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Home My WebLink AboutWAT2024-00154 - WAT Application - 3/6/2024 wAT 02 415 N.6'Sbnat 584 MASON COUNTY Shdt. Shdmn,WA 400 COMMUNITY SERVICES 80fa¢360J2 4460,ESL 400 aelfeir:360-2]5-046],Eat 900 au,avwimcu..:oom.w xdmca, row.in Elmer 360482-5269,Eat.400 Application for Determination of Water Adequacy 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. 1 Submit completed application,with any required attachments for review. 4. Ana roved buildingsite Ian must accom an this application. Part 1: Applicant/ /Parcel Identification Name on Applicant: l kf-r Ie,� �O�hSf6�/"l Date: Mailing Address: ` 7 f1LIQ•� Phone: Parcel Number. aQ0I'7-a4-9aQ/J Type of Water System Reason for Application 4 Public/Community Water System(2 or more Building permit connections) ❑ Division of land: Individual water source(one connection), #of Parcels? SPL V 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 wail, check the PublWCommunity Water signature required) System box. ,j gL.2o" 'D O023 Part 2: Water Connection Inforrnation Complete the section appropriate for the type of water connection being evaluated: 'LZo 1 Public Water System _ _c(- lkl Name of Water System: 5 n n Water Facility Inventory(WFI)Number: (write`none'for two-parry) ❑ 1 am the manager of lhi water system.The water system has been approved for services. There are presently I connaction(s) in use.This will be the_connection. ❑ I 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 an 'mis by al and local regulation. Sgnature of Water System Manager Date This form may be scanned and available for public view at www oo mason wa us. Psviad M42018 1:\En Fans\Dnn ng Wax Individual Water Well Water well report(attached to application). Depth `.C ft. �t /'�(� M' Well capacity Test(attached to application) pm >`1,6 0 pd. 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 rapacity test, a well capacity test,which provides stabilization of draw-down and recovery data, must be performed by a licensed contractor. W Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) EDevelopment within which WRIA htttnt Il is.co.masonwa.usl tannin 14 N15_16_22_ r limitation recorded...�!N / Yes............................................................... 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) 7Recommended ctory Determination: 7Gh d uate supply ofermination does not address adequacy of the distribution system,geqdefinitely in the future,or guarantee compliance with all applicable resource regulations.nded approval indicates requirements of Sanitary Code,Title 6, 040-Determination ofcy for Building Permits are satisfied. Addifional Growth Managemets may apply. ChapterRCW.sfactory Determination:nts water supply does not appear adequate to meet the needs of ite for the following s). Reviewer's Signatures: Environ.Health: col/� Date This form may be scanned and available for public view at www m mason.wa.us. Page 2 of1 • • -' P D R i S...t Cold S.. 086M P A T E iTATQ 0f YYSYIMM ester COY Perot Ye. ____ my ev.rvm•vv ,4-..vvv..mv..sv (_1) OI_EE•r M _ �.v=v mvrotor•m.v...v.v v..••vv�.mv v....e v �. .s LRS•MWE E 210 Gtt LAIN OR OLYWA,y 1/4 ..rmr 17 T 20 Y.. R 2Y YN (2> LDGTIDS lu WELL: r ty` SA" .vm. /2e1 DAY/PeIY: K STMT "USE DP TELL (tt ne reet .dtlrs.) .mvvm..e®v.v. r.rvmmvv m�.mrvv.vv.rmv.,,..®.vmrmmvm .•m (10) TELL L« (3) iR0P0fED IlSE.0041E-m.TlCmvmv.ay.v.uv.v.vvm.ev tAKKM. •R• N E•tK(Sl • 0rrr'• Yu er .f wtL Porwtlon: poKribe hY oLor. (4) TYPE of WORK: red .t,Lctur•. N •hoe thicbree N ep11fK, ord MIMI nee. (11 oor. N.n ane) d n.[W... 0 the rt.ri.l in .h •oetw Deree YEW 1ELL Method: IIDIAM N Lett one entry for o.eh dsp {n fertat on. (5) otSEY71(E5: Dl Eeenr of well 6 ft. --TIER "" IROI TD Drilled 199 1t. D•pth N rnepleted well 199 tt. _ SESAAAIM 0 14 �v . WIpM SAW t GRAVEL14 GD BADEAS 65 (6) DDYfTIIUDTItII DETAILS: it. 193 Crfry intalled: L . D1.. frw Di.. froo N 5 ft- to ft. to 199 ft. OEM MAY 93 111) WELDED 110 In • DH. fraw ... ....._._ ft- SLUE __ft,_.. SLIE fa, cur L SAMID 173 167 .......................................... SLUE 541E L OGVEL DSY P.Morotfan: b BUG 00110.5E SAID L LATER 1B1 199 TVpS N prferKw uDed in. by in- it.N prfon[IaE prfentien fra 1t. I. ft. prlorNten frs ft. to it. prfar-tiuE fra______ ft_ to ft_____________ Scroen/: In YESLO Su1YfKtwr.r'. N•s Yod.l No. T)q. SLOTTED frs 193 ft. to 199 ft. Dies. 5 Wt •1.. 20 irm ft. to ft. Dr.. Slot Disc ............................. DrMI pocked: 106 si xa of Srml Drawl pt.ced frn ft. to ft. _. ................... ........ SYrf K. .YI: YE7 To Jut dgtM 20 ft. Yef.ri•t wed in •sI BEYTGUITE Did we s• contain ueI••nie.17 oeth of tt p T rat. ft. Y Yetlth a t wd or •slim .[nb ore _ m,m..rmrrm.r..r...rrrmr IT) PWAIP: Neruf.cturtt's Yes B.P. TVpe v.. m <!) ,TER LEVELS�vm�vLEd-u f.e- �LMtIM r 1t� •hot• SeK •M Leeel .. Stock lMl in ft. Doi . top of w11 veto 12/11V92 Artslen pree.w- 11. per .goer- Inch Dot* ,,.I. Wtw contr9lled hV Work Dbrted 12/1S/9E [otplo[ed 12/29/9L Yam_ .v.ma.vrvrc. MR7 (9) YELL TESTS: Dr•eda.W i. sou.[ ester lMl 1. Ja W Delay r LEE` wg ewd IfIG WOE' for con' .t.tia IMI. t[rtpfl all a} S11I/ wl). Yd r"1. ta0pl1Y1-e Yllb ell Yr • PW test ..de) w If ws, try MaN Yield: Ml./Yin Si th ft. droodan -tier nra. erd the ootimlon reported •hw'.er�dtt" best oiW toot kwYLedao End belief. RoeaeerY date ypo or pin[) Ties Wttt LMI Tis water Lvel Tis Y.ter Level YAK A0.0AD,A D+n' or corpor.tlOn) (T ADDRESS aE 171 J: PASS RD Dot. of test Lltne Mo. 0950 M Niter t Kl/Sin. ft. dreYdow otter hn. [f[LYE01 a Air tat 15 9elpin. Y/ ets st et 150 ft. for Dot.1 hrs. CaNrec[or'•..r.et.a...v...ww.mm...mr...�.m 0.ei• ntton Mo. ARGAD01095K, Dot.m1I1 v30/92 eet.r • atell enat'lD se T�retur. N mm . .......... .rm.vm.v.Printed From Mason County DMS Printed train Mason County DMS Thurston County Environmental Health 412 Ully Rd NE al Olympia,WA 98506 360 867-2631 en TeauRsawssNn ""' COLIFORM BACTERIA ANALYSIS Date Sample Cdllamd Time Sample County 3 ' Lp' z() 1L 210R aim .h M Yes Type of Water System(check only one box) ❑ PN&HousehuM ❑GroupA ❑Group 8 Etother Group A and Group B Systems-pmde from Water Facilities Inventoy(WFIT System Name: Contact Person: Day phone: Q 7 Cell Phone:( ) E-mail. Send res (Aim Iln am, xlp «emaaay 9t�� n C) nsz�7---- __� SAMPLE INFORMATION San*o.#Ncled by I Sp.dac)location or add.wfiere sample cotecad: SpecidN m mn inswlioorcaentx Type of Sample(must check only one box 01#1 through W Fsbd below) d.V Routine Distribution Semple 2.Repeal Sample(after uneaL routine) Chlom-md:Yaa_No_ ❑Distnbudon System Chlorin,Residual:Tidal_Free_ Chbnnaled:Yes_No_ 3.Rae Water Souris Sample Chlorine Residual:Total_Free ❑E.Pon-GWR(MP) ❑Fecal-tw e.cm.sruw Oumnson) Uns.mfadory routine lab number. FillereG Yes_No_ __--- ❑Assessment Monitoring(AR) UnsaNfaclorymulinesollecldale: ❑Other I Fi _..-.I-------- �_. 1 S 4.❑Sample Collected for Inlormation Only Invxugatiw_ ConstructJonlikepaUs_ other_ LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑UnsaUefechry TOW,Colgorm PresentSatbbcloryand o librmdetecm ❑E.cay prexnt ❑E.wa abxnl Replacement Sample Required: ❑Sample ten old(>30 hours) ❑TNTC ❑ Baclenal Density Results:Total COliform I100m1. EmM H00m1. Fecal CI&M 1100ml Enterococd ItOD rot Method Code: SM9223B ❑SM9222D Dateand Nme ReceivM: y()Z SM 9215B ❑EmmleMB 4 Dale and Time Mager: _ _ Dale Reported. ssr,Nuuorrrc Nnumre,piuenwdge) LeD Das ONy 0 8 0