best of my knowledge and belief. Raeovan aw !time bean r sera when pump Ur,ad asl (.Nr Meal - .. . Tana Wal., -.11 Tlm. waM Iwael Ten._ woo.r,ba ..._—.F.,�p ,'` --_Ca..._.Ln.c.........- meawrtd Isom wall by b wear looetl an .r WepsraNml (Tyas r Wart) .......------ - "---- ..__.. .... . .. _.._._._..._ 1� _......__.._.-. ..- ._... ......___....- .._---- ---- _... .._._._. . --._....---._...................... dramwn.ttr __.tea.. (wall nafu.n aArtesianapw.—_�.._..------wm. nab.._.._.__--- 1077 ..Data_[0 6._._ A 0 'rbspenatre use wabe—.__._Wu•MaW W awyW meat rr❑ Nx0 Idteaee D_.._._..___.--.-. (Dar ADDDicla L sritiel'a D'NLCE.ad%Y) —a EC,arOt-re Thurston County Environmental Health RECEIVED 412 Lilly Rd NE•Olympia,WA 98506 =T 360867-2631 JUL 18 2024 COLIFORM BACTERIA ANALYSIS Dam Sm"Qkdbia Tare Sar9M County 15 W. Alder Street comma 7111112�I lgSOn Type of Wamr Symm(tlmkonpane bm) � ENVIRONMENTAL ❑GwA ❑Gwpa Group Anna Group R Symn.-pawtleman Wffir Failime ln.r"(WFO: kllral HEALTH O5 sym;o Name: — — — — CaMact Peron: Dry Phwa:( > Call Phone: ) Eaney. Eve.Phpre:( ) S^enOmJb .pMnM wne.a-tldt®aMl_m_aevma I Ar%OrAQ Anal el ecTvnfyahcr�.Cam SAMPLE INFORMATION Sampb comcleb by(,"). _ 4 Ck Specific lmzdon oraddrem when ae p cob : sepal' pymaa(ramanm: 2.z3�r,ykeny {2d Ilddtiss Ig lmn wer 5 1Am45W Co. Typo of Semple(mua cM1eU only one boa algt through W mbtl bebw) 1.I911RoWne 0lebibuuon Sample 2.RWW SampN(abruo.t roudee) c nnAd:Yes_1 ❑O6bDulbn Symm hlm'ae R.Uuol:Tab._Foe_ ChbiFaled:Yp—No_ a.RawWaterSoumlboVN Chorine RaNautl:Total_Foe_ ❑E cpN-am pvo) ❑Feel-awu,GwM1 n+^T4.�aum1 Unee6dwory mNne ltl numb . fYlutl:Yn uo_ ❑AmralaMMonibnnp(API UirevENecbry nwma mlleGaeb: — . ❑Other ___/J S J a.❑&mp4 Calmcmd mrlMamalbn Only lnwypaSx— OomWGanyRepain—LAB r— LAB USE ONLY ORINNING WATER RESULTS LAB USE ONLY ❑UuuWmmryTowl CulSmmpmnMaul Satlahmry ❑EwSVmnnt ❑Eoayebeenl o Imrmdemclaa RaPmcemem SampMRp lW: 0Samp1eWoUP00hounl ❑TNTC ❑ Bemnel Gensly Reum:TOW CRISom�—I1rom1 Ew6 ItOdnl. Fe CdHolm It00W EnMomcd /f00 m1. MSIWCade: B22S8 ❑SMVMD yu rrod . ❑SM 5215E gEraerom45 7 1-77411 Maad TYna Ne6ztl: 5- hm Rapwwd — eemaanewlppllrwtrµsaw 1 IMlaa QiF 0 B 0 C'k 8555 �2 - �-