HomeMy WebLinkAboutWAT2024-00276 - WAT Application - 7/9/2024 WAT `�I�- ooa-t/n
0 MASON COUNTY
COMMUNITY DEVELOPMENT
ftmk nli nn`Ue Oundim Punnmc
415 N 6' Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 4 Belfair
275,1467
427 7787 M 400 4 Elma:(360)482-5269 ext 400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No determination can be ade until Part 1 is fully completed.
m
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. Ana roved buildin site plan must accompany
ccom an this a lication.
Part1: Applicant/ Parcel
Identification
�l
Name on Applicant: A1,4D1,4 JI K�L IUA Dale:
Mailing Address: r-aYat �b+> p�,Date
� ' - JOL(8
Parcel Number: 53017f i�- I CO3O
Type of Water System Reason for Application��yaqq��
❑ Public/Community Water System (2 or more 8 Building permit SLr,/4 O'R'd1 —W0/
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels?_ SPL
CS Well ❑ Boundary line adjustment
❑ Spdng/surface water ❑ Other(explain)
❑ Other(explain) ❑ Replacement or Remodel (please indicate name
If you have mom than one residence connected of water system below if applicable-no
to this well, check the PublirdCommunity 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 am 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 (is.: 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.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mawn.wa.us.
IEH Fmms\Drinking Wamr
,/ Individual Water Well
p�Water well report(attached to application). Dept/h�� —(O —ft. f1
fal/We11 capacity Test(attached to application) 9pm yopd.
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-down and recovery data, must be performed
` /by a licensed contractor.
Satisfactory bacteriological test(attach to application).
+� 1 Water Resource Inventory Area (WRIA)
Development within which WRIA itto:/Iais.co.mason.wa.usJplanning 14=]1S[=16022=1
Water use or limitation recorded................................... N/A_[_]—Ye$Q
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 on..
atisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the future,or guarantee compliance with all applicable WDOE water resource regulations.
Recommended approval indicates requirement of Sanitary Code,Title 6,Chapter 6.68.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirement may apply. Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applicants water supply does not appear adequate to meal the needs of its intended use for the following
reason(s).
,t. Reviewer's Signatures:
Environ. Health: ,r S � Date
2 of2
CSD Director: Date
• w A T E R s t L L R R P O A T Start Card M. asAANf
uni'. M31 S.D. I A
dthn W aA9RIM0Oal Mature RSqR Pamir E.
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•_••"••••• a 1304 HOLY Y tR6a. Y 10584-
COMOVIt! N. SOONER, ross'
IYSOI
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............................ ............. . ... . . _ .u..
- Y 1/t Not 1/4 Bw St T AO E., i M Y
I11 tOCATIM OF : Cd+nty
STNM AWREoS or IO .area[ . .l N, sloe ..
ook
............................re.......................................... .. ____.._______...eo..e..... .. ......eu
(3) PROPOSED ME: re"N'T e 1 1101 IYZ Iola
......................................... ............a ___________________________________ ..
cha
ial
(tl TYPE OF RJ0.11: l(If wor.M than
of well lotYt.: 4, Now, by Color, was of er, fers Of Nho kind
(If were tMn owl and nature of, and NxoN,otarial
aMenses[ of eat" s end ted kind
sY Ra Mtn: [DIRS I and nature of tM for
In ach, suetrw pautretnd. with
_ ......I at luN ow entry for wch ch,aoga In lorr+cinv.
Olmr.r of sell i lneh,w _________________________________________________'oxos To
Orlll.d at Lt. O.peh of eawl.ead .11 S!J h. I YTEIAL
........................................................•..s.....I avvE cmn sA10 tmf aaW emR I 0 I 1
cf) GWSs1AIKtxIX1 DETAILS: I !lY a Tfi011 QiT WATER s1tAm I t u
b i' xnKalled: a Die. flaw .1.S ft. Co 55.1 ft. RRYY SLUM
Wt a.CL li
iT 1 14 I
wCyY WING Ms. fra ft. to ft saw a mcm TIM CIM !INNER MTiR NaaRHD Sa I L
Dia. Eras ft. co ft. also a calm YALIAwf czar MOTOR DfYTY 11 tS
_____________ _____________________ axon,
p a 1Y uRETYls YIN, CLAY 3m I N I S!
varforeciw.: AD
Type of perforator used I I
SIZE of perforaclon. in. by
perforations frog ft. to ft. I I I
perforati.. ft. ft. to ft.
wJesusifor.t is I . ft. to--'__- to
I
__ ____ __ ------- ..I
Mnof"turez'. Ea Ns Mdel
Tws doe Sire f. ft. to h. I
Dies. I I
Dian. slot else Ins fee is h. i tN •st I t
31. Of gravel_ ________________ ______.._._.
DnNal poked: YO I �= Yt ArT1e I I
Drawl placed fns ft. to fee __ . ______.__.I - �
__________________________________________ _ _
AUrfan seal. YE To what depth,? 20 eft. 1 ^2 r
Mcerlal used in Nasal
e1001TE I 1C -a I I
Did any .teat• con"I. onu.abl. wtar? 110 I
[aca fee
TypN of "ter T Dth of h ep
...... MthM of minim strata off ...............�I < O I I
.................................... RS
m V E P: Mmf.et...r•. Mw i a
TYM R.P.
.................................................................
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(a) Nam LNEIS: land-s.rfac. elevatton 1 1 I
.how sun u. 1.1 ... ft. 1
static lwel I4.1 ft. blows top of well Date 01/10/ts I
"realm tar
iN. per swan inch Mr.
..I...I. er eoncrollM by I ryrk .—mod av/she .�. ...••.....�����..
.....................................uve u
............................................. .......•
(!) E6i. TSSTE: Dr.edoarr is mount "tar 1M3 is lowered halos I wly tOnOrRVCacR ttRiiRQT2Qr:
steels level. I 1 cenetrucced aM/Pr aoe.pt r.gAmelbililY foot das-
Maa Isms use a.da? E It ya. by shwi •r rnetian of this nll, and it. eorpllaNe with dl
Yield: g.l./dn with ft. draadOw after hre. xeanl.gtm sell Cease .Ptlan .u.darda. Amrthla used
_ +M the ioferwtlon '.ported tones ass tLW to dy 11,st
sro•ledge and caller.
Racwery dace EIW611ILLIIR pR2,LYp M.
Tim Eatez Level Tim Noce,
Level rise s.tar Level j (MINn fin, or rorpmti.) ITyp. or pfintl
Aonam P 0 Ent///�a1 tammf
Dace of cnc / / I (pf u• L1etNe M. Sff!
Bailor tat gel/von. R. drawsow dn [tree hr.. I ISiaMol NAA
Air test 07.5 gal/gin, s/ Is. sac at 15 ft. for 1 hr..I
"teal.. flow 9 0 - Date I rnncratnr'•
Taarature of ter was a chemical avlyel. wade? aN I Ragi.hraeion M. s1111oll6da0 Cam n1/11/9!
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...................... .. .. .. ...... . ............ .........._..............
Vanguard Laboratory
2635 Parkmoot Lane SW
Olympia,WA 98502
360.967.7010
VANGUARD Report of Laboratory Analysis
LABORATORY
Culleeled by:
American Pump and Dolling Martz Drudd g Wotn
J60-7544867 Laboratory ID: V2412274
Sampling Addrem: Date Sampled: 12IM4 BAD
1010 W Boyer Rd Date Reeeived: 12127Q415:58
SMllem WA 99584 Dale Reported: 12RIQ
Sample ID: 1010 W Boyer Rd
Analysis Result SDRL MCL Units DF Dine Analyzed
Total Coliform&E.toll by SM 9223B(IDEW BeaM1 ID:VNIM7 4 Aaym:KS
Coliform,Total Negative I 1 MPN/IUOmL 1 12/27/241719
E coli Negatve I 1 MPN/100mL 1 IMM417:29
No.
MPN.Mwt Probable Number
ppm:qna lcmillim
m:.-Meet Reviewetl by Loma New m Lbw,Mtector on 12/JlaH
Ne:.a applicable
SDRL.Star Deteeu-RVp gLimit Appmvd by Teri JObmon,Operaaom Manager on 12/31=4
DF:Ulubw Feiner 1701,101,01
MCl:Muimm.Camt—inmt Ltvel LaaPe@av
Smnplu wain rtaivcd i.ecupeble<wNti-.lM tuulge)in Nie rep..relate-ly to Ue pbti-.fthe wnplge)ttpM.All WMdW,were performed-.rinem
wi:F Ne Queliry Aewtance ping®of VmguW lebmnmy.Pleax c-bin Ne la�abry ifyw eM1-Id love-Y 9uwd-r abom We rcwlta.
2635 Pmkvant Ln SW,Suite A,Olympia WA 98502 Once:360.%7.7010I testingoavanguardlabommry.com I
w .vsngusrdlaboratory.cmn
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