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HomeMy WebLinkAboutWAT2024-00270 - WAT Application - 6/2/2024 WAT f N` �--La-e.w-L0 MASON COUNTYCEIVED Sh W e 94 Shelton:360427-9670,En 4W Public Health & Human Servicelk -3 2024 Eelfan 360-275-4467,En 400 5 W. Alder Street �WRONMENTAL Application for Determination of Water Ade HEALTH Instructions f: Complete.Part 1. No determination can be made untl6 Pant is fully completed. 2. Complete only the portion of Pan 2 applying to the type of water connection utilized. 3. Submit completed.application with any required attachments for review. 4. An roved building site an must a,Z' n this application. Part 1: Applicant/ Parcel Identification Name of Applicant: Leonard Anderson Date: 06/2r2024 _ Mailing Address: 616 W Broadway Montesano We 96563 Phone: 360-5913-2120 Parcel Number: Type of Water System Reason for Application ❑ Public/Community Water System(2 or more 19 Building permit owz q connections) ❑ Division of land: ® Individual water source (one connection), #of Parcels? SPL 91 Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) ❑ Other(explain) ❑ Replacement or Remodel (please indicate name If you have more than one rasktenoe connected of water system below if applicable—no to this well, check the PubliclCommunity 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) ❑ I am the manager of this water system.The water system has been approved for_services. There are presently wrinection(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). Pleese 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. Print Name of Water System Manager Phone Signature of Water System Manager Date This form may be scanned and available for public view at www masoncountvwaaov 1:\En Fans\AinkiN Water Rcis 05/08/2024 Pap 1of2 Group B Water Systems 77� Satisfactory bacteriological test within last year(attach to application). 6/Z ZrlW tc-6 1 Individual Water Well IN Water well report(attached to application). Depth 100 ft. op11,�jj�,m Well capacity Test(attached to application) 20 gpm 10W apd. The well driller often performs well rapacity 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 lest, a well capacity test,which provides stabilization of draw-down and recovery data, must be performed by a licensed contractor. c M Satisfactory bacteriological test within last year(attach to application). 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 asupply of water indefinitely in the future,or guarantee compliance with all applicable WDOE water ms6'uP6e Agulations. 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: 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 This form may be scanned and available for public view at www.masonoauntvwa.aov Page 2 or 2 RECEIVED �L�o2oa �297 ENVIRONMENTAL JUL -3 20A HEALTH 41ATWmAbderNS#®®*w No. WE44492 WATER WELL REPORT --• ECOLOGY un;gm emlagy Wall oragNo, Erds99e lyPn aWwk: .—of wasNngton Sile Well Name(ifmwethaatmllll): _. I7 Comm - ❑ n.<pmmiviw d oigmmimWk..WIN k. Weter Right ParmilMenifKwe Na Peapwed uan roDemmac ❑I:d:unul ❑Munkipsl Propnty Omer Name Leonard Mdemn ❑Oewwrioe ❑Irrynio: ❑Tw IV<g Ogaer Wall Strew Addems8lWBenNen Rtl Cownmdon Tlw: Watnade City Ektm County Meavn O New wall ❑Almrmion oWn o ❑hmd hkbRo Tu Pmel No8193Ui3WWI m O 9omma ❑oa IR.emkma lnkmwnofw6ns 8 a..n 100 e. Wesa vmiance ammvtd fbr thin xell? ❑Yaa (]No pewM1ofcwipkw.ifi 100 fl lfye;xfiasxss the vatinme toff Cmunnegnn"Bia: waa ".inn lino Dkn:mef Fmm To TNnlmia Swl PYCWdaea'Rawd [9WWMor0E\VM ® ❑ a in. o Jg_ an In ❑ 1 ❑ 0 1 ❑ Lacelian(seeimtruwiwwm page 2): ❑ I ❑ __a in. ❑ I ❑ ❑ 1 ❑ SW IA-Kofthe SE Y°:Saa m W Twmahip 19N Range OW ❑ ❑ __in _ n ❑ ❑ ❑ I ❑ lalitude(Emmpld 47.12145) 47.09748 ❑ I O n — 1.onghade(blmmple:-12D.12345)-123.47870 Perfwnbm: MYw Oft Typeofpenfmmmun<d Nr Porwalmd Or{Iler'p LogR'oaslrKlion or Retpmwkdov Prmtduw No.ofpeAa+dmf 4Q_. Simofperfo:Miam .25 by 1,25 in Foinmm�:l%mrihe nY cnb.cha:xrtt.sire o(mMe:iY Wwucnm,walhe 4iva eM ywg, aamm,1♦g &.24 R.hekwmanasmfea nwaFlh<minislwexh by<rpnenek4 wilhv ken one wiry fuexa cMnae of ❑KAcY<r b Fkpa:_R iK wkn Un dliliomth i(rccessary &reem: ❑Yn ®No M at firialal From To alm:uknmeh Name maM Nm 0. 9 Typ< Brown file to rnatlllnn a revel. D:waw_ Sla t�e_kwm _Rw_R. Mulgevlored meMssm tie nation 9ravdl. 9 m.mew_. sw me_mawn _n.w._fl ( hl.d 18 $n.dlRdbrpmF.❑Yn WHO Siwofpmkmnami—w. &a5vn medium In cont9a renal 18 nlwariw.ale fiflm--R. wasa,VPoler u m_� smsms.l: 24 100 MY., IN, Tewaa aaplm 18 fl Gra sarMslane motlerMv,tl hkeedduxdknal BenbMl CARD! ON m:yawacovminwuseMcwmell ❑Yes flN Tmofwmcn py0ofm:m McRwdofum�mnb oft Pump:hlwok<lurcr'S Nape TYW: MP__ Pumpimekedeplh:_fl. nnireeaG wmkr_lWn Nnnlenla: Wd+m4eeelem�bn abpsro mew meleapl�fl Srihupofwpofw<II miry_R.same am:N smkw SnR<wnrksrol a5 e.bebwwpotwA miw Deb 11I19121 An<tiwproseme_Iln.purmp:neloch MIC��. Amnknwmnisaww11ad 6y Pan Nw.m') Wtll Tnn: WneP:wpio8lm pnkmual ll No ❑Yn b aywbum7 - YkM_Nm wiw_fl.d,awdown.Rer_Iw. Yield_%pm-ah_fl.dnndawna6m�hn. Ykla__apm won_n.anwenwn.Mr_hn umm dw Pima=uro•aae�pump is rvmN oR-wm kwl rowed Rom wen mplowmrk o 15me Wwrl<wl T won E—d Time W.w L.H nab ofpor,pi:pnu — asik<bm_pPmwan_fl-40ft n Airmm 20 gpn:mm wmwu/O .b1 hn. pb 11119121 Awaiw Pow__Ppm T<mpamrvm ofwmer_°F Wn.aaeminl.relni.mWe? ❑Yw ©No Swn Dak ll/19121 Canplekd Ome 11/192t.. \YELL C,NSrRUCf10X CERTIFICATION: 1cmstmcwd"a,amepl rmawnibilitY M blief fw mmwetimot 1l,eb iN mmpliam wethdl WvsalslgWn xs0 comhlmim AaMardt'Meletiah used nail the inJ,mmim wpoded above urc 1.to my best kamiAgc alieF .. .__n_.....a V dia Drlftg lac ❑. Dtilla❑Twitxc❑1'E-Print a er PaNhlan Mdress PO eoz 1790 Me City,Sam Zip ShwWn,WA 9g884 Licmw Ny.2883 Cant tor'a IF TRAINEES sw'e Licctlae Na. Re 'slntim No.ARCADO1098R1 Dek 11/19121 S 's Si Spectra Labs - Kitsap,LLC (Poulsbo) J SPECTRA Laboratories -Kitsap 26276 Twelve Trees Ln NW Ste.C Poulsbo,WA 98370 S I V E D Phone: (360)779-5141 ENVIRp www.spectra-lab.com NMENTAL JUL -3 2o2a �jl.►�p'tdMI OO7R� HEALTH V. Alder Street Spectra Labs- Mtsap,LLC(Poulsbo)received samples for Leonard Anderson on Friday,June 21,2024 at 2:45 pm. Unless otherwise noted,all samples were received in good condition and were tested in accordance with the laboratory's quality control procedures. A summary of the samples received are outlined below. Sample No. Description Location Sampled 241130-0I Leonard Anderson Well Head BMS099 0621/201A 12:15 241130-02 Leonard Anderson BMS099 06/212021 12:15 This report package contains laboratory sample results and any attachments listed below. If you have any questions please call(360)779-5141 or email us at www.spectra-lab.com. Attachments 01) COCCopies 02) Bacteria Result This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at 360-443-7945 and destroy this report promptly. Tbese results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced except in full,without prior express written approval by Spectra Laboratories. 06/272024 Page t of I 2627 e Trees Ln NW Site.C Poulsllso,bo,WA 98370 JSPECTRA (360)779-5141 Laboratories - Kitsap ...Where experience matters IOC TEST PANEL Complete or Selected Inorganics SystemID No: SyMw C'r°°P�4'Pe' Rivme Semple Number. 010-13002 System Nm: Leonard Anderson Sample Loca0oD: BMS099 Cowry: Masan Sampler: Source Number(s): Sampler Phoce No: Sample Purpose: Older Hate Collected: 062MM 12:15 Semple Compost¢on: Date Received: 6 V202414A5 Sample Type: UnDealtd:DW Uate Reposed: 627207A Send Report to: Bill to: Leonard Anderson Leonard Anderson 616 W Broadway 616 W Broadway Montesano.WA 99563 Monceano,WA 98563 DOH# AnaF/Y ReM#n Wd. Urlia SDRL POL Trigger MCL EMxcead MetlgO An A olli DO 0020 NAai ND — mryi 0.5 _I 0.0330�5 10 EPA300.0 NV 0821Q410:5T NDT •crnflemman Include the aipnal lab number,ample number.and refection date of original win*in eater lab or sampler comments section. SDRL (Shale Defacers Retching Limm The minimum reformable detection of an aayle as establishetl by the department.Trigger Level DOH drinking water response level.Systems with mmpands detaemed at mncentraions in excess at this awl may heretrainee to take additional samples or manden nine hequemN.Please arrant your WH dnnkiN water regional office far Wither informaten. MCL: (Maximum Comaminant Level)it the anromeant amount exceeds tlseMCL,plea wntact your real DOH office to determine follow-up actions. NA: (Not Mafymd(In me re,ob oe mn,mass.or.remp .M was at included in Me artentanalysis. ND: (Not fathom)in to reaps resume,indicates flu compeoM was am"and at deraded at a level greater Nan or equal M the SDRL. <(0.0ax): The mmprund was nudehded in Me ample at or stave the whoutration iWea hhaally the this hatred reporting limit). mgA-: milligrams per liter or pains per mNkn. NTU: nephefomeaic hatealy uers(a maare of water daily). pmhoskm: Mirm ohms per renumber(a meagre of the ability of sec wafer to whether Mae"),one mine ohm per mormeter¢aurvaknt to one mom shemen per ohmmeter(uSmn). No existing iryger or MCL value. 1: Sewndary MCL(Established for eesMesc purposes,at hesllh based). Page 1 of 241130-02 PoWs Twelve Trees La NW Ste.C Poulsbo,WA98370 SPECTRA Laboratories - Kitsap (360)779-5141 ...Where experience matters Final Page of Report Lob Quaft, Comm rose This report is issued wkly for the use of the person or company w whom it is addressed.Any use,eopyin6 or disclosure other than by the intended recipient is uarruthoriaed.If ymav w have ,this repot m error,please edify the sender immediately at 360-443-7045 and destroy this report promptly. These malts relate only to the items tested and the sample(s)as txeived by the labooay. This report shall not be reproduced except in fall,witheat prior express written approval by Stec=laboawdes. a� Approved By Jason Patrick Laboratory Manager Page 2 of 2 241130-02 2627E T 1: T..I NW se.c SPECTRA Laboratories Kitsap F.10^WA M70 ts6o>nv-sut COLIFORM BACTERIA ANALYSIS FORM Cogeod Gew Smpb Co9zkd ikese«ew Cmay Vim" qSO+ Maw pry Y. Type a W awe Synm(�o*am B«) ❑C+ WA ❑Gm a so1m G"AWGMWBSYe -PmBafm Wax Fmllm kim"M'FTF IDR _ - - - sydwnRmw: goDN4 ih YrfU� Cmlad Pwam: Ath '� �Pdr PSve Emlk a q 6ea rer P*umn..mimwep.sarrwrraxwrar9 SAMPLE RVORMATION SanpwmdmYO Y(m t SpadPel«aSmara mmge alxed �17 smma wawema«aammem: }-// �t-a jLLj�`�f—� TmaamWewwa«+renmr) t. Routlro DbhiOWon 5uma.p'e WPI 2.❑ RapwtSmiph OM Cl nswd:Y. ❑ wl _, �� V l Wptlebgoiy�autlnebEnelEec CObMO R�dual:Tool_Fm_ _ 3.WImnC56WSI�Mr Ruw - pSanp16 G1Ym4�b1Y1mBYwmwtld§W Ls� _ II_ CNDffiWd:Ym_NO_ ❑TdmF (P) O& mRdaak TaYL_Fme_ ❑Aramwnlvm AMdm .Pal Ruwseree WawrSmgla lF/uamta�m) I . I I ❑ E.c9 ❑Fed 5.❑SunpMW.bFMSWi Ortlr tABUSEONLY pWNKNGY0ITERRESULTS IAB USE OILY ❑BmatlahCWYTaal Uo 1Pma1wa smdaawY ❑E.Vjp w ❑EoaabW aaeewla DwwBY RruY:Tavel COYam_.—mMtOBrL EmLJnP�� Fad Coxm aW100m IPC rJttltm ppyownwO BmWw Ramaw[ ❑TNTC ❑smW Wed ❑ Sampw volime ❑BenapedCmwYm ❑ FWTmw R.umt N -C 'Z�� LQMIWI®ID wF OmOa. t4t- FJUN2 .n r 010. uoxw.mueusmm M276 TweW0 � Trem Le NW Rm.o SPECTRA Labordtorics - Kitsup POWeb0,WA M370 (360)7N5141 COUFORAIBACTFRIAARALY IFORY Dab San^�9yb tbYnclm Calm'b,a Om/ Type pf Wab Sya"(d*&oedy am bWx) ❑Gm9A ❑Grope Gmp Aand pag88Abdl/-Pmdtlebdn Web FrlrtrmibYMfll: DI .^ Syebm Nam/: Qpena / h i �) a✓I caYd Pereen: 07 Dey Phm Rnit Emat 9m0ndY b:PMY�n6aYrddemYaMeewbnaYeaW�nYl &MVUSWnMATION Sempb nbO dby(name): Spdbbmun Mere angle aWcbd.. Sp wkmudbmwwm Y�� lrA T,psf$vWbV" a b=) b.❑Radtna GbdeMBOn 4Wpb(AF) 2.❑ROPntS PW) Oa^eeaeMm ersem dtr uaL nNie) CbbmmYd:Ya ❑ NoL91 IlaebFaPNm rouPne lab-0A .. Chbrine RaldabTobl_Fae_ _ b.Gmnd Wab Rub Paantmnpb DpaA��naay mu6ne cddmm: pdainabd:Ya_No_ ❑TOWp pJP) cm L.Pis"TaW_Fme_ ❑AneamdM d.Ruche W WM Rntaua Wum Mqb lFennmre5ad I e I I ❑ E OOP ❑Fen) meee r.._w_ L.�•�•� 5.❑smile carrwav Mmnu6an Oor IABUSEWLY ORMNMWATERRESULTS LAB 115E ONLY ❑umatb9 cwYTOWWbnn Premmeu ❑PebbaeiY ❑Fool Pm/d ❑En/ebad Ba dY Dents RwW:TM COb----MWOCAF VO�00m1 FenlCOafam ObNOOW. IP'C OWlnt Replenment www Requbd: ❑TNTC ❑Sanpwmm ❑ sw&VOYme ❑DwMWCmA*W ❑ tMldtbeReewtl: 'C Reap Tm V:Z7J� ��d1 lolaL.ElOTCmNNSYaP2ID D]bi[ Wedfa bYeaaea�laaa�e•Y /�Y��NY4Y ��yyyW IemYY�at1MM1�� YAeeYel�li OONIe63eWe/ ywri�YYYrYY�Yp11� O1B� anY.eeuerweml SPECTRA Laboratories—Kitsap,LLC DRINIdNG WATER SAMPLE INFORMATION(WSO FOR INORGANIC CHEMICAL ANALYSIS See Sampling Instructions on back of page 1.System D7 No: 2.System Name: 3.Group(circle) A B Private 4.Sample location: &Dateffime C led: Lab Number:Lob me 6.Sample Collected By: 7.Sampler Ph a Number: en Is :( is one) ted (tow Treated UnkuoW 9.County:(circle one) 10. Sample Purpose: 11.Sample Composition 12. Boom No(a): eIG'tsap Clallam Jefferson [I Routine Compliance ❑ Single Source =�_= Pierce Thurston ❑ Other,Investigative ❑ Blended Isls¢d King Grays ❑ Permit ❑ Composite —�—� Harbor ❑ Distribution --'-- Other: 13.Send /Report /To. lprint NamJe,Address Zip Code) 14.Phone No.: u K/---/J�"UaLl��7 15.Fax No.: �G3 16.Email: P&/' 17.Special low felons: OPrimary,IOC A11111I Olnorganic Chemicals, IOC OKsteap 5(NON,Fe,Ma CI}C.ud) (Sb^1u,BeQ;Cr,CN,F, Requested (Group A&B systems) He,MSe,TI,NOrN,NOrN, Bo,cd,cr,cN,F,RaN1,sr,T4 OPierce County IOC N.,Tarb M(o) GReck a NO,rN,NOrN,CFFe,Mv,Ag 40..Z0.Na. (Sb,M,Ba,Be,CdCr,CN,F.H&Nl,SgT1, group h.rd,evd,turgosbrq PL,Cu) NO,N,NOrN,FeMNII tarb+PbFu) OOther(circle or circle individual individual (}{Nitrate only OJeffereon County(NO>N,C) test or write in new test tests below • � below EPA EPA REGULATED EPA REGULATED STATE UNREGULATED REGULATED ecooda REGULATED Antimony is NdmI(NOrN) Chloride(Cl') Sodium(No) Alkalinity Arsenic(As) Ninite-N(NOrN) Iron(Fe) Hardness Calcium(Ca) Barium(Ba) Total Nitmte�irite Ni;g c(Mn) Comisenviry Magnesium(Mg) Beryllium(Be) Nickel(Ni) Silver(Ag) Turbidity Porsaium(K) Cadmium(eel) selenium(Se) sulfare(SOt2) Color pH Other: (list) Chlodne Residual (cirek) Chromium(Cr) Thallium(TI) Zinc VD) Free an or Total STATE Tool Organic Carbon Orlhophosphste-P Cyanide(CM) UNREGULATED OC -P Fluoride(F) Lead(Ph) Total Dissolved Solids Sulfide(IIrS) Mercury(Hg) Copper(CU) Bromine(Bros") Temin S.amle slmm ue Mh True• /.O 11:11 su l,hhed BY: IR Y S.mPreRaeived nea.lare 1)•h T:ee: CovdilMn.nd Tempenmreoo Rxeiq: 26276 Twelve Trees Line Suite C ♦Poulsbo WA 98370A(360)279-5141 A Fu'(360)779.5150 A www.S=tm-lab.Wm s:UM:inaaadre\Fomaaod Template\Tempbt�s\senq,Ic Mmegemnt\C1mm1 WSI Proms\W Foul 6.205N21.dac Revivon due 052021