HomeMy WebLinkAboutWAT2024-00380 - WAT Application - 12/16/2024 i
WAT �
MASON COUNTY 415 N.6 Str4
Sheltoq WA 9858
Shelton:360427-9670,Ext.400
Public Health & Human Services Belfair:360-275407,Ext.400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No detemtination 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. Ana roved buildingsite Ian must accompany this application.
Part 1: Applicant/ Parcel Identification / / / !�
Name of Applicant: PQrr fif✓
rel DMS L�I�-" Date: r ?/ ( 6/ ZD Z—t
Mailing Address: 4/0 ASFG Alf fvl( C n Phone:
Parcel Number: ZR 2-O
Type of Water System Reason for Application
PubliclCommunity,Water System(2 or more ❑ Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Remodel (please indicate name
#you have more than one residence connected of water system below if applicable—no
to this well, check the Public/Community,Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
F Public Water System z
Name of Water System: Bi SPO W hW(
Water Facility Inventory(WFI)Number: Mop, (write`none"for two-parry)
1 am the manager of this water system.The water system has been approved for services. There
are presently a 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. I /
Print Name of Water System Manager\ t '=
— Phone:D f5 411�t�
Signature of Water System Manag ate 1-2(I--;
This form may be scanned and available for public view at www.ntasoncountywa.gov
1:\EH Proms\Drinking Water Revised 05MS/2024 Pagel oft
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) apm qpd.
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 resou regulations.
Recommended approval indicates requirements of Sanitary Code'Title 6, Chapter 6.68.040- ^yhafion of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may hapler
36.70A RCW.
❑ Unsatisfactory Determination:
sn'�
Applicant's water supply I does not a ear atl uate[o meet the O
P PP Y PP eq a needs of its intended usY the 'n
9
reasons .
Fy 61p14 Q
Reviewer's Signatures: G/moo?
Environ. Health: Dater L 91H�
l
This form may be scanned and available for public view at www.masoncountvwa.eov,
Page 2 or2
�IECEJVED
WATER WELL REPORT DEPARTMENT Of Nolwamflnlent No. 1ACH166
ECOLOGY Unpa hsology Well ID Tag No. 800059 n 7 f 7 DDOL
Tmr.rworh: state of Washington Site Well Name(if maw than one vela:
C0amn tb^ A State Department
❑ pavan.... O 0nRivahno11mon NOl No. Water Right RnniLCutif ate No. OV
Yrapwed w<: N Danw.wa ❑Immmil ❑Mmddwl pm eaty Owaf Name Darre Ddtie D1 Eeologv (SW RO)
❑Dewerdna ❑im...- ❑Ten Wall ❑Omer Well Stem Address 410 SE See Dar Hat LO
C meth vTYpc: waludi Croy CIrN Comity MpOR
O New well OAllerRlvm ❑Fovea ❑letlW ❑Cable Tad
❑ impiam, ❑odwr ❑0w 0 Air ❑Mm4tolmy Tex peal No. 22020719069E SU
mamma ee: fliamee:ofbaliva a b.m Y20 t. Waavmieaesppmxcdforlhisud1417 Yes IBM
Deem ofwwwed man 219 E irm sabM was the wriaae fart
Cvwtrwilo-Demob: Wall
Cain, Lima Uumekr Fmm T. fwiomaaa seal "C Wtllad la:m/ p WWR1 a❑EWM
N I ❑ 6 :n w 216 .26 in o I ❑ 0 1 ❑ Lo,a,ma(sai much.on page 2k
❑ 1 ❑ _la. _in ❑ I ❑ ❑ 1 ❑ NW /Y.of the NW %;Seoul 29 Toeoahip 2ON RaW 2W
❑ ❑ --io —b. ❑ I ❑ �f (FiwRWe'.41A23d5) 4719M
❑ 1 ❑ —w ❑ ❑ I Lanitoda(Fxamwe:.120UMSN -122.96837
IaeYaaean: ❑Yw GINo Tyw orpp9elarpd lcra la accto,, rmeBaa Oe UalaaYalralYlaR Aea[{8N
Na orpr amioaa_ ladarpw6aswblia Y Polmnf numie67 avow,atrmaam,aak moameaalamlaea4aide tlolwm
Pmmoo man_fl.b_L bmkwOAMammmw ammeoflhmlWeialnapa mYm pmaalmra,wabmW meeanybsadyaor
&reeve: Wife, Do GR44M O pa9m 212 !. aamrmmbn. Uw adJtieaal mhwwifemeaaaay.
Mmummmer'a Name AJI Machine Nbb hLterial Finn To
Type Stainless slotletl hladd No. elmwl sll sarM and ravel 0 21
Di^mean 5_ Sw eve 014 m awn 214 E w 219 R. Bnc21 32
Compeer_ SMsiw_uEam -am-a- Boadvri 98aMY Gay
elDe a 32 150
Sa.erv9w.paeb❑Yin R]No Sveorp.ek:ame:in_is sit revel,weal 150 182
Mpmukplmedfiam_fl.m_R. fl ai acrid 162 167
.sans.Real: WYes ON. T.want Aph118 9. Ora 911 9Ba111,an151 rawl 197 19D
Mmerial mad b wd 8e 1 Ile cta Gist Sam,I,aaoing,water 190 220
Did any veal.wnwin unumble wadi ❑Y. 0No
Type vfwpn4 Oy1RafWO
hleWvd nfrnlinB rve x oR
Rmp: hlmukanverl Name TYw:
IIF._ 1'umpinlakedep:h:_fl. Dn:p:N bow rW:_apm
Wamr Lerely l.entlemka elevation above peanw4+wl 110 a.
SIwY-wofmPafwellewine 1_5 fl eMv<9wmmwW
,a,,aamrlewl 66 Rbelnwmpuf-u-:q Ilwm 91 L4
,mamp:ersurt_Ibm.per wpw:e uch ILm
AMaim wane ncm:mllm b/ (wpm ratve•ek.)
Wall Tam:
Wua pumpin9lml pafwn:M a Na ❑Yam by whom?
ya,_,wim_R, lormloa a&r_t-
Ykld_Wp wim_a.dmmdmvn after_hn
Yield__Imp wub_a dnwdoWm fi"_hum
Iewovery ma pipe-man wbenwamnnv«E^R wweria-1-murtd RamweR
by m wpm keen
Tar Wnar Level Time W.level Tim^ WMmlaswl
Dam ofpumpi:p kw
Bailer ran_Iamwlh_L dmvdowe afle_M
Ab re 30 it,with comae at 180 f.kr 1 M. DMe 9l.1d21
".mi m time_9pm
Temw:mmeof«em 50 .
G wm.rM:aiaalmallau eudev ❑Yin ®No Slant Elate 92524 Complaed DMe 9f3024
WELL CDNSrRUCrION CERTIFICATION: 1 camamaa a,aaWa a:rept rcspwmibility fawmuoaliom ofthis well,aM iu appliance with all Wuhillgbn well
castpniwn amadMds.Meaeneu used BM the mfwmstia mpanad above art tea 10 pY hest kru wledr atd belief
KI Driller❑Tmiame O M- Jah Kea U'ILng CamnMW Af�l Drilling Inc
Sglwre // ' Address PO So.1790
Licamic No 2874 / City,SM,zip Shelton,WA 9RSiR
IF TRAINEE:Site 'it 61.No Conlracla's
Spwswi S'punae ReBut lion Na ARCADD1098KI Gate 913WP4
ECY0S0.�anw,aeae0Wl8)bv mnrl call lflj/IVasl,InfBrwa Raby semen Prrawu wlfh a dmbillrY 87I4134311�71
Vanguard Laboratory
2635 Parkmont Lane SW,Suite A
Olympia WA 98502
oaf ouAFD 360-967-7010
COLIFORM BACTERIA ANALYSIS FORM
Dan Gargle Cobcbd TMre Snipe Caunb
10/11/2024 D mma Ow MASON
ra.w mr ry — _Nw
TRm d weer Sysem(�nib ore timl
❑GmryA ❑GMwB ®Corm
GruW A mN Gmup B%V*M-PmvBe hom Wald FS bw kww"(WFII:
ID7 _ - - - - -
Syeemrlmw: LOGAN SPEAR
CmWPaam:Arc&*a DdMM,Irm
DarMOw:(360 )426-3M Ce1Rmre:( 1
EmeB:
SaMiealaG(RW NI narn,mess atl�oacaamaq
enelnOavamwp.mm AW o I W moa®aaWmnp.aa"
SAMPLE INFORMATION
Sample wkced by("):SHAD
Spearn:WOMWhore Son"CDbced: SPeaalrebmtiaWUlmmallb:
410 BE Sea Der Hok Ln,SheRon Counts Please
TWW 0IS"(5W8d0rNmab"ot5MVehQfo WM l IM*5 hdaa)
1.0 Routine DKMWtim SwnPk(AP) 2.❑ Repel Sam*OJP)
Chbdnmed.Yes—to_ Ihomaseibuu"n syeam4bunew.mueie)
Chbree Residual:Toel_Free uwfistacbrymuereehnmrber
3.Grom4 Water Roo Soume Sampe ——— —
UmaxkLbymuBe cow d1@
Dabdreea:Yee_No_
O Tdggered(AIP) CftWm RwWwt Tdd_Fme_
❑Aeseseme"I (Am)
4. Surfm or MI Raw Soume Wafer San*(Emmemtion)
❑E.m ❑Fecal rum ni% ILS ly`I JI
5.®5meue Caeantl M Mammon ooh:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Una &WM Toel Cdlonn Pment and (�Sdkbeleey
❑Ecub Vreeml ❑EcoA'abent
Baebdal Dwar RMha:Tcel CWM IlDDrd. Eoo ry00ni.
Fecal Caifam 1100m1. MPC 11 nil.
Replacement Sam*Required: ❑TMC ❑S"p Moid
❑ SarWla Vdume ❑Damaged Cawhw ❑
RMO "Pp 11.0 "Ytlq°�48: SM9223B
CWRe"aaeb WN U4Wpy:
WHtapgarel/t
285- 01110