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HomeMy WebLinkAboutBLD Water Adequacy .......... ...... . s�u,m a 4[ t 7 798 P. 10 MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX 16e$ SHELTON, WA 98584 (206) 427-9670 APPLICATION FOR DETERMINATION OF ADEQUACY FAX 427-8425 eovis.d 02/01,12 INSTRUCTIONS 1. 2. Complete Part 1• No determination can be made until part 1 is full completed. D e oniy the portion of Part 2 applying to the t y 3. Submit completed application, With att YDa of water tmetem or review. achoante to the health department for review. PART 1: APPLICANTIPARCEL IDENTIFICATION 111111Illlilltl lltlillllll!IIIIIIH IIINIIIii11i 11111IIIIIIIiiI lililllllll I II I Illitiill illliill I I111IIIIRItRiil I I11 it I I IIlIi11R111NI11t111UINtIN]NUIIitOttltlll I1111 NAME OF APPLICANT Donohue Cons truCti2n CO. C. DATE '1 - 14- 9� _ MAILING ADDRESS 730 Sleater-Kinne Rd E _— LdCe TELEPHONE ( 206 4 $- qqg camr W ec.m� y ASSESSOR'S PARCEL NUMBER 32 132- 239 - 0001 a— h• i. pe.c. SUBDIVISION (If Applicable) Stonebridr LDT . 1 (Short Plat 2253 (M) TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Cheek One) © Public/community Water Systam X Building permit, Single Family Aaa ❑ Individual System, Drilled Well Building Permit, Commercial El Individual System, Dug Wall El Building Permit, Replace/Remodel 13 Individual System, Spring El Land Ume Application ElPP tiwn Individual System, Surface Water Name Individual System, Other Other PART 2-A: PUBLIC WATER SYSTEM IIIIIIIIIIII II OIIIINIII N 111ItliD IIIII II Dil In1I11111I1111111IIIUIIIIIIIIIIiII I IIIIu111uNiltltuNlllllllll ltlllBiillil III!luDltl II iWl lluiRnnitll it I Il I1111i11 NAME IOr�Fvt'WATER SYSTEM "Stonebria " WFI ID # Pending 7^' The ratty P rInar fur OAS rystu had Ptaviwuly ❑1" . nartalcato pf At. Wo di.triat. gnaay rSth tee health El 1 am at.gar at the ama tarma.m.d rotor my.tq• no rater system ham Doe approval tot toonctSono, rlth _ manactieu pn..ntly 1a me. Th. ."11m.na has a , •p um. e.axea gC terse m tno .PPlkaot for dosutie Dptov.l to eomant to NL. .mty pa,m .. 1. rm.x.tont rich D mm th.rats goome Plan and th1 rater right p.rdt p,dowtly Sn mff) T. vacar liamm at* m•silahA u tee spPlxmmatrm gd"daty Sind, oe the appllcmt ham we 1oti-umcty ura,smamu U s.t..d tha lA.m. BIDWTDma or ayrtlht aaleoaa PART 2-Bl INDIVIDUAL WELL IIIIDi Illllf IIIIIIN111111IIIDI II IIII IIIIIIIIIIIIi111111111111111i11111111111111111111111I IIIIDHIN I Illilillinl I I I IIIIIIIIIIIIDIIIIIIIIIg1i11111I I I III IIIIIIIIU1111111 HELL DEPTH 3r1 PC WELL CAPACISY Gallana/Minot, Gallona/Day Well 109 is attached to this application Y Well capacity test results are attached to this application d IiOars� wall .-YO."y teat. a" an. p.a., by he wll dtill.r at [ba tlea [b. veal is me. +ttnatta. Teen results from "es. tes" are anted on the well lm. deallt. Eros wwe applice.[1 be,well w by the health depar[ynt. Ir a wll 1" Cement be Inner" by the PidltY test met be parfore, by a 1lcesead earromor, 3, w Pare tee" are momptable, provid.d stabill."lw of araw-dhvn he. bamn . —"w and racOmW. Satisfactory total coliform test la attached to this application. PART 2-C: INDIVIDUAL SPRING OR SURFACE WATER IIIIIIIIIIIIIIIINIIII I I I I I1Hi711101111111111111111I1nuliJDI1111iINi111111NNInhgUlumul U111um111111Di1111i1Ut0111N:I:111ii1 Hli I H❑Dili i IINUIIIill ll ;'OCR parmit is attached to this application I have reason to bellave tha spring proposed as the water acorn, will supply adequate water its intended purPoee. This belief is based on the following obearvationst AUTHOR Of STATEMENT DATE RELATIONSHIP TO APPLICANT POIIz In addition to provldlmp the above mtetgnb the e"llcant .111 mead on .rtaape an ..-.it. ioapertlm by "% b"IM dlattimn Prinr " da[eraiw"w of Wagwey. PART 3. HEALTH DISTRICT EVALUATION (Health District Use Only) IIIIIINI111111111011111111I IIIIIIIIIIIIIII11111111111HiltiIIIIIIIIniI1111i0uIluD1111tI1HN1I1111 nIIlNfinllnul lDllbnmHU1ti11b111 II IIIIIIINIIIII IIIIIIIII SATISFACTORY DETER MINATIONI Applicant', water supply appears adequate to most needa of its intended use. Not" This "t"Ounatlen de`a _mot Wdtuu adgwmy dt ton, distribution "are, puwer%es an "Mar. mmpply of water, imannitaly late the future, or Venetia cnepliame, with all applicable soda ester "mmenne ream- UNSATISFACTORY DSTERMINATIONI Applicant , water supply does not appear ade- I---- " NTT' IIYYYs Ht i00 Luuna i ia use oI [no Iollaulmy PIRISM1)9), HEALTH INSPECTOR DATE ARGADIA WELL DRILLING TEL N0 .426 1455 Jul 14 .93 12: 17 P .02 a A 7 M R R O L I. R O p 0 it T start Met NO. 00/11 , offers or "ONfROfQ1 Meese light Permit Me,' It1�oMMst�t ...........n.wa.1.t.v1u. .......................................................................................................... •�s»• •••.•.•.•.•.•.•.•.•.•.•.•.•_••.n.e.e.r.e.o...•.•.•.n...to....�.S.t.•.•.•.1�. .a.a..•1•u...•.pow••.•.•.•.•.•.•.•.•••.•.•.•e•.•.•.•.•.•.•.• .•.•.• .•.•.•.•.•.•.•.•.•.•.•. tll UtIa. a WELL, Don[, Ma A1/e D1/1 mobil tfUR,. R1M tM (l.) t . DR" M .MLt far ne..e.t dd. ..l . n.. .. . . .... • 111 PROPOSED not, c IC 1 (101 t 100 ..... ...... . ...............•.... .1............................................................... 14) TIP& OP "R, Chop", M.hor of all Faratldnt Describe by color, eareeteri mile of material fIf was tan mn� a I Eno akxueeara. and show, thfelma.. of !,wire d r. and the k(m bM MILL Plell d. IIOTAM and ..mete" et the material in each scrotum penetrated, with ....................... .t ].at no entry for e.ch theme in ferwwrlon. 101 ciMn0I039 DiaKlr e/ all / ft, 1- .................. •••••••.••.................. ............ gellled )P ft...I Depth... of .......d all if ... I mA MA 1 0ROM I TO L .es...........................................1.•.•...u.•w....• aR01M OAmc rM 1 0 SLI 161 ttlMont1crIm cMTAIAO: ..ant am MY a MM I a.1 I me a. citing Snetall<d, 1 • Dip. from .T ft. to Is ft. Oeob ea" Pat I fl I f0 - .y MtllM • 0[e. from ft. to ft. M ML a MATQ 1 IO 1 It +t ' Di.. if. ft. to ft. 1 ............................... .._......,..__.I I PerTretlmei fro I I miss mf rf .ti. ue.d" i 1 DIES at per[..orK Sens Sn. Ly !n. 1 1 pertprwti . from ft. 1. ft. I 1 I imrferael..ens from t. to t pe m f ft, I I 1 rfereel a frm t. to --- I 1 Noreen.. ftI I I IMnefoetunr's Farm I I type Laval No. I I plam. *let sit* few «. to Dim., slot Wasfrom ft. to !t. . ........................................................ I Otoal psc Ibat As lin of wml drnal placed few ft. to ft. __________________________________________________________1 1 OReto" wiI, to To most datht IO fe. 1 1 Matorlal Wed In owl #iRtlRt# I I I old am Otto" contain unstable water? IM I " be "tot? Depth of west. ft. I I I Method of [mall"# wrote oft I 1 I .... MMt•lYaf......... t o ••.....•we..................... •I I I trP* R.P. I I I ......we ......................we I I 111 MMOR "is, ~tow-wrfa ola I I I shove wen wee level ... it. I I I stalls level 1s ft, brim cop of well Date 01/st/I2 1 I Artesian Ptwaeera lb.. per ewsa Itch gets I 1 Arlo.lan ..ter contrcilmd by I 1 I Mork started 04/01/93 Wryleted 0e/01/13 eau.......................................e....euuuolr......e .......e..................----------- .... ............... . !I1 HELL TOOTsi staticXI 1P taunt weer lml le Rear" Miw I RSLI con'tRDCTDd LtarIPItaceptt static I.I. i ruct@vend as/wa 1. she its for can- Rte " pump see[ aAev with if yes, by ewd. 1 wettest Ron of this all, too its piers., a with a.1 ?told, 9.1./elm math Lc. drardom after ha. 1 and seem all iMetAorted abMaare.true to wla atd II` knowledge the lntetatlie reported about are tors to wy Mw MOvledMt world belief. bTiesry data I ' yyp� Ties X.<tr t.ewel Time Xeenr, t.e.•t] tf me Marer Level I aRM sae" Of M.P, (Per.on, tices,l[n, oe 00rporttlon) Irype or print) vCi I Ascents .e 110 P La of teat ° seller, tat !t 1/wen. , drt.dorn Mlez hr.. to N. I Ulatwl icen.e No. Se Air bat 10 qti/min. ./ stem art or )I h. for 1 hn•I ArtalAn flew g.p.n, owe I Lbotnc[m'e `{ t.mp.i'.tnrs oL water Was a [hewletl enely.fa ads] DD I .egleer.elm me. . .. ..I ... cote 04/02/13 uu u a t' ........ .. ....•...u.............................. oo. fo" oou............. . ... ... a.o.....11u1.•.•.•uu1 WAT ER AL'MAOEMESIRES LABS .++� ``m'f TACOAiA. ("6)531.3121 WATER BACTERIOLOGICAL ANALYSIS ' SAMN F ratrtTIDN:Aron INSTnuccoNs DN BACK Of W DINM COPY n bnrvnlom•:.nel leno«ed,anpN«III be rejected. sFAT," LL E TIME LfCTE COUNTY NAMES MO H DAY YEAR L L 93 ❑m j SM a= fi 1 NSOhI -- 1�1Y_ PE OF S I IP PUBLIC SYSTEM,COIiLITE: pp-POBLIC BM ROLE IIP 'K INDIVIDUAL LD. No, n: A B NAME OF SYSTEM. �„' S S/a,jr�rier — SPF LIpP®I p I�r M�Mm.� TINP�— INE N�J/ qp 4 ) 1124 3r-Ki,.i1'/I /ILG�1 EVE �NMEflRAOR.:IN/nro) SAM US C �tED B (NAM })IARp lec ! — U DROUND WAT UNDER SURFA WnUENCF " IJ SURFACE U WELL POISED L)SPRIND [3,,URCHINTERTR EO or D C o7„ER ION BENU nC —d roll N Arpee Ad Zy Cad•I — �Cr.<(rq r;lUn 1.�L S6 /7U�+��rGi 4�K Kml . TYP ofof aAMPLE INlaw aw as WE ISM COMM) n%INE ❑ .4MlbMMMI IR/NduM'..,i++E/N� � Dr11 VINO WA;1 rr w^� cAeok. EE ❑ RKene I C't'+"•P'f .l'a�lii ❑ Umr..tsd a ry.. ❑ REPEAT SAMPLE PreWeoe WeAml prowPee Lab N.AmUe oddam Mena: DMe�.irJ :.�+MJ.ru�P�A4rl'ViO n RAW SOURCE Ne WATER Bnie .® lJ tow Comm ❑ NEW CONSTRUCTIONa REPAIRS" "'" �'L]JEdj OOIMIII"` REMARKS Fct~- : METHOD USED —_ �_ MP MPN PA M O TOTAL 00UFORM IOO ml 'E,DOLE JEW ow "- fECAL COLIFORM_�tdp ml NETERORIOPHIC—JENn ml ANOTHER SAMPLE REQUIRED SAMPLE Nat TESTED BECAUIS: TEST UNIUITABLI OECAM; ❑ 8emyle lop ow ❑CeAN:rM Wo/M ❑Wrong ecdelnn D TNTO p!Rngls.T ❑ Incompble brm 0 Turad WNW",gin (�_ —� ❑ EXal1/deaf .. — "'—�� Di11NgNG WATER SAMPLE REBURI _ ui1eMIISFAcranr,uwnn«R.wM sAn6rncTDRr, QOYlame ep� IAMPLE �E.rANaCMN L]C.DdI•In•M SAMPLE$ AEOVIPED U ieeel pIPMM ❑fad eaeM SF REVERS[SIDE DF ONFFN f.OPY fOR E%PLANAI ION OF RESULTS DA IME RECEIVID VED BY