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Home My WebLink AboutWAT2024-00278 - WAT Application WAT MASON COUNTY COMMUNITY DEVELOPMENT Permlt/uslsUnce Centel,Sullding,Planning 415 N 6-Street,Bldg 8,Shelton WA 98584, Shelton:(360)427-9670 ext 400 4- Belfer:(360)2754467 ext 400 4- Elms:(360)4825269 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: Chris Colley & Lonnie Evans Date: Mailing Address: 7426 NE 155th ST Kenmore, WAPhone: Chris 206-940-5672 Parcel Number: 32223-75.00150 98528 Lonnie 206-940-6660 Type of Water System Reason for A�pt�plilicpattiiog ❑ Public/Community Water System (2 or more ❑ Building permit connections) ❑ Division of land: El Individual water source (one connection), #of Parcels? SPL El Well Exising ❑ 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.wam . J:\EH Fusms\Drinking Water Revised 1/25MIR Individual Water Well El Water well report(attached to application). Depth 80 ft. EI Well capacity Test(attached to application) 30 gpm 7 Kd 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. El Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA httpJlgis.co.mason.wa.us/planning 140 150 16=22= Water use or limitation recorded................................... N/AQ YesQ Well Drilled ............................................................... Date 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: 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 RCK I 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: Environ. Health: Date CSD Director: Date 2 of2 tOWATER WELL REPORT NoR�otlntmrdNo. W 163215 o r.'i OnVna &In copy-Ecology.2ad copy-owner,Jrd copy driller�a Unique Ecology Well m Tag No. AGE 709 CorelrudlordDecommissoD("x'in male) 0 Concoction Weer Right Pemut No. O QDecommtssion ORIGINAL CONSTRUCITON Nonce /4 of Intent Number Proper[y0µsier Name Tnnnia Franc PROPOSEDUSE: nj Doonesoc Ofishearml Muomyul WellSMet Address NE 490 Klah[nrva Rd. ❑newaur ❑kngahon ❑Test Well DOthm (yty Tahrygg NA 98 County: Mafarlri 171'PEOFWORK: Owveh number of well(dire dun one) EWM merle ®New Well ORecumbi ned Meshed ❑Dug ❑Bored ❑Driven Location t�a_l/4-1/a f1Fa_U4 Scc�i� Tw R.31d_ us ❑Deepened KICable ❑RouD ❑)dted Last oLngg A bhin/S ec l.af/Inn WWM cacao DIMENSIONS: Dmm or of wi,l] A Wises,dedled RO It O,Lr snlg LA Deg -- L Depsh of completed well�_fl REQUIRED) tong Deg-- Long CONSTRUCTION DETAILS Tax Parcel No. i 23-7 5-001 50 Casing [Welded __6 Dume from T1 ft 0 75 It CONSTRUCTION OR DECOMMISSION PROCEDURE Installed: OLmermstaBed Dum from nto_ft Fosmabm Ducnbe by color,gWmcmr,site of materiel nvdswcime,and We Threaded Dram from k aft, kmd soil name of Ne material ov each slmmm penetrated,wish ar lean one n"for each change of information Indicate all water encountered Perfaradurse [I Yes 0No (USE ADDITIONAL SHEETS IF NECESSARY) Typc of efform.used MATERIAL FROM TD SIZE ofperls_m by_m arid. oflerfr_kom ft a ft Screens:®Yes ❑No ®K-ft, Locance 7.3. Manufacturer's Name k Typedai]... Model No Dram 5 Slot Sou__3G__fmm___75_____ft m fl Silty fine brown and with Diem scot seta ko rt m n some gravel and water 19 58 GraveMlierpacked: ❑Yee IRNo ❑SoreofgmvNxand Mammals placed from ft m k. Cetrented sand & gmyel wi Surface Seal: IR Yer ❑No To what depth 1 R k Materials mil io seal Ratrmi to Did any suamoomes unusable warn+ Dyes f1 No • TypeofwauR Demh of Sams McNod of sWtvg straw on FIRM?: Mumbemrers Name r-1Au Type H P WATERLEVELS: I -swf=elevatimabovemeaysealevel ft Some level 36 It below top of well Dam Arienm pressure_ He persquaremeh Date Anenan water.e controlled by Wm eta WELL TESTS: Dnwdown ss ya afm'lamt wets level is lowered below snot kvel Wss apump ast made�DYes No lryes,bywMm> • yield gal/coo with ft drawdownaner I. I Yield isyrmn with ft dnwdown after bn Yield wiW ft dmwdown after lass Recoverydnm(raneiAenwiemwhenpumpmmee oftwauri i tun mdf wen m,e m comer lowly Tome Wiser Level Time Water Level Time Water Level 1 2�� Bnls,Rat_3D� j/min wiN�_n dmwdownaRer1rsh Wash ,ton t tt Amica[ gal/tam wMsle-Wa1 0 enarl Me It Of LC 10�0 Artesoad Oow a p m Dam Tempcmtme ofwater_Wuachemral atulysu model Oven ON. Stun Dau 1/8/03 Completed Dale 1/10/03 WELL CONSTRUCTION CERTIFICATION: I constructed and/or accept responsibility for construction of this well,and in compliance with all Washington well construction standards.Materials used and the unformanon reported above are trot,Is my best knowledge and belief. q Driller ❑Eginic" ❑Tmnee Name nun) n.,a //g�y)_� Drilling Company flavi a Dri ll my Driller/Engneer/Ccatnee Signalu ,ate � Address 3.19 e+13 Dayis Farm FW. Duller or Trmnee License Ol No. 17nF City,-=,Zip Bfaire Wa 98528 Co a It trainee,llcerued driller's RegisUistratioion NppAVISDI1100A Dare ilea-A3 Sigmture astd 1.ittiase no. Ecology is an Equal Opportunity Employer ECY 050.1-20(Rev almp Thurston County Environmental Health 2000 Lakeridge Dr.SW 6 Olympia,WA 98502 nsuxsroacourrrr 360867-2631 COLIFORM BACTERIA ANALYSIS Dab Samoa w0cu'E Time Sample County xoen 44on Yu"f TYPa MWebr system(dack only ors box) ❑ Private Hau U o ❑GmupA ❑Group B wcsh;C 1fr ,/ Group A and Group B Systems-pro"from Wale,Facllilies Inventory(WFI): ID# _ System Name: comeoperson: ✓" Day Phone: ,b) .(�' CBHPhone:( ) E Eve.Plwne:( ) dowrAnh(Pdnthanua . eMAPa ur grocers) ` 1.. _;'611t2�Z.L� 0 SAMPLE INFORMATION Semple cMkcbd by(na"): bcetlonoraddmeswhem sanpk cdpcted: Special linsWdions arcanmw1w: n TYPO of Sample(Matched only one box M#1 through M4 kaW below( 1.IRRoutlne Distribution Semple ].Repast Sample unreel routine) Chbdrabd:Yes_No ❑Dismt,Mbn System Chlorine Resdual:Tote--Fors_ Chlorinated:Yea_No 7;Raw Water Source Sample Chlorine Residual:Tots_Free ❑E.wli-GWR(AP) r ❑fecal-swn,cra.vsnmvy,,,,,nannl Unalidsclay rouse,let,numb.,. Flamed Yea_No_ ❑Assessment Wnhohn,f P) amegaagpiy routine collect dab: Dove. s 4.❑Semple CMlecled for Mformation only Imrestigalive_ ConeWcdon/Repairs_ other_ LAB USE ONLY DRINKING WATER RESULTS USE ONLY ❑Unsafistactory Total Cahbim present and Satisfactory ❑E.cdipreseM ❑Ectl4 absent o lifgm debcled� Replacement Sample Required: ❑Samgle too rid(>30 hours) ❑TNTC ❑ Bacbdal Density Results:iobl ocsfoms /f00m1. EaW nOmN. Fecal Colibnn NOpnl EntamwcG ngD ml. is d Catl.: SM"'tt 0SM 92220 Daaantlhre Reunad:r , SM 9215E ❑Enbmlwlp - 7t Dale aM nme Ariwyzed �aJI - L4 Dek Samnk Nualy pDHmmO.pYpMt4jbl Lea Ua ..