HomeMy WebLinkAboutWAT Application - 5/20/2024 . . MASON COUNTY WAT
COMMUNPiTDEVELOPMENT xl `J l
Permx MustameC W,rulldr4,PlonniP(
415 N6M Street,Bldg B,Shalton WA 90564, RECEIVED
Shelton:(360)427-9670 ext 400 d aelfair:(360)275-4467 ext 400 O Elma:(360)4625269 e#400
FAX(360)427-7787 JUN 24 2024
Application for Determination of Water Adequacy
6 15 W. Alder Street
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 she plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: O'Dair, at al, Nancy J. Date: 5/20/24
Mailing Address: 9105 Peacock Hill Ave, Gig Harbtphone: 253 592 9583
Parcel Number. 22003-34-00030
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more ❑ Building permit
connections) ❑ Division of land:
O Individual water source(one connection), #of Parcels? SPL
0 Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
O Replacement Remodel lease indicate name
/f you have more than one residence connected of water system applicable—no
to this wet( check the Publir✓Community Water signature/"required �_O�
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: w 1�
Water Facility Inventory(WFI)Number: o32_yy T
/(write"none'for two-party) Y�J1
� 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-ae-the PXt sk konnection.
❑ 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 b state and local regulation.
Signature of Water System Manage 5/20/24
This form may be scanned and available for public view at vnvw.co.mason.wa.us.
f:TH Fomet Ddw n,wPta Re iui Ma011l
Individual Water Well
O Water"it report(attached to application). Depth 124 ft.
EI Well capacity Test(attached to application) 14 gpm 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 http�/Igism.mason.wa.us/planning 14015=16=22=
Water use or limitation recorded................................... N/A_=Yes Q
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)
F Satisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely In fhe future,or guarantee compliance with all applicable W DOE 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.
C Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
( ,, ,�nY 1 'Reviewer's Signatures:
Environ. Health: 1�J9--1' Al V Date
CSD Director: Date ""
WATER
MANAGEMENT
LABORATORIES wc_
S1515 barb.E,T.ce e,WA 98 W
COLIFORM BACTERIA ANALYSIS FORM
Daa Sample Collected Time Sample Cuunly
Collected
I ❑eu
.,n Wy Ya —OPM
Type of Wear Syslem(tllerk ) -
❑GroupA G B ❑Othei____..__
Group AaM Group Systems-RoNdahere Weser Facilities Inventory(WF)'.
IDp
I Syakm Name:
Corned Person:
Day Phone-
Email: Eve.Phone( )
Send reael6 to(Pdnl(call name address and zle coded
SAMPLE INFORMATION
Sample collected by(name)'.
Specific bratan elnere sample collected: Special inslructionsorwmments:
Typeof5mv0l(eeleclonlyam"afserrpkftmrypestthmugh5bebw)
1.❑Routine DleblbWon Sample(AN) 2.❑ Repeal Sample(AIP)
Chbnnaled:Yes No (hum disbibmmn 9yns.®Aer wear.roumm)
UnsaDsfadnry naullne lab number
Chorine Residual:Toad_Free_
3.Ground Water Rule Source Sample
Unsatlefadory mtNm oalleddale:
S I —J—�
Chadnated:Yes_Nc_
❑Trlllgemd(NP) Chloride Residual:Tool Free_
❑Assessment (AR)
<. Surpass w GWA New Source Water Sample(Enumeration)
S
❑E.wa ❑Feal eub,.e r. a
5.❑Sample Colleced fix labonsaw Ony:
LAS USE ONLY DRINIDNG WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total ColAorm Present and tiahona y
❑Ecoli present ❑E.whabsent
Bacterial Density Real Total CdDarm IIDDM. Em'i JIDDmI.
Fecal Colifom I1dDml. HPC Hml.
Replacement Sample Required: ❑TNTC ❑Semple tan,ale
❑ Sample Volume ❑Damaged Container ❑
Demme Remrved': Iab f W apls NenW
/<� �AI
lees 0Temp C': atMhad CaMa
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Date Reported le DQH Ira IIU Wy.
DDH LaaSanplep
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Environmental Health Rn;d Mtstru Amn, rHt hack 1 ,doln • I,agd, eny L._._
vsrEMIDHo 2. cUTAm
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COMMICTION!
LEWJS, . FRANK F. RFLM:': I1Z, l
WJ1FW:4�atH<M'EO. .. .
_ i . .. NVgHER NIXIRESIDENT4L LbNHELT1W15
".' 1aEH-ERILYEMOE"M,NCNAIERIOENTULPOY 1*ioH
•. 9EAVE9 c..E.CH OORTR M.E ENTRY FOR EACH UONT..
EVENWT'ELEPHCNE �
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PaWSE.FORORSRGr PELRFAiIONAL
BUSIHESSIHDUSTRUL.
G^,qA D04£RYI•tiM1^ AGRIWLT!<1At:COMMERLUL A.TOTALNUI•®fR Oi SEffJIGE IS.D�SPo&R,ON HEa._-.'.s
;LOUHt1'.CCnY'R'JD LODGING.FOOD SERVICE TOTKGAPAI'r'"
HATER U_TR•C'. CONNECTgNS METEPEO
__ATE SCHOOL I DAY DARE
--_c _ O HEP(CHURCHES ETCI 'A--
HAMf USYil+40LL01NJf A
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wMfAREA_
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GMNSES SIGNAiWE OF OOX gEVEWEfl
Appendix F-4
Pump Test Data Collection Form
System ID: Owner: Well Tag No.:
DOH Source ID: S stem Name:Howard Cove Well Name:
Type of Test: Conducted B : Jeff Minch Date: 1l5l2021
Static Water Level (m measured from reference point): 18.71 County: Mason
Observation Wells? Well Elevation MSL :
Distance of observation well r from pumped well(ft):
Time(t)since
pumping Depth to Pumping
began Water Drawdown Rate(Q)
Time (min) Level ft U R r= [gpml Comments
9:40 0 18.71 0
9:41 1 19.5 .79 14
42 266 1.95 14
9:43 3 20.87 2.16
9:44 4 21.30 2.59
9:45 5 21.61 2.9
9:46 6 21.75 3.04
9:47 7 22 3.93
9:48 8 22.35 3.65
9:49 9 22.50 3.79
9150 10 22.75 4.04
955 15 23 4.29
10:00 20 23 4.29
10:15 35 23 4.29
10:20 40 23 4.29
10:30 50 23 4.29
10:45 65 23 4.29
11:00 80 23 4.29
1130 110 23 4.29
11:45 125 23 4.29
12:00 140 23 4.29
12:30 770 23 4.29
100 200 23 4.29
1:30 230 23 4.29
1:55 235 23 4.29 Shut off pump
1:56 236 21.12
1:57 237 20.2
1:58 238 1975.
1:59 239 19.5
2:00 240 19.40
2:10 250 19.02
2:45 255 18.60
Group B Water System Design Guidelines(DOH 331-467) Page 96
September 2018