HomeMy WebLinkAboutWAT2024-00389 - WAT Application - 12/3/2024 WATilk
MASON COUNTY Shelton,WA98584 ED
Shelton:360-42y-9W ors s/,
Public Health & Human Services Belfai 360275a 1 2024
615 W.Alder Sweet
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
Nameon Applicant: M1cr%nEl_ H12p Date: 1z oa I01A
Mailing Address: 1-11 S-6. PRuIr AN 1-N Phone: amn '101 . OM2
Parcel Number. R1gn -ll-9ooR2
Type of Water System Reason for Application
❑ PublictCommunity Water System(2 or more ❑ Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), If of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Remodel(please indicate name
I/you have more than one residence connected of water system below if applicable-no
to this well, check the Public/Commun/fy Water signature required)
System box.
Pant: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: 4SXPP D0.FVfca WI FA
Water Facility Inventory (WFI) Number. nb / (write"none'for two-party)
❑ I am the manager of this water system.The water system has bee 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 form may be scanned and available for public view at www.masoncountywa.00v
1:1EFi Forms\Drinking Wear Revised 05AMCO24 Page 1 of2
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
x/Water well report(attached to application). Depth
T
j �/
Well capacity Test(attached to application) V gpm�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 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 within last year(attach to application).
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 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 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:
Applicants water supply does not appear adequate to meet the needs of Its intended use for the following
reason(s).
(�
�R�eyvile/w�er's Signatures:
Environ. Health:P 1 Date `z"("
This form may be scanned and available for public view at www.masoncountvwa.aov
Page 2 of2
WATER WEL,: REPORT NCURRENTt Nw v 1 5 0 5 9 2
OnSial&In copy-Ecology.tad copy-owor,3N copy-driller AEA987
Unique Ecology Well ID Tag Na
moo f's•k clrckl
® Contraction Water Right l'am[No.
O Decomorisdon ORIGINALCONST'RUC110N Notice
v , wnaN Michael c h a e l KID DofINew Nanber ft"mO
FROPOSEDUSE: MDousafic C ISdaaal Maldpal Well Sued Addpg I'c y n Lan e
❑DCWamr ❑bdipsia OTntWa p0tw city
ty She I ton g;... Na a o n
rYPEOFVVORX- Owsels Sumbraof wrL(Hmom ihao ae) BIVM cycle
®New Well ❑Recoat6oned M,dmd•0y DOS 13509 d ❑Drive Loesdon SS w l/ -I/4 S W 1/4 So 7`wo 1 9 N 3 Y a .
DcaW E yIhbk ❑Roary ❑Jdftd Lwuldng: LaI Deg _ LaI MTdSec WWM
DIMENSIONS: DiVann of well ,ddged 1 5 9 R (.t'n81 .
Dept afmmpidsd won 1 3 9 ft REQUIRED) Iaog Deg— Long MWSre
CONSTRUCTION DRTA Tu Farcal No. 31 9 D 2 7 7 9 0 0 3 2
C-sing Inwskiod 6 Dlam_hoe +1 . 5 ft m 1 5 6 R CONSTRUCTION OR DECOMMISSION FROCEDURR
Installub QDy ummiled Dism.6om ftm—a. Fancadm:Demibeby cola,cbuxlc.sicofarnaialammaamnmdte
�71weadni & Dam.hoe Rm—R ksdaad came of to asocial t each sustain penninod.with lost cas
aay for each ebmge of Woneadoo.lndiae W wsus coeoummM
FarrWadoai ❑Yc ®No (USE ADDITIONAL SHEETS IF NECESSARY.)
ofpmfsuatar •«A MATERIAL FROM TO
SIZE of pcR_Tn byJn.sod m.of pda_ham fL is JL Top Sol 1 0. 2
SceaNCYn ❑No ®K-Pc t^="on_ 151 Brown con loeerate 2 11
Me°"fecav l'N-- Johnson Brown Hardpan 11 15
Type slotted Model No
Diem.5 Slm Sk• • 020 tcas 154 f, 159 rt Loose brown con losers a 13 23
Dian Scot Sise taco ftm rt Lita brown hardpan 23 46
G.MmilMepeckrd: Dyes INNS 05beafyavrdhsod Brown sand, pea-gravel 46
Mausnu Vinod fro ft to R a o f a t 49
Sarsee Sash )Ely" ❑No To whe dcptt 21 R Medium dark e l a , sand 49
Marais cord in.1 Be n ton I t a a o I St 57
Did ay sale retain tamable sole'? Ely. ®No Medium dark grey clay 57
Typeofwabs? Dcat of with gravel , sand 68
MdbndafraftnoxaaR Gray clay dry, laces 68
PUMPS . MaookcourYa N=^- of wood 1 1 6
T)'pC: H.P. Gray gravel , elay 116
WATER LEVELS: cemented dry 1 3 4
Static Ic,d 135 Rbdow cop of we0 o- 12-27-01
Anima prtcme IDs ps squate i.1 Dan Gray clay with gravel 134
Ms•^•^welsh aoaoBM by and seepage 155
ami Sand, Gravel g ..for 155 159
WET L TITS: Ilnwtlowa v amount rasa I{vtl u bwaadbcbw 01ic Ierrl.
Wasapuvatmtmada7[Yc EINo Ifyes,bywhum7
Yvlt�alJndv.wit. RdnwdaOaaGc I'm
Yxld:_�Jlada wit - R dmwdows son--lac
Yidt_�NJmi6.rim R do wd eau d±•
A,o.,dam frkw m}ea ae o"o wh,ayamp mm,dgffx mrkwla,a Wjrom
wwu cop m war kw0
Time Was,lewd M. Ware l<vel Time WaWL[ d
Damof L —
Badarat 1Q of/min mt 0_Rdnwdowv aaa 4 hn.
A'naal , cal/ativ.whh seem sec st R for hrs.
Amnia Row e.p.n. Dam Sad Dam l2-TB-01 Complsmd Dam l2-27-Dt
Teveuame of watrt_W"Z&nniolsulymmadc7 Oyu ONo
WELL CONSTRUCTION CERTIFICATION: I calsaucted and/or aaept responsibility for coaWction of this well,and its contphance with W
xWw.ashington well constracuon standards.Materials used and the infononica repaid above ate tare to my best knowledge and belief.
Ll DriBc 084— ❑Trsiae Nurc(P{i Mark ark H w 1 e I on Dallmg Congmy Arcadia Drilling Inc .
DrillmEngioecR}aioee Siglab • CAS✓ Amy 1 7 0 S E w a l k e r P a r k R o a d
Driller m Thd=license No. 1992 pty1 Satn1 zip Shelton wA 9BS84
Conbacttds ARCADD1098KI 12-27-01
Iftladnee,licensed driBer's Ragiwabon Ng DYe
kSlgaatue and I.irme no.
Thurston County Environmental Health
412 Lilly Rd NE h
Olympia,WA 98506
360-867-2631
YNUIRICN COIIMY
COLIFORM BACTERIA ANALYSIS
DSY Sups C.IYem Tbm So mb County
I —201.20d I0� gro p/n B l)
IeM� W Y. —a—:W" Y/ • 1
Typo of WO,Sysbm(dad"one butqFftw NowNmb�� �['�
❑GMWA ❑GmmB ❑GM ^
Gmm Aem1 Gmp B Syabam-P."bomYr rFacBSss hmnbry(WFD:
LLW _
Spbm Nam:
Domed Person: rntchAe-4 I-
DrypMm O) Q—OY CsIFMm: z
j FmR rAgipp5 Q A1A(I,cow Ew.Plms:( t
I Smdm�glrcl�t Yirr�.sabasmdMwdeaamaYtliw)
yc�l.Rdy!
SA''MPLE INFORMATION,/
Senpe mllecbd bY(name): 141iliA�� ja r r7
Speft b.draem w akin WMm ampY-%b d: Spsdd'aWw4oneaao n*
Ins' Ae TavcC+
Typea(Sampls(mugq odyomboags1Nmuphd4bbdbe )
%951.Wna Dbtdbudbn Sampa 2.Repeat Sample(aNer unsat mutim)
ClWwWW:Yes_N. ❑DlWbulbn Sydwn
ChWm Re u*Tool_Free_ Chlomgd:Yee_No_
I.Rsw Wster Source Sam W Chbme Retldwl:Tohl_Fm_
❑E mb-GWR W➢I
OF"-eWaa.mm.obpo^ ) Unsahsfaiar .m Iabmmber.
FR.ed Y.--No— -
❑As»aarcnihbnibrcg(av) Umabisdaymuam wlagdaY:
❑over _J�_
S
/.❑Sample Cg4ged for Inbmmtbn Only
ImwdpaSw_ O« hucdonl Repsbs_ Obm_
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Umsfid"bry TOW Gown N mvand Set ad Y W
❑E.w1"w1 ❑EMIAMt
Rspscament SamPY Re lrl :
❑SemplewoM(>whwm) ❑TNTC ❑
B,d,,WDwds R .,lls:ToWCoftm nOGN. Ecd IlDW
FbwICOMom 11M Fsbmcocd ---------ADO M.
M"Cade: SM9223B ❑SM922ZD
❑SM921% ❑&n ww
passwTb.r v"
WRa Nm�unfw-pyu-MSYN llEUee pil! .
0 8 0 7 L--