HomeMy WebLinkAboutWAI2024-00335 - WAI Health Waiver - 9/24/2024 wn1 2�-MASON COUNTY 00335
COMMUNITY DEVELOPMENT
rmnnft.inanceunW.eu;lainr.r.nninr RECEIVED
415 N 61''Street, Bldg 8, Shelton WA 98584,
Shelton:(360)427-9670 ext400 O Belfaic (360)2754 67 eA 400 0 Elma: (360)482-5269rep4g4 Z024
FAX(360)427-7787
Application for Determination of Water Adequaq'y5 W Air Street
Instructions
1. Complete Pall 1. No determination can be made until Pan 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 accomRany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: 2 21 cvyf y�yaGV+r,�•��Date: T
Mailing Address: Stj gift ip? Phone: 3(do Li'/S 2""?
Parcel Number: !qJ]&C-0-aAKT
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more -Building permit
connections) ❑ Division of land:
-fJ- Individual water source (one connection), ft of Parcels? SPL
fil- 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 well, check the PubliclCommunify 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 fallowing 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.
1:1EN Fo s\Drinking Water Rc i.d 1I2X 018
Individual Water Well
��T111� Water well report(attached to application). Depth `eft.
tcul Well capacity Test(attached to application) 2-0 gpm_!r gpd.
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. It 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-down and recovery data, must be performed
by a licensed contractor.
Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htto://gis.co.masdn.wa.usiolannirw 14=15=]16022=
Water use or limitation recorded................................... N/A=Yeses
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
Satisfactory Determination:
This determination dam not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely In the future,a guarantee compliance with all applicable WDOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.0404Detemtination of
Adequacy for Building Permits are entered. Additional Growth Management requirements may apply. Chapter
36.70A RCN.
❑ Unsatisfactory Determination:
Applicants water supply does not appear adequate to meal the needs of its intended use for the following
remon(s).
�Rtevvii�ees Signatures:
Environ. Health:
CSD Director. Date 2°r2
WATER WELL REPORT �DEPARTMENTOF NmkeoflmenlNa. WE57323
ECOLOGY Unique Ecology Well IT Tag No BOCOIl
Type or Work Sute amom.ges,
OO Cwnuinon Site Well Name(ifmme than one wall):
❑ Oewmmissioo o qi®ail mollanoe N0l No, Water Right PelmiuUnnifieale No.
Proposed U.: RIMmmti, ❑IMmonsi ❑Mwicipl Pre emr,Comer Name Make Lord
❑Dewnmv:g Oletlgmkn ❑Tim WeH 0F1M1m
Well Street Address W Clem Lake Rd
CoN--11e TYPe: Madm0[moe
O New w,ll ❑Almniaa ❑D:iwe ❑lemd ❑c.bk Tool City St1e8m Cooney Mason
❑Decnning 00dwr ❑Dug OAu- ❑MW-Roluy Tex Feet No. 42135fiO00050
Dimemlom: Dumercrofberbm 6 u.,k 157 E. Was a van.spprovd fnr lMs well? 0 Yes 2 No
DegM1of<wpknedwe1115%d
Conert DeM16: WA Ifyes,w1:it was Iho nomme foil
Cmug Lim Diameter Fmm To Thirlum glxl PVC Welded Time,
N ❑ e in. 0 tsas .25 to R 1 ❑ Ill 1 ❑ Location(am imlrweimm;on peg 2y 11WWM or❑EWM
❑ ❑ in. ❑ 1 ❑ ❑ 1 ❑ MN Y.-'/.of the SW 9r Secion 35 Township 21N Rmge 4W
❑ ❑ m. in ❑ 1 ❑ ❑ I ❑
❑ 1 ❑ — o. ❑ 1 ❑ ❑ 1 ❑ Lotmelo(Example'.47.12M5) 47.26474 N
longitude(Example:-120.12M5) .123.16163
hrkmtlom: ❑Yea WNo Typeofpeefwmoroeed
No ofpmmnw sveofperfonsw_mq_u Driller',Log/Coaeteection or Decommission Procedure
Pm6nrcd fiom_R.to R bebw Mo::M s:ufice To—,— Monte by ro ncln br,<br ,nor of,em tial mtl nm<mn,end Ibe kind vd
mwe<fi]w mmmial in moh le c,pemtnled,vitm to kml one,tiny fm each doong,of
Sereena: NYm ❑No ®R-Piker b Depth 151 R imbo::mion Uu eddiliorolaMna if rccessery.
Mmnfaclu:m'.Nome Alloy Mechlne Works Materiel I. To
Time Wh WraOped Mwil N<.
Diomeler 5_ Slot me;020 at Wm 151 R,m 15/ R. BmWrlflneto messi s ravel D 5
Dumelm_ slel rmi—in eosin n lo_e. Rrown fine to merinos sand lavel,sltlll cur 5 15
Urille &own fine M medimn sit sand and revel, 15
Moneollternmk❑Yon 9No ft ofpxkmmid_im l0oae,d 34
emruly Pines Rvm_R.lo_R. Brown fine t0 meclum silty gloel 34 79
am„sod: WY" ONe Towhmaope? 18 R. Grey fide to medium silly inindy,graimi 79 103
Momid:nd in oed Benlo ile&IM
Din mY etnk<onuinwmbk wmerr ❑Yon ONo Gra SII Sa loose 1 124
Typsofwm0 Deptl:ormam Brown floe Satisfy,mulHCObretl al level, 124
24
Method amoling meu w loose,oeeps R—
Form:
Brown fine sandy,multi-Dolored line to medium 138
Mmaremmrs None TYPn: ravel,loose,water bead
H.P. PmnpweAedc,i:_fl. Dm:gW Row rW:_Wm
WRra lwek: ImM1snfece ekvabaeborx me mlmwl US ft
Stile-reptu jo,oI i14S ire t_a ofwc, ratio emFew
Slmic wmm level 11=5 fl.beln s mmv inth uu:e Dew B/12R4
A wanpmsun_tolby moan imM1 mi
AMauewpau<tmmlkd by (<aP.vehe,M)
WA ink:
Wm a met wo Peefi med? ®No ❑Ym U by whom?
Yidd_epos wiN_ft dnwdown aM_ba
Yield _gm wirh_fl.Aawdown aRr_M.
Yield _apmwite_4NrvWwo after Ws.
Ram<rydm(lime=aeon wlwn Wmp i mm,d oN-wemr level nmu:M boos wsll
mp l<wmer keep
Time Wenr Level Time Waln Lewl Time Wmx lsval
Dos ofpampi:q ml
Hole'nn_apm mob_R.m.waowa eRer_M
Ah not 20 8pn wise neon on is IQ Rom 1 M. Ihw 9112/24
Attention Ikw_epos
Tempennm ofwarca 51 •F WmocMmi,alamlyaemtle? OYm el Rti sm--mt 9/1221 Compdd Date B/12/24
WELL CONSTRUCTION CERTIFICATION: 1 cmutmald andsm accept responsibility for,mote s m oflh,S wall,and it mmplierce with all Washington well
eaWnoetion standards.Materiels used ad Hon informmion report above are one in my best knowledge and belief
❑Driller 0 Trainee❑PE-Print limeC,,Johnsen Drilling Company Arcadia Drilling Inc.
Signor re 7 Address PO Box 179D
License,No. 3441TP Cry Smile,Zip Shelton WA 98584
1F TRAINEE,Sponsor Contractor's
Spore ' Si®moue Reg slit on No.ARCADDIO981(1 Dete 9/12124
ECY05 1-20(Reo O9/18) If3ou neeArMs dorumem In an aUernaleformaf.Plane coif Me Wamr Rerou¢es Program al360J0]6871.
Pemmoa with UnrJng loss can my711for Washo,son Relay Service. Pen wbhaepeech&wbiltfymnmll8 7 743 3-6341.
vanguard laooraary
2635 Parlandnt Lane SW,Suite A
Olympia WA 98502
oA4BHAFD 360-967-7010
COLIFORM BACTERIA ANALYSIS FORM
Dab Ser"Colkc4tl Tire Sample County
Coleftl
09/24/2024 a 0. MASON
owe M vm —a.
Typed Wow Sysbm(dleck only one bw)
❑Group A ❑GmupB ■orw
Group A end Gomm Syabrm—Pmvide hum Water FadlNw Imeday(WFI):
ON _ _ _ _ _ —
s,starbName: BLAKE LORD
ConW Pason:Arcadta Drilling,Inc
Day PMre:(360 )426-3395 Cell Phone:( I
Email. Ew.Phone:( )
SBIIU IRY1611(PIiM A1ll II«m �m66 dM la Cml IXBiaBi)
mNe®«Ca]ie]nAi,gcan PNO p,n®y4]is]nlMe.mm _
SAMPLE INFORMATION
So plecdlxbd ly(name):SHAD
Speak bcabon whom son"coloded. Spatial lmbmb sor commems
Lot 19 Clear Lk Dr, Shelton
Type of Sample(wbctantyare typedaeple hen bOw 1 timuo 5 below)
t.❑Robane Distribution Sample(W 2.❑ Repeal Semple(AR)
pmmdismhution systemaA«umat muow)
Chbfinaled.Vw_No_ umbsoact"MUM lab mftw
Chbme Resitlual:Tool_Free_
3.GmIund W&1vPj*Smm*Sample UreeAefacbrytauae cdleddeb.
I I
Chbm.aad:Yw_N0_
0TdA3emd(NP) Chbme RwiAld:Tobl_Fme_
❑Asawsmunt(AIP)
4. Sudwacr OWl Rae Bourgbuster Sample(EmmvaSon) I a I I I
❑E cW ❑Feral rrese V�w_ I�L�LJ
5.Bsame Call hx MoneseenOct/:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Urealishcbry Total Coamm Present am IN setlafacbry
❑E.cp pq t ❑E.Col~
Bacterial Dentlry Rashb:Tobi Coyb,m___---JlMd. E.00l HORN.
Fecal Colftm HWtd. NPC HW.
Replacement Sample Reluired: ❑TNTC ❑Somplel000b
❑ SaWle VoLma ❑Damaged Gambler ❑
ISE wM«ea lia,iber
5 amp —I D
gramnI Me°"dr`Oe SM9223B
DM Re,o 0BBH Lab lea Bdl
BBR r6nsapea
285- 92510