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Home My WebLink AboutWAT Application - 8/17/1993 MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX 1666 SHELTON, WA 98584 (206) 427-9670 FAX 427-8425 APPLICATION FOR DETERMINATION OF ADEQUACY Reeiaed 09/01/92 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 system utilized. 3. Submit completed application, with attachments to the health department for review. PART 1: APPLICANT/PARCEL IDENTIFICATION !!!D t l i I I I I I I I i i i l 11!I i l❑I i l e!i!!t t i 1!t!I!P.!!!t!!!i i t i!i i i i i i i!!i 0!I I I H i i l i l l l i l i l i 1!i❑!I!I N 11 t!{i i l I!i l i i l i i i 1011 i I!I I I I!11111111!1❑111!!!!i!i!{I I I D I t i t t i I I I H 1111 NAME OF APPLICANT 6h'g[ Gcoaflc o' (Y)AJe DATE S-i7 93 MAILING ADDRESS 17,?9 a7�''ALc / TELEPHONE (0106 ) $aY-7/YO CYey 5 e4-HI i WASh ASSESSOR'S PARCEL NUMBER 3J93 Y- 75'90/e) SUBDIVISION (If Applicable) LOT TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Check One) 0p Public/Community Water System Building Permit, Single Family Rea 1� Individual System, Drilled Well Building Permit, Commercial Individual System, Dug Well El Building Permit, Replace/Remodel Individual System, Spring Land Use Application ❑ Name Individual System, Surface Water Type Individual System, Other Other PART 2-A: PUBLIC WATER SYSTEM ❑I t l t!!31 i i i!i i{!i!{!{I I I R t i l i!I N I I!!I D I I I I i i l i l l i l l i l i l l I!!!I I!11 i i{!{!{D I i i l l i l i l l i i l l i l l l l l i l l i i l l i l N 1!!I!I!I B D i!!!i!❑i I(1!I I I I I I I I D I i 111111 L'!!I i i{!:i l i{i l l i i i NAME OF WATER SYSTEM WFI ID ElThe water purveyor for this systas has previously filed a Certificate of war= adeguaoy with the health dlatritt. I am manager of the above referenced water system. no water system has DOH approval for _ rvice connections, win ...Clone presently in use. The applicant hen epproval to connect to thin water system. service of water to the applicant for d®estic purposes is consistent win both the water system plan and the water right permit presently in affect. water lines are available to the applicant's property line, or na applicant her made satisfactory arrangements to extend the Sine. 9I4RANP5 or Sfsl MARAGER DM'E W-7 PART 2-B: INDIVIDUAL WELL i�wl l?�hill U I i i l l!I D!I i i I I I I I I I I I I I I I I I I I I I I I I I U I i i 111 i i l I I I I I I I I I I I I I i l l l i l l0I U I1111I I I I I I I I I I I I I I I L'l l U I!i!I1111I I I I a i i i i i i I I I U I i l i l U l i i WELL DEPTH of.�-5- Pt WELL CAPACITY /O /yYoa- Nh,� of A: y O(de Gallons/Minute Gallons/Day Well log is attached to this application Well capacity test results are attached to this application horns: well capacity testa are often performed by the well driller at the time the well is con- structed. Teat reauita If.. these teat. ere noted on the well log. Remit. ft. these testa will re accepted by the health department. If a well log cannot be located by Ne applicant, a well capacity teat met be performed by a licensed contractor. Baler or pump testa are acceptable, provided atabillrati.. of draw-dcwn has bees aemured and recctded. Satisfactory total coliform teat is attached to this application. PART 2-C: INDIVIDUAL SPRING OR SURFACE WATER I I I:i U:H i i H i!H i!u n n n n:n r,m u:;;;:;:�;;[;::::u m H i i i i i i i i i i i i i i i h;s:n w:r.n u H??i i I E i 7131 H i i❑I U I I i i i i I.l i i l i 7 i i l i i i i i l i I i i E l i i i i i I I I I I I H I I i??737171?!? ❑ WDOE permit is attached to this application I have reason to believe the spring proposed as the water source will supply adequate water its intended purpose. This belief is based on the following observations: AUTHOR OF STATEMENT DATE RELATIONSHIP TO APPLICANT noTe: I. .edition to pr—idi.1 to. .. .iat—I, the aIli. w111 need w nc ange an on-.its Inspection by the taalth dlattict prior to determination of adequacy. PART 3: HEALTH DISTRICT EVALUATION (Health District Use Only) SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to meet needs of its intended use. Note: This determination does not address adequacy of the distribution "at=, guarantee an adequate supply of water indefinitely into the future, or guarantee compliance with all applicable whos water resource In, latiose. UNSATISFACTORY DETERMINATION: Applicant's water supply does not appear ade- quate to meet needs of its intended use for the following reason(s) : HEALTH INSPECTOR DATE Rnv- a:01/92 erle onnnd and Tint copy With WATER WELL REPORT Application No. secondCopy e nd C p at Ironer' - ODY—OwneYapDY '.Tire c,DY—ammr•e Copy - STATE OF NAS8INOTON Pump No. .... . -._. . ....._— 1. ' .(DOWNER: Narna.....LiiQy 0.1son __ ......_..___.____ __ . Addreae...__._.... .___. _....... . (2) LOCATION OF WELL: C.._HfiS.D.II....,.. B"rhm and distance tree notion or subdmmnn mrM. _ (S) PROPOSED USE: Dpmadc ¢ and sirfal ❑ mumclpet ❑ (10) WELL LOG: ' Irri[auon ❑ Teat Well ❑ Othm ❑ Ferman.:DeaMba b rotor,eb.,soss .rlu o1 mnnrN(as,aervetmq -" show thtcknear o1 opur/na and tke kl"a"nature of 1M moranal m awh' UwnerY number o[ wen agross. panetroled, with of taut one entry for each champ. 01 /drmdaaa. (4) TYPE OF WORK: - _— (I[ morp Nan one).... ....._...............__._.... mATIIIIAL BROm TO Nev Well ot memos: DUB ❑ Bond ❑ :...- D.P.0 Cl Cable ❑( DA. O .-.__.___ _ Recoaduooed ❑ Rotary❑ pen" ❑ Brow1k - nglOnrOrate (S) DIMENSIONS: Diameter o< ww .....fi__. mehu. Ha�i1:PIa 4 owl". _._2d1._._._tt. Depot of aompletea —f raveld &sand v (S) CONSTRUCTION DETAILS: Cemented `Ce}ing installed:......6_-- Di.. from ...._S1_ n. to -.3.5_ R. with water .. . ThrwaeE❑ .�--'• Mans. from _.__..__ el.m ____.__ ft Welded�f _.___" Dlam. from --------ft ts _-___ R. „~Perforations: vs.Cl No - Cemented sand R: eravel Type of perforator with water SUM of pertoiadom .._.___._ iso..tw _______,.___ ho . _.. wr:onuaro frogs - ff. td n. Sand ,� Let whir water ._..., perforations from _.__._ tt. as �___ R. perforatlorw Cam _ tt, m _—_._..�R. Screens: Yea❑ No:❑ _ I No o Obmo ..._.,. slot ass'._�_tram _._..._._._ R.m _.__ R. —-- Diem __._. sot slra—from .1._.._—ft W ft r Gravel packed: Yea O No® s a srsea:._____—... Grovel placed from— la W _- R. ,e Surface seal:,Ye,❑t No❑ To what depth? - mateuag tWd In eat ...Aa.Lonite ...._.._. Did any snaps conWn unusable water" Yes No(4 ! ..Ty"of w Depth Of --- '.. metlnd a"sun sprats as-------- — (7) PUMP: m.nu[aue Nmrw.._BesklBy _._. (S) WATER LEVELS: ad-r rfe;."w ie a.. __.x. - ... Badge lend Ar(satsn p glean _... :,'._ .Ib: per aavara Imb - ♦i ArWdan Water is matmued by--.— -._ .. - p (Cap, vat - t 1q " kxip 'F""r.•`;t it� SWfPat'u�t7aYeiV •f �', pw3s"k � hmp tut nuadef:Yn❑ N M-.n yurbY wtioml.. - YI 18 rat/min with ft. drawdown after �hn. WELL DRILLEWS STATEMENT:' a' This Well was drilled under my Jurisdiction and this report Is �, •• true to the beet of my knowledge and belief.. It(mvary sale lame taken u sero When pump turn" on) (water gavel - 1 mamur" from wen top is gavel) Mavis Drilling ts Tune Wag.? Lsoal Ttms Won, La e1 Tlma a (Typ m Water f.suai NAME.._.......... .... ...._ . ... - IPartan, firm, o m Ponudn) or D, U 1 ... -_._ [Sgl ........_..... ... Aadrmfxkt__. 96528,.,-. ........ ....._ -�,,.... ...............�.......�......._.....__._. ..._...._......... .. Dam m _�._.___...__ (SianBdl.....y.._......_.-._._°:. ._�0".,� _, Bagger Wt_ .Y_.aagJmin.wim... .r..._._.Jl.dnveoWn oftsr...__..y.......bn. .. ...•..�••....�_•.............. .... •(Wall]kuleq . DAW.................._._.._..—.____.- '/ Tempafaturo of wabr._..._...... Was a chemlcW analysis medal Vas No d' (..Genes Na.._().f..97......_._................ Data........Jlt e. .. ....., tp.. d. T:P nnr11T1 �N\! <fIFFTS IF NFPFF<nn V, _— SIAfE OF WASHING ION OEPAR'fMENT OF HEALTH WATER BACTERIOLOGICAL ANALYSIS If Instructions m nolldlow,q,umpN w111 M n)ecyq a' DATE COLLEC FED ME COLLECTED I COLIN ,NAME /g x'AN_ TYPEOFSYSTEM Ir PUBUCSYSTEM.CDNPLETE: PUBLIC INDIVIDUAL I� CIRCLE GROUP I.D.No. Iaen.a a,wlu.M.wli'--� I A B NAME OF SYSTEM TiO11C1Uut.6N lllsi1:,,^IN,':a Clwa..:a :•_i._,.••-.-:?. --- . �/Jyf/a700 [tea WFaflc P DAY cu,37a .777 L SAMPLEL LECTED BY:(Name)�--' 4YSTEM OWNE[YMGq.. Nor f SOURRPE� ❑JiUNO WATER UNDER SURFACE INLUENLE77 ❑SURFACE KWELL FIELD WELL or ❑RING ❑IPU CHASED. ❑CTIE orOOIINATION ER ND REPORT T6.(Prm F.HN ..Addna An,Zip Co,,,) h & Li M N aTd P5 TYPE OF SAMPLE!crvc:a c:..:.. �a..:.Mc DRUTINE NN NG WATER ❑Orson—IRe 'rail—Tdal fTae) cnaraooarnrrl --- ❑ Filldry '�I:Ns'een.r Omn ❑ REPEAT SAMPLE -- --------` Prevnus cdibm presence Lao, Date --- RAW SOURCE WATER Sou-I m Tgal Collldm C_I NEW CONSTRUCTION d REPAIRS �I�—l1JJ ❑Fecal Colilam �] OTHER(Specily) REMARKS: 1 (L.:DLC_.;.'L.)ORINKINGWATERRESUL��1TS))) u UN$Ai1SFACTOgY.Colilwma preaenl SATISFACTORY. Wlibrma apum REPEAT ❑ E.Cdi presem ❑E.Cdiarant SAMPLES ❑ Ferelpeaenl ❑ Fecal araenl REQUIRED _ - ---- OTHER LABORATORY RESULTS TOTAI-MIFORM_limn, E.COLI __...-NTIMe FECALCOUFORM_/IWN PLATECOUNT__Art ANOTHER SAMPLE REOURED SAMPLE NOT TESTED BECAUSE: TEST UNSUITABLE BECAUSE: ❑$amp191aooii ❑Cgnfi-on vosin ❑Wrpq cont inor ❑TNTC C I InaIr,"N Inlet ❑T-w wllwa ❑ 0 Eedu darn, LAB W.p Dio TS) E.TIME HECDVEo XECEIVEU IN oAT[NEYOIIIEo J L/aG{Inl(YLY !1 r Ge "33A32 /�� L3 �PBREm.ATM SYSTEM DESIGN FORM — PAGE TWO a..f..a ml7mLn + PLOT PLAN �STSS7n-TiCEELm/• - - - _. 166 . . . . . . . . . . R• - - - . . . . . . . . . . . . . . . . . . . . f - . . . . . . . . . . . . . . . . . . . . . . t9o. 67a . . . . . . . . . - .� . . - - - - pl. HeaItST Mason county DeO . wtWs JUN 0 7 1993 DNSIGMM PLOT PLANK COCOCKLIST &led plot plan if lot is under Eacres tion and dimensions of reserve area 1aisting and proposed welle,. includinq ByiYdinge, roadways, easements, parking j lls within 100 1t of property lines Property lines, building stub-out ,Topographical features, cuts, banks, - El ' cent and direction of slops - Hound horizontal gradients, andslops . and upslope/downslope widths overall Location and orientation of eurtdin 'fill longth. and width, depth of mound �J[ain a all absorption_'area components _ -cap at center and edges of bad - -