HomeMy WebLinkAboutWAT2024-00375 - WAT Application - 11/12/2024 WAT�-003'15
MASON COUNTY
COMMUNITY DEVELOPMENT
P.,mii ua,euilain.rlanni�
415 N 6-Street,Bldg 8,Shelton WA 98584.
Shelton:(360)427-9670 ext 400 d BelfFAX(60)2 42�787 xt 400 O Eli(360)482-5269 ant 400
Application for Determination of Water Adequacy
Instructions
1. :On Part 1. No determination can be made until Part 1 is fully comoleted.
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 a licalion.
Part 1: Applicant/ Parcel Identification 1
Name on Applicant: Mr� &A2AA,-) _Date:
Mailing Address: 21 t, TGLfkoVT ST wQ Phone: '{60- Q1"I6-68�3
Parcel Number: 1=0 -s0'a 00.3
Type of Water System Reason for Application
Public/Community Water System(2 or more ;l<Building permit_Bid 2624- O 13LK1
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
ff you have more than one residence connected of water system below if applicable-no
to this well, check the Public/Community Wafer 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: NOViG
(write 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.
❑ I 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)conneclion(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 masoon.wafi-
o a
19aa Fame\Dunking waz.7
Individual Water, elWell
�
Water well report(attached to application). Depth�' y!ft.
Well capacity Test(attached to application)�gprm—2gpd
—
f 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 date, must be performed
by a licensed contractor.
Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htto ligis.co.mason.wa.us/Rianning 14=]15C]16[j]22[—_]
Water use or limitation recorded................................... N/AJ:D—Yes
WellDrilled ............................................................... 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)
�q0 Satisfactory Determination:
r This determination does not address adequacy of the distribution system,guarantee an adequate suppI
water indefinitely in the future,or guarantee compliance with all applicable WDOE water resource regul
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-DeterminaAdequacy for Building Permits are satisfied. Additional Growth Management requirements may apply.36.70A RCW.
❑ Unsatisfactory Determination:Applicant's water supply does not appear adequate to meet the needs of Its intended use for the follow
reason(s).
_Reviewer's Signatures: ( y�
Environ. Health: ��r' — ' "1" Y Date
zoi2
CSD Director: Date
*0k
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WATER WELL REPORT 01PARTMbNT OF Na«n ofmlem No wESAOse
'ECOLOGY Oniquo Ecology Well1.T,No. 1`175
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Q [ommetiu Site Well Name lifmae thou one,cell):
❑ Uuo^u:iaeio^ .-1 Orgooimuu.. (a uo. Water Right PamulDcrol re No
Propmed Um III Damao, ❑wll ❑M:xiPl Property Owvp Name MMnmr&4 ConallopOIRL UC
nl aaaa olrriguion ❑Ton Will ❑. Wall Sort Addax 371 E S,dhara St
eras"Pe Mabod:
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Can^a Inw Diameter From To Tbikwr Said PVC weMa Timad
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Srreem: W1 ❑No M K'Paeba b Depth 154 R aromatic Uxedlifiouldaenifmruuy.
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Emma Arcs Anyoul and spiry,dfty sand 33 48
SaudlFOurpac!❑Ya WNo Sueofpukenalumal Bryan fine to manduara Fravel and land 48 55
".—N vlmmd wro to n Brown fide silty sand,same static 55 67
Berates Sea: my. ❑No Towhuhpla 18 ft Bnoml fine silty scand.day 57 AT
hle:aiat:eediorcd BenlontiN cg Brown fine silty sand."t 87 88
aid my eumaromi^wwba wrt!/ 0. Chi,
Typeofwewn Dcdofnraa Brownfine ravel and si sand,8-12 GPIA 88 109
Med:oi nfmnlingo:maoR Blown fire silty Sand.wees,Rose 1W 130
Broom that,to medium send mdsl 130 152
Popp: hlanmlictua'e None Type: Broom fine to median grincellysand.heayi ,'AN 152 151
NF._ Pumpinumdc,dc—d. Recalro]IMw M._sae 'iZIP wlorW fire to aaedium gariel.tram aend IV
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WELL CONSIRUCTTON CERTIFICATION: 1 cmame rl andlaaceept rmpaaibility fineonnnderma ofRia aaall,and incompliance vah all Washington call
cumamaion i mndandS.Womals used Md the inflammation r¢p:aMd abom arc Vise to my bat bnowlialp and belief
❑Boller I3 TMirae❑PE-Part Name Copy Johnson Fadint,Cranpomy Alsetia ONIIrg ma
sormatur, Adams PO Box 1790
License No.344IT City,San,Z' Shigdn WA 98584
IF TRARTEB.S 's Liarar No 3 Conla old"
Spun $Mlmn Negi N AOIOB ARCOBK1 Bonn 4SQ4
ECYO5 1-20(Rev(0118) Ifdmuamed ahisda'umeau In aO alumaae/dmaa.Plea+¢rollahe Water Rraources Progmmcd.1 N07-68I2.
Permwtollh heurrng lossmn toll pl//m IVOJ�iagnan Reby Servir'e. Ferraro mrrFaspemAdimdffity ear rnll8plR3}d]Il.
Arcadia Drilling Inc.
P.O. Box 1790
Site omen:Address: Ray 371 Mc Sullivan Street,Allyn Shelton,WA.96�P]T 60 ag#: B175 �FC �1pj�
Date of Test: 4/172024 Static: 50,
Pump Set: 120'
TIME GPM LEVEL RECOVERY
1 Min 3.2 50.9 TIME 1 LEVEL
2 Min 3.2 51 1 Min 50.5
3 Min 3.2 511 2 Mi 1 50.2
4 Min 3.2 51
5 Min 13.3 51
6 Min 13.3 52.3
7 Min 13.3 53.1
8 Min 13.3 53
9 Min 13.3 N55
10 Min 17.8
15 Min 20.6
20 Min 20.6
25 Min 20.6
30 Min 20.6
35 Min 20.640 Min 20.6
45 Min 20.6 55
50 Min 20.6 55
55 Min 20.6 55
1 Hr 20.6 55
1 Hr 10 Min 20.6 55
1 Hr 20 Min 20.6 1 55
• vanguard "burauny
2631 Parkmont lane SW,Suite A
Olympia WA 98502
V?ffD 360-967.7010
COLIFORM BACTERIA ANALYSIS FORM
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