HomeMy WebLinkAboutWAI2024-00292 - WAI Health Waiver - 8/1/2024 WAT 02 2H - QQ21
415 N.s^street
MASON COUNTY shelter,WA 99594
COMMUNITY SERVICES shelwr:360427-9670,Ed.400
Eelfair:360475A467,Ext.400
aa3,e N—"Eavrcn—Ia�a<nm—x a.sim Elma:3 664 8 2-5 2 69,ExL 400
Application for Determination of Water Adequacy
Instructions
F24.
. Complete Part 1. No determination can be made until Part 1 is fully completed.
. 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.
An approved building she plan must accompany this application.
Part 1: Applicantif artc_el Iden action I
Name, Applicant: Yh, c1'G J Date:
Mailing Address: I1 r��//n� ' Plane: fyw�+Parcel Number: 5h"r1 W-A oa4
Type of Water System Reason for Application
0--Public/Community Water System (2 or more R Building permit 61CI 207-4 -Li�f4`I
connections) ❑ Division of land:
-0 Individual water source (one nnection), It of Parcels? SPL
�p 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 wefl, 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.
I IEH Fomu Dnnkin8 water Revival VVNIa
```��-///��� Individual Water Weill
T.�Water well report(attached to application). Depth ���'I (t. Lf ,t�,,'1
Well capacity Test(attached to application) "0 gpro — Jopd.
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 drew-down and recovery data, must be performed
VVby a licensed contractor.
t Satisfactory bacteriological lest(attach to application).
II Water Resource Inventory Area RIA)
Development within which WRIA http Ilgis.co.mason.wa.us/planning 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
❑ 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)
atisfactory 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 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).
Reviewer's Signatures: u
Environ. Health: Date 1 U I7
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
WATER WELL REPORT =DEPARTMENT or Noticeoflnlmt No. WEW977
ECOLOGY Unigoc Ecelogy VVNIMTag No. BOL611
Typeaf Work: Somof Washington
cowlmaion Eric Won Namc(if.than at.11):
❑ Oecommioioa a Original imoUnfir iNot No. Water Right Permit/Certificate No.
Promised U.: ■oomrnic ❑l:dustrhl ❑Mon:inpal Pre avi Ihonor Name Patncag Patemaa
❑IKw:emg ❑er'nm ❑Tat Wen ❑Qher
Well SDcet Address 5980 SE Hatlm Rd
Co oType: Mind":
EN—Ol ❑ on ❑Driv ❑jew ❑ - l City show county Mason
❑oerpaie ❑other ,Do, ■Air- ❑"Nooen' Tu Pemel No. 319015080121
Dimeaalone: DiamaerufWnng 8 m..m 285 ft. Wasavarianccappmvedforthiewoll? ❑Yn ONO
Deptbafconglorcl—ll 29a K.
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co" Mmr Diaaem From To Thiehry Seed PVC WaNsl Tluad
❑ 9 to. .1S 284 .25 In. E 1 ❑ ❑ 1 ❑ Locmim pa inabucfions on pegs 2): EWWM or❑EWM
❑ ❑ ^ ❑ 1 ❑ ❑ ❑ NE .Zofthc NE 'qS . 01 Township 19N Rmlge 0_
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Longitide(Exierr :-120.12345) -122.88613
hrfineaom: ❑Yes ENo lype o(perloremrmN 9rnlee'a Leg/COoatroeftoi UemmMol^n Pooramie,
No.ofperfmtiom_ Sueafpv6:aliom_irt by_ Fore ian:Ranim,by arlor,cMeroo. ireofinennalaN Arai and NekindaM
peRomlN fimn_ftm_ftlebwgouM suRxe mM1veoftle oin in eeeb leyerpeneea:W,Onto leev ore entry fm web cNnge of
Semas: ❑Yes ON. ❑K-Picker b Gpb_ft infamnliom UwatlNtiomisMesifrcainer,
Menuactwv's Nape Mermen From To
Type mod No.
Dre.e,_ i^ Slates_ in Wm Rm_ft sm 0 1
oumea_in Sleeve_ inemn_ft:o_fl ,sin,sand,gmai brown/hard 1 9
in,sans gravel, 9 31
SamdlF di laerpeek:�YNi ENO SveofPiNk:oode ,
Mer:ials placed fmm_fl m_fl Send,,sift,finibred,fewd IhinM n 31 88
Sarfee SeJ: Yes ❑No Tow o hqb? 18 A sand.
fine,tin clay W E9 9B
Maarud wed in-1 Bento:um Chines Sift,mn0.flue,Min Wpm, /soft 9B 132
Did my seam contain unmabk when ❑Yes ON.
in,fine Ni Ted 132 1T5
Typeof—to? Ognhofdoor , ra Red 175 222
MebW ofamliagsmn oft antl fine,some quiroid,girsylhand 272 276
Sand,fine umNAI,pRoduaing file mrd QW111ird 278 281
POOR: Maaafucmnrs Nene WA Tme'. antl, reireel,grayAh.od,wb 281 285
HP._ Putepinmkedemb'ifl Wigmtllbw:C:_gpm
WaMr4mo lenMmficeekvarionaWw mu sees level,Rd _ft
SticFupa,k,,i wellcaaing lcf5 of.ellgmurd DM
A. wmerkv. 120 ft.below NP ofR sing one W181Z021
Anion preou:e_Iba.per I..MR Dales
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WeD Tech:
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mm nime-um wleovu:rybn�1oa-want been musued aan well
Tic mwal
Tine Wa:<r level Tine Weer lercl Time Wmrlesel
oueufpampim-e —
Daikrrnr_gpm with R doi aM_bon.
Airmn 40 gpm wiMercnold-20 11 1 bn pent W1W2024
A.m.now_®m
Tor,re :urtofwater_-F was—buroalamyahmtle? ❑Yes �No
Stan Dsa WlW2024 Completed Dete 91IWM24
WELL CON UMON CERTIFICATION: I coaslmmd donor aaept mspansibiliry far aammeiwofthis well.Roth.complia.with dl Wuhingtan well
cmmnumian smMegds.Mmmda Imd and tho informed.rcponed ehoOO am Due m any bet knowledge end belief,
■Drdler❑Tatinee❑PE-Print Name Chns Jones Dolling COmpany Months&Sans Pump and Drilling
si T{)vNlt. Addrev 1162NWState Avenue
Licar No. 2253 Ciry,State,Zip Chehalis WA98532
IF TRAINEE Spare's Liccnm No. ConDacmr's
Sponrvr's Siodore Rcgmedm No. MOERKSP072N5 Dam MOIM24
ECY05 1-20(Ravll/I8) /faumodanddtrater li---larmorcformaA plaaaaall the Water Resources Program to
360-40]-68]2. Pomne with hem:ng loft can mil)llfor Washington Roby Servire. Pemoat withaspeech dDaBiirymtcdl
877433-6341.
Vanguard Laboratory
2635 Parkmout Lane SW
Olympia,WA 98502
360.967.7010
VANGUARID Report of Laboratory Analysis
LABORATORY
CdImu,d by:
Mmrke aM Sort Mntrlr Drinking Water
360-748-3W5 Laboratory lD: V24W27-6
Sampling Addreno Date SampW: 9272414:W
54M SE Lynch Ed Date Received:90n,114AD
Shelmn WA 98584 Date Reported:9/302024
Sample ID: 5480 SE Lyneh Rd
Analysis Result SDRL MCL Units OF DateAlmlyad
Total Colilemn&E.roll by SM 9223B(IDEW Batch ID:V240927-6 Analyst,AF
Coliform.Total Negative 1 I MPN/I W mL I 927241617
F.mli Nsgdive 1 1 MPN/IWmL I 927241617
Notes:
MPN:Mml Probable Numbv
ppm:prn permillion
nd:non-deem Reviewed by Dustin Newmmn.Laboratory Director on09/3D2024
rats not appliouble
SDRL Src:e lleleobm Re na Limit Appinved by Too 3oMsoR OM bans Manager on 09/302024
OF.Dilution Factor
400b,17035aa11
MCL:Maumum Conuminant Level auu:oar
SmnPla wart rtaivM in eecepuble condition.7lw rceulQa)in IM1ie repua Marc on1Y lotl:e pu:tion oFtbe semPlq'a)Ieald.All analyses wme perfwmM conaialent
wiN Me Qudity Auurmce pmam:oFVmguutl labaelo:y Please centcl tM1e lab:atoryiryau abouldM1rve anyqunrima abmt:M1ereeulb.
2635 Parkmont Ln SW,Suite A,Olympia WA 985021 ice:360.%7.7010I Rsfing®vanguurdlaborMory.com I
www.vanguardlnboramry.com
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