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HomeMy WebLinkAboutWAT Application - 4/8/1996 MASON COUNTY DEPARTMENT OF HEALTH SERVICES Enaironmanml Haald m eor paahty Pe.eonal Health PO BOX 1666 SH E LTON,WA 98684 LOCAL(360)427-9670 BELFAIR(360)275-4467&4468 Application for Determination of Adequacy TOLL FREE 1-800-562-5628 FAX(360)427-7798 Instructions 1 CompletePul.P. No determination can be made until part lin fully rnmuleled. 2 Complete only the portion ofPmt.2 applying to the type of water system utilized. 3 Subnul completed application,with attachments to the heath dcprruncnt forrevimv _ _j PART 1: ApplicantTarcel Identification // p Name of Applicant Q��KL iN SM 7ril Date Mailing Address /_D ROTC 3 73 Telephone 3/oa ;9 75- 05�'r�/ n. r r.✓ , A 4A.SaA � t Assessor's Parcel Number /-2 316 22 (000 3 0 Type of Water System Check One : Reason or K(explain)— PART ion G7reck One ❑ Public/Coinmtn ity water System(z comma Building 000ax—) ❑ Land usen,if so.. ❑ Individual water source(oae 000 oa),ff so- ❑ f land well ls? ❑ Spring/surface water ❑ Other(explain) ❑ fine adjustment ❑ plain) PART 2: Water System Information Complete the section appropriate for the type of water system being evaluated for adequacy: Public Water System Name of Water System Water Facility Inventory(WFI)Number: ❑ The water purveyor has filed a letter grunting blanket hookups to this water system. ❑ I the manager of this water system. The water system has be®approved for services. There are presently eamections in use. ibis will be the connection. water system is able and willing to prowata to this(these)co®ections wiilrout a—xc�ee mg the limits of the water system or any limits set by slate and local regulation. Signature of Water System Manager Date H:uMATAWCHNEIWATER 3.WP Update:Oclober 20,1995 W-7 File Original mdFftad COPY eddh Appeo.t. N.,Tetra copr-nmlera copy I aloe WATER WELL REPORT KATE OF WASWN02TON pseadit No. .... .__......................... (1) OWNER: Name—— yurIIn T!th.................... Address tile box 373 Bfslfair,_WAX_9e5?6. (2) LOCATION OF WELL: Co.,. taiwan .......- . In Fee_:_._. T. --N.. R..........._WM. sea Ipand dialmon from avalle. or mbdillsim eoiner (3) PROPOSEDI USE: Domestic N luddalabel 0 abodiciPat 0 (10) WELL LOG: kAgm.. 0 Teat wan 0 Me, 0 Formeban Don"MM onler.aha�tm oftelp thicknzer of a I ba size at nottKal and sd�ta",and V.ma ta,ad and amere of the Matmal in OaCh aned".Inneddefild. IN at hand One ." Joe mOh �hdapl .1 lOnandean. (4) TYPE OF WORK. 0,ji'Ma, ........... FROM TO No.sell M.M., De, a Blead E3 Demeaned ❑ Cable M Drfvnd (3 Reemalledand 0 Salary 0 Jeff" 13 To; Coil 0 4 (5) DIMENSIONS: numator of .41 Joanna. Braun an onforate 4 1:1 D�ad -A. Depth Of completed well., Hsrd� a 12 --30 (6) CONSTRUCTION DETAILS: Send & Gravel 30 5d Casing installed: Diana. from 60 Sand. Craval & F120 50 6P Dbm. mom ........ R. 0 Welded 0 M..brom -- ..... R. Perfaratiom Yen[3 If.a r,,no a maymn,nand ........... SUE 0 jealed— � In. In, In. enforatione from -.- - -- U.ft R. mforationat flon, ..............-.. ft. ft. xurtarmans from ............-- N.W .............— ft. '3' 'a Johnson NavYfactunrYNamf i-A-11........._.._ Yodel.---*I- -No---------......... Vion, lead I. 50. nned N.be R. Dbun--- Slat She Gravel packed: Fee o No M sin of Vneel;- G..l Placed tyana ---------- ..........-.......... Surface, seal: No d I Yee N. slatmialt used In .......... Did my anata eantain unusable water? y"C3 No 19 T,,a of vOnar?................---...... Depth of alaida. .......................... ltath�of maleaII larma Pff..... .............. (7) PUMP: maboymunne" NeM, ..........-.................... Type: H.P.................. (8) WATEI�LEVELS: Lend-eurfun move Ma- .... ...*/L-- sim. f.,.l , _,() Aft.Nine,le,of aOeD Date C incil n IN. Per mume in h Date ............. AntmIm wader W controlled by WELL TESTS: 1=tj-level ft 19--.- Completed- ..............Is Wee a PUMP load Made? Yes 0 No 0 If Fee,by .................... Yntld: '.1/m..enno ft. dreadOoM After Inn. WELL DRILLEWS STATEMENT: This well was drilled under uly jurisdiction and this report is tr.e to the best of ey, knowledge and belief. H..,e, data (tinne take- an Pan anind P—P maned 'i" ('"m kd meaeuretl Com all top la willar l.'el) Ty �o .ell brillfing 711. Wed., Lev I Time_ Fr-. Water I,m.I NAME-. IFaraP arm, or nrpantlonl (Type or willi; ................................ --.......... ....... ..). (lox 36 Allyn i;h. 4V.524 Address.............................................. .................................... .......... ........... ................ ....... I .............. sails cat ZQ-9aMdfl with fta.d..mm'-.1- an jljbesm flMa.-- Data......-............... 0797 Tafa,x,ratbre of water Was a cbmdeal analysis model Yes 0 No;& LAcense No_...................................... Date.... is..... IUSZ ADDITIONAL SHEETS IF NECESSARY) r � STATE OF WASHINGTON -DEPARTMENT OF HEALTH WATER BACTERIOLOGICAL ANALYSIS SAMPLE COLLECTION:READ INSTRUCTIONS ON BACK OF GREEN COPY R Inatructlons are not followed,sample will be rejected. DATE COLLECTED LL COUNTY NAME MONTH DAY YEAR . 1/1 D / / AM.:. PMAd (J/v TYPE OF SYSTEM I n-PUDUC SYSTEM,COMPLETE: PUBLIC I'iTI II LD.ND. CIRCLE GROUP INDIVIDUAL L B lae�va•Dory I neHenwl NAME OF SYSTEM SPECIFIC LOCATION WHERE SIMPLE COLLECTED TELEPHONE NO. DAY AM 7,5 EVENIN / SA LE COLLIE TE :(Name) GYS M OWNE R /MGR.:(Name)' SOURCE TYPE GROUND WATER UNDER Sd,ACE INFLUENCE/ SURFACE XWFyL or .SPRING '_'PVRCHASEDor [_COMBINATION WELL FIELD INTERTIE or OTHER 29 GEN RED T (Pd 11 Ne dress and Zip Cone) 06 d)L 373 //11fi �p� F PLE(cpapk onq one in this column)WASHINGTON 76.So.p_ Chlodnamd Poedual:_TOelFree WgTER I tment—). I FilteretlT_ Umreared or Other AMPLElit'presence LapDamRCE WATER Bwrcap❑Sm Tate CalNorm j ❑ NEW CONTRUCTION or REPAIRS OTHER(Speody) Fecal Coliman REMARKS: (LAB USE ONLY)DRINKING WATER RESU TS -1 UNSATSFACTOgV,calitwma present REPEAT — SATISFACTORY, SAMPLES " E.Call present _ E.Gap epseM COIOo,ma epsanl REWIRE Fecal PRi _ Fecal append OTHER LABORATORY RESULTS TOTAL COLIFORM_Ji0pm1 E.COU FECAL OOLIFDRM �J100m1 /10pm1 PLATE COUNT�l ANOTHER SAMPLE REQUIRED SAMPLE NOT TESTED BECAUSE: TEST UNSUITABLE BECAUSE: J Sample modtl - Wrw9danieiner ConPuant9roMh �I lncomplem roan - TNTC Tproiacunure EoCassdabrm SEE REVERSE E1SIDE OF GREEN COPY FOR E%PLANATIW OF RESULTS uBf� }YyvC/" I y3 DATE TI RECEIVED 5J )� ©/ RECELVED BY RE�gTEJ)/n LABORq'Tb/OR/L/Y/: 7 1./G/�