HomeMy WebLinkAboutWAT2024-00213 - WAT Application - 5/7/2024 ENVIRONMENTA WAT pD a13
HEALTH R E
MASON COUNTY tto.,W Street
MAy -7 2024 Shelton,WA t.400
Public Health & Human Services Shelton:360-427-4467,Ext.400
615 W. Alder Street Belfair:360-276-0467,Ext.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.
3. Submit completed application with any required attachments for review.
4. An approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant:6 l \, a-WN'6f, IA tI
Mailing Address: , L hone: 3
Parcel Number: aa �- 'n1,4— -2
Type of Water System Reason for Application
X Public/Community Water System (2 or more Building permit &90?02y VwAAnn
t573
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
Other(explain) ( P )
❑ Replacement or Remodel (please indicate name
If you have more than one residence connected of water system below if applicable—no
to this well, check the PublicYCommunity Water signature required)
System box. 2�0
,1a
Part 2: Water Connection Information V&—L 27q-00001—
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-parry)
❑ 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.
Print Name of Water System Manager Phone
Signature of Water System Manager Dale
This forth may be scanned and available for public view at www.masoncountvwa.aov
J:TH Forms\Drinking Water Reviud NJ 1 V2024 Page I of2
Individual Water Well
Water well report(attached to application). Depth`�ft.
Well capacity Test(attached to application) 1 S gpm�pd.
l 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 draw-0own and recovery data, must be performed
r�by a licensed contractor.
Satisfactory bacteriological test(attach to application).
/J 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 Dale
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 as adequate supply of
water indefinitely in the future,or guarantee compliance with all applicable WOOE 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.
❑ 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: /7
Environ. Health: b I v / Date
This form may be scanned and available for public view at www.masoncountywa.gov
Pap 2 of 2
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Arcadia Drilling Inc.
P.O.Box 1790
Shelton,WA.98684
Customer: Roy&Julia Bunnell Well Tag#: ALJ503
Site Address: Grapeview Loop Road, Shelton Depth: 220'
Date of Test: 9/112006 Static: 145.3
TIME GPM LEVEL RECOVERY
1 Min 5.26 146.65 TIME LEVEL
2 Min 5.26 148.35 1 Min 155.5
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3 Min 5.26 9.55 2 Min 151.1
4 Min 5.26 150.35 3 Min 148.8
5 Min 15 150.85 4 Min 147.5
6 Min 15 156.5 5 Min 146.8
7 Min 15 159.6 6 Min 146.3
8 Min 15 161.4 7 Min 146
9 Min 15 162.6
10 Min 15 163.2
15 Min 15 164.2
20 Min 15 162.4
25 Min 15 162.4
30 Min 15 162.4
35 Min 15 162.4
40 Min 15 162.4
45 Min 15 162.4
50 Min 15 162.4
55 Min 15 162.4
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