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Home My WebLink AboutBLD Water Adequacy - 5/3/2006 MASON COUNTY DEPARTMENT OF HEALTH SERVICES Environmental Health - —�" Personal Health PO BOX 16W SHELTON,WA 9858 LOCAL(360)427-967 BELFAIR(360)275-446 Application for Determination of Adequacy FAX(360)427-779 Instructions q. 6Crq a gbtl nilthd: PART 1: Applicant/Parcel Identification Name of Applicant -7 p6�j LAA r h 1- I 5 S Date 5 - - O Mailing Address 0 ' OOX 2-82- 5Lett0",V�elephone y32 - 7933 Assessor's Parcel Number 5 Z 1 2, ZZZ 90q-s-93 Type of Water System Check One): Reason for Application Check One): Public/Community Water System(2 or more III Building permit connections)" ❑ Land use application, if so.. ❑ Individual water source(one connection), ❑ Division of land: if so_ ❑ Well #of Parcels? SPL ❑ Spnng/surface water ❑ Boundary line adjustment ❑ Other(explain) ❑ Other(explain) •' If you have more than one residence ❑ Replacement(please indicate name of water system connected to this well,check the Public box. below if applicable-no signature required) PART 2: Water System Information Complete the section appropriate for the type of water system being evaluated: Public Water S stem Name of Water System Water Facility Inventory (WFI) Number: (write "none"for two party) ❑ 1 am the manager of this water system. The water system has been approved for_services. There are presently connections)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(ie: 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. Signature of Water System Manager Date H:IWELLIWEEPAGEU 11 SMIWAMS D4.DOC Update:April 2006 Individual Water Weff [07Water well report(attach to application)Depthcapacity test(attach to application) gpm apd e wall d r1ler olgin performs capaa tests a time ewe Is cons me esu from these tests are noted on the wafer 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 recoverydata must be erformed b a licensed contractor. ❑ Satisfactory bacteriological test(aaach to apprio0on) Individual SpdnglSurface 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 IN ADDITION TO PROVIDING THE ABOVE s-rATEMENT,THE APPLICANT WILL NEED TO ARRANGE AN ON-SITE INSPECTION BY THE HEALTH DEPARTMENT PRIOR TO DETERMINATION OF ADEQUACY. Departmental use only. Do not write below this line. PART 3: Health Department Evaluation (Staff Use Only) n SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to meet the needs of its intended use. This determination does not address adequacy of the distribution system, guarantee an adequate supply of water indefinitely into the future, or guarantee compliance with all applicable WDOE water resource regulations. I UNSATISFACTORY DETERMINATION. Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason (s): REVIEWER'S SIGNATURE DATE H,t ELLIWEEPAGEIWEBSIOWATEEAD4DOCUpdatc:April 2M Mason County Department of Health somhous 410 Norm em,SMNom WA 9e594,41I-9e7e an.M TYPO Of Sample lMUMcheckonly(rwbox of el through 141ietedbebN) COLIFORM BACTERIA ANALYSIS t.bLRocah a Distribution Sample a.❑Repeal Semple I011a ( Gate Slope Collateral Time Sample Cowed County Provide information below to an unsatisfactorysamplee)) Chlrin oaled Provide information below. ! Ax :V95 No 'x Unsatisfactory raai�lab number: Mash Gay Ym �: OG w l;ti9Fl � Chlorine Residual:Tdal_Fee $ f� e.O Raw Water Source Sample $ Type M Water System(check aNy one hm) Required for Surface Water,GWl,and Unsatisfactory rapine rated date: ❑ Unit A Pudic 9Pmele Moutabold some Spring Sources) /�— F Q _ 5 I Ch�mted:lgs_ No_! O ❑ Gratq B Pudk ❑ Other PUM"ams must private Source Number 1. Chbne Readjust � O Gmlq A and Gmup B Systems-Prmtlde from Water FaCaMes Wekr total.luenory 09F0 Tolel_ Free_ S Inventory QYR): e.❑Sample Collected for Information OMy c X IDA_ _ __ _ _ Cansbuction��RepairsPrdate Resitlence-X--Othar System Nwre: LAS USE ONLY I DRINIONGWATER RESULTS USE ONLY b T Sg Total Colliorm-Present ate t alai Cd'ltk�Abaent Cadaot llrian. ( K G( ❑E.c W Menem ❑E.cok absent �i ' ❑Fecal cdibrm present 17 Fecal cdikom abrierd s N Dry phone(:/ Call Phone: ❑ Replacement Sample Required ( ) 732 �G 3 (3L-0 il'? �yr'/ Sample not tested because: Test unsuitable because Eualf+lnre: �+ - FA'7t/,, > ElSample ho oho(,30 yours) ❑TNTC /9 33 1 � l U-76 aS 0 lmpmpmwntainar 00 Toadddkna l SAMPLE INFORMATION i Bilateral DGnsq Bmft:Plate Count N. E.Caf /LOOM. Sample cdleged M(namq-'L' Total Cdibrm. Il00rd Fecal cdN,mrm nopm. _ .: / 6 O -t-I S Method Cods: rod Received \ s and location where sample collected(address or sample site, MICR 1SW 1 Candrypent fa ): 3c irc, r E.� Dale Meryzetl: -�-�t�6 Data "Y-, Si edal instructions orcommentt�vim+� tG Sample umbsr NDN rurtap4s frs tipib) Evergxeen Well Drilling WAM qoq. RE. 81Mtm,WA ON" (M)425-3545 1-BOw39-365 FP (35W)425-2398 AAP- ii oY-os -d6 oY 05-&6 anASs m9R sTASr wtx3 Px6xs6 9wx6 'A90RZ56 or 5231051106 CIn SPAYZ ZIP SAN<< .U159653 OP mu IOCAYIOA CIn 51:AY6 ZIP �SEO� HRH - 9Y� 1 A95A CODZ / PtloN2 A1111BA1 PAIICSt 1161®E9 TA61 PBSYOBIRD BY 1RE LEVEL am COLOR RECOVERY 1 lVog 1 9 TM LEVEL 21 It : IO 1 91 3 I /Sro✓n �S91 411 17 o ' 3 5111 15 I it.) , .vW 4 e :12 alwl sill 16 1 1.S c 7 9 / :l-/ 1 L c- C/�— W ir, I 11's 61 i i1 S II' S c%, 1 12 it 130 I .S G ,, 11 13//:T 5 11, 1.J c%i 72 14IIAO 11' Cl,,, 13 75 11.r G 14 16 12:o G 15 17 " I S 16 12 .30 I 17 19 IB 28 19 21 22 25 28 DRAW OOM_ - m STATIC 9 PI SEr�O /rya l�z w 31 32 OPY �J J 33 35 . . . .� _ d