HomeMy WebLinkAboutBLD CD Environmental Health Review - 6/9/1995 MASON COUNTY DEPARTMENT ON HEALTH SERVICES
�-- - - - POST OFFICE BOX`^16664"OW
SHELTON, WA 98584
(206) 427-9670
FAX 427-8425
APPLICATION FOR DETERMINATION OF ADEQUACY
A i.l 09/01/92
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 agetem utilized.
3. Submit completed application, with attachments to the health department for review.
-
PART 1: APPLICANT/PARCEL IDENTMCATION
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MANE OF APPLICANT 4Le TGV/Nd&_`� _ DATE 1n� -7 /
MAILING ADDRESS O- a1A) "7— a0 TELEPHONE (MO I iiZ6-1 23
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ASSESSOR'S PARCEL NUMBER Z3(0 3S OYJDID
s•. ... ..SUBDIVISION (If(If Applicable) LOT
TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Check One)
MIA Public/Community Water System l Building Permit, Single Family Res
Individual System, Drilled Well Building Permit, Commercial
EJ Individual System, Dug Well El Building Permit, Replace/Remodel
Individual System, Spring El Land Use Application
Name
_.-, - ❑, Individual,System, Surface WWater Type
Individual system, Other �^wa w" �-kIi«. .Other
- PART 2-A: PUBLIC WATER .SYSTEM
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NAME OF WATER SYSTEM WFI ID
to water purveyor far W. ayg W prevlee.ly f11ed a prtSficate of water adegoaey rite the health
dlattict.
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pie and the water right permit preemLly iE effect. water Sin— aveileDla to Na applicmt'g prapazty
live, er fie appliemt ma mde satisfamc arraegmemta tD m, M the lieee.
SIO MME OF ST9Tn1 M AGEF _ . ._..... DATF
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MAT 6 R N 8 L L 0. E PORT $CHI. Grd No. N32{01
•• 57A116 OF MASNINCICN war.eight Peralt Ned. Masi]
++ta _
(1) CNNFR; Name TG —z
(31 1/XJ7I0N OF WELL: County N DW - sm 1/0 NI 1/a Sec 10 T 19N N., R Ise M1
13a1 S... ADORE55 OF WELL for nearest address)
____________________ .__ _ _ _
(3) PROPOSED USE: aPrteilC I (101 WELL LCf
IU TYPE OF WORK: Omer's Number of all I Fornwriom Oeacrllx by color, character, size Of material
(If woe thin ...I 3 and structure, and show thicknesa of aoulfers and the kind
NiM N6L Method 0011.RY and nature of the aaterlal in each Stratum pmecrated, with
............................••.•._._...._.•....•......__--._..... at least one entry for each change in formatlen.
(5), ., @ SIONS: Diameter of well { inches _ ---------------------
Drilled 131 ft. Popth of rocs laced well 131 ft. MATERIAL I FROM I m
.. . . ... . . . .... BROR! dAY a aR1V6 1 a I D
I6) CVMSIRUCTSON DETAILS: I aMY , S a GRAVEL 1. 11 136
Caa4g installed: a - Dia. free .1 ft. to "a ft. I SMY CMY 1 14 1 15.5
NEEDED • Dia, frM ft. to ft. I ERITd QJ.Y. 119.5 I 21
' • Dia. f. it. to ft. I Seat msy 1 ]1 1 13
-I aRO1er mall FAR 1 33 1 ]5
Perforation. M I GRAY mJla FAN I 25 I fe
Type of perforator used I sea, dAY 1 ]a I tl
SIZE of p cf.rati.. in. by in. 1 aRaar CUY 1 41 1 a{
perforatiore from ft. to ft. I agars svm P. 1 a{ 1 51
perforstiw free f0. to ft. I Ea3'VDN OMY ERm 1 3E 1 99
perforatfees fray ft. to ft. I sARo rear car I es I 73
__________________________________________________________1 aRAr CwY I 71 I Ta
Enreene: Yl9 I alias clar I TS 110.5
moofatturer'. Naas statists I saRD Star Cfar ( So.s 1 a5
Typa Swrr. Nedel No. I swra P. moll I as I u
Dine. a lot site .014 free na ft. to 133 ft. I mar m.nr I as 194.5
Dias. slot .its free ft. ts, ft. I EAfm eras PYT soa 19a.5 197
__________________________ _________________1 slab SMY cv.Y 1 97 199
arawel packed:-No site of gravel I same a.Ar 199 1 100
Gravel placed f. ft. to ft. 1 aRAr ears . mut m. 1 100 1 Sol
_•__________________________________••_____________.I m,ND eta m.af 1101 1 log
Surface oral. TES m .mat drPts? la ft. I dear czar rearm, 1 lag 1119
Meterlal eaed So seal Smll'Qrse 1 m'a3 sale SMe6 a 9arsor 1119 I lla
Did any strata tmtain urn.able water? M 1 I I
Type of water? Depth of strata ft. I I I
......
mthed of sealis, strata off I 1 I
........................................................... I I
(7) Pam: wnufaetvrer'. NameYPs I I I
.............. N.P. ...I I I
(a) 3DtTER IMES: l+M-aorface elawatiOn
allows mean ... level ... ft. I I I
Static level lie ft. below top of sell Data 07/19/93 1 1 1
Artesian Free. lbs. per aaaare ftrh Date I I 1
AttealM water controlled by I I 1
I Nora .Carted 47/14p3 Cotplstal 47/24/93
(9) Wet INISfSr Dr.wdow I. .aamt star 1.1 la lowers balent I Wm.L tDte3RaCN0. ®!i'IPIC)[TISNr
atatfe level. I 3 apestarketa .0. +trope r..pee.ibility far am-
Sea . psa,, teat sae? m If yes, by wham) I strue[ie. of chi. m11, and ite eapl3mvoa With all
Yield. gal./are •lth ft. draapwn after Dn. 1 Naahin9toe Well etrecsaeeiae seaMarde. Materegla ass
1 as the Tnfarmatioo reported above .re tine te, W base
i k3wrledge as belief.
Recovery Seta I
If. Water Level Tim Nate. ?.reel Tlse Water Level 1 SAME DRILf.Lra SNO•
1 (Person, firs, or a3ipreatim) (Type or Print)
I
AWAE53
Seta of test
"List tease 9-1/an. ft. draaoWn .fter Sera. 1 (s1amst] awe No. 2453
Air tut 13 gal/e1n. w/ stea set at us ft. for 1 hea.1
Arteaian flex 9.ps. mt. I contractors
Teaperatire of at Nu a chealoel aulysl. made? No I Registration No. Date 07/37/93