HomeMy WebLinkAboutWAT2025-00006 - WAT Application - 12/17/2024 WAT $ - QA^l(�
MASON COUNTY Sh 415N8584
40 elton,WAS
Public Health & Human Services Shelton:360-427-9670,Ext.400
Bdhb:360-275-4467,Ea.400
Application for Determination of Water Adequacy
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 connection utilized.
3. Submit completed application with any required attachments for review.
4. An appmved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification Name on Applicant: �T0150N �Gt.G -'- Date: _ In I Z4 "
Mailing Address: 1076 F E&,21f. &.4 bl, hone: -Vp0-4gD-r'(07U
Parcel Number.
Type of Water System Reason for Application BO.10?S-Ooa55 /-
❑ -G Public/Community Water System(2 or more JiL Building permit Fkvhwe- BtoAbV_x0) 0*1
connections) ❑ Division of land:
P1 Individual water source(one connection), If of Parcels? SPL
01 Well ❑ Boundary line adjustment
❑ Spring/surface water
❑ Other(explain) ❑ Other(explain)
❑ Replacement or Remodel(please indicate name
If 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. rJ g I I
Y )
Part 2: Water Connection Information
Complete the section a NICLZd7f1��o
p appropriate for the type of water connection being evaluated:
Public Water System
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 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.
Print Name of Water System Manager Phone
Signature of Water System Manager Date
This form may be scanned and available for public view at www.masoncountinimmov
J,\U1 Fomu\Drinking Water RVji 05NBI2024 Pagel of2
Group B Water Systems
❑ Satisfactory bacteriological lest within last year(attach to application).
Individual Water Well
Water"it report(attached to application). Depths } 1 q ft.
Well capacity Test(attached to application) //� gpm 7 pd.
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
A /by a licensed contractor.
IX 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 600 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 resource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Determination of
Adequacy for Building Pernits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of fls intended use for the following
reason(s).
{!�/ Reviewer's Signatures: /
Environ. Health: 0.�dL4.WVll°'b`/✓� Date bn L r
This form may be scanned and available for public view at www.masoncountvwa.eov
Page 2 of2
WATER WELL REPORT CURRENT
OJOavt&1^rapt-Emla6.3mnm-a•rvm,]rsmW-drillw dN.H.AT Na WEMM h3 3u (I4 3
ECOLOGY COnStruction(DeMMmk59ion("x•'incbrie) Unique Erngy Well MTNNo IN. ALUMS n state gluimi...F_
Construction -lent
Right R;ghtPrnnrt No. of FCn1n� Cir:iRO)
❑ Decommission OlVaoce L nient umber N -
Nrdxe o Intent Number Pmpwry Otmcr Name Jason&Kelly Laek
PROPOSEDUSE: ® Dinene ❑ ndurw.l ❑ MAAkiw WCIISUWAddress 1070 E Eagle Point Drive
❑ Mwamr ❑ Irrisaum: ❑ Tra wan ❑ aw.r City Shelton County Mason
Tee OFWORR: Owrch mmMofwell6fmmetlm arc)_ LKretian IIwNl4-Ind 0g-1/4 SK Twn 21N R dW EWM ❑
Naw wall ❑ Recwdnk:mi AkaM ❑ D:0 ❑ Beal ❑ Ha. U.1 r Still REQUIRED) Or
[IDegved ❑r4Nc M Rota:)' ❑ lenrd
DIMENSIONS: Oia:mlerah'ell 6 irches.dulkd]80_D. N1Wm
nl l ong
:h.rwm lead wellm it Dg g tat IT V,91]"N
ONSTRUT0n DElnD Lung Deg 123 Lang MiAVSK TO-23.930"R'
CULg ® WeWed 6 " Db:n Ann +] 779 it
Im.uca: ❑ Later imulkd_' Dwm.tw A s in_ .m . Tax parcel No.(Requiad) 421221200020
❑ TModul Dian,F..—it a_n.
Perrarad.m: 0 Y. M No CONSTRUCTION OR DECOMMISSION PROCEDURE
l"ofI''c:ffar m.d Fwmatiun:Describe by color,chamber,size ofmwerisl and mucture,
and the kind and Hewn,Aube materiel in each stmlmn penehatted,with At
SlzL ofpM_k.by_in.aM na dfpxB_Avm_8.m fl. leaston,Anu formchcheeV.fhdormation, (USEADDITIONAL
S.reem: ❑ Yes 9 No ❑ K-Ar Lomkn SHEETS IF NECESSARY.
stmn6mmers Name MATERIAL FROM TO
'lyp. Model No. Branco fine to medium s..dy xryd. 0
main_sMai:_Som A.m_A cobbles light,dr, 34
u.m. Sbuke Awn 0m d. Brow.Afty to frneand'gravel wilb 14
a 11111m.pa.k.d: ❑ Y. ■ No waaafw.cd/amM_ cobbles tight,dry 51
1jAara6p1a.ed fiam_a m_R Bron'n fi.e to medium s.Ad,dr,, 51 54
sanave ah EYea ❑ R. Townaaclxni sa n Brown fine to medium sand 'sharp ravel 54
nweriil.dinwl a®+ , tight,sill bound dr, III
Ind an,uma...o.mabk wmen ❑ Yes ■ N. Black fine to medium sand'errvel, Ill
Typaorwnal' Dcahofa:ma ve silt binder,dra 126
McAAAi.f.ma m.maff Brow.ft.e to medium sandy graval,d 126 133
PUMP: nlaaaomo.rarva:ac Franklin Matar/Ceotrioro Pump Black medium sandy gravel, nv silty 133
Tsu: Submcrisible RP, I UP 311115 GPM el.y hiadleg.dm 1 139
WATER LEVELS: Land.adau c4a:ion abme mein®kae1361 A. Brown git brown day,dr, 139 154
Smut k..1 318 a.bebw mpa —n Dam 7/192018 Brown flat to re.di.a....dy grawel, 154
Naaia.pmau._R.pnquart^.'h Dwe sill bound,moist 162
Amdea wearuwmalkdlimit,vdve,ea.) Black&brown medau An sand 'grarrel, 162
wELLTESrsi pawtl.wnisamow:water lave]is lmveM below sink level xTry silt binding dry 171
Wm.pm.pw:mnde? 11 Y.. ❑ No Igms,by wtmma Driller Oran eailt bound brown gr.,AI,figh1,dv,i 171 184
laid. 12 ml.noi..wim9 a.dawdown Ala 2 n:z. Brow.fine to medium sand 'gravel, 184
Yield:_,aI./min.wih Bdnndon,t afler_M.
YeM._1mllmi..wim_n.Eawd.wn aflm M siltmsand bound. gravel,
25E
fte .,Al n(ax:emdena•u.o.eenpnmp m.nnlapj(astir lnelmm aMfma: Brown medium ceps, ravel,loose 252
„norm m.ater rU,vl moist weeps,sal 269
Ti:rc wmrtee'<I Time x'aar tenet Time N'an level MuRFcoloredm dry
send ravel 269
tight.ere 291
Black fine aaraly grarvcl, n silt bound 281 313
_ Brown medium send y revel light,wet 313 331
as anmi
Black fine sandy grarvel, rai ,ilt bi.diz 331
tight,du 346
e.ue.ka_p.Trmi..wbn_a.mowaawO.fle._N.. Gn eta aBRd 746 364
Aimm 30._savmi..«ran gem aau 370 e.A,1_Fm. Brow.medium and nvellihtweter 364 379
Aneeinntlow_ePm Dine Black fine gursadly grayela dry 279 380
T.nq..ma.ofw.el—%V..cMndca nelyaie.ader ❑ Y. ❑ Na Swn Dine 7//82018 Completed Dale 7/192mR
WELL CONSTRUCTION CERTIFICATION: 1 constructed And/or amept mimmibibty foreamuuetion OftlAS ndl,end its cwnphmce with all Washiagmn well
co:Wrucn xi standards Metenals used wet dw inforrwlion rupnned ulxsau am vue to my best knmvlydge end bclkf
®Driller❑Engineer❑France NameR Dnlline CAmHeny Aveadaa Drilhagl.e.
rhaller/Emin AnTaii wSiamwre Address PO Be.1790
OJIIK or trrainee License Nn. 2053 City Sure,Zip Shelton,WA 98584
IF TRAINEE Driller.L'cense Na: 2 � Conraaew
Driller's Signaaue: Registration No. ARCADDID99KI On, 7/192018
ECY070-I-20(Rev 02-2010) Ta rcgaevrADA nrrpmmedndon including nwrriab in afommffprthr vnua8j•tmpNmd,roll Ervle&WmerRuoarcex Prvgram
w3ei"076872. Prnam rvRAimpnind Ararircg ram roll n'm0ingan ftel J'Senire nr 7ll. Persom arrh apearh dimhilig ram rNl7TYar B))-833-G3dl.
Vanguard Laboratory
2635 Parkmont Lane SW,Suite A
Olympia WA 98502
VMR,., D 360-967-7010
COLIFORM BACTERIA ANALYSIS FORM
Dale Semple CdleY Time Sampla Caanly
10/30/2024 :col�� MASON
aaam ow ram — —�fM
Type M Wale SWlan(ehed only one brn)
❑G.PA ❑G.PB ■CSIa
Gmup AaM Gmup B Syalaes-Pra,$ehan WaW FaCRIN Malay(WFI).
System Nana: Jason Zack 1070 E Eagle Point Drive
Calved Persm:Arcadia Drillitg,Inc
Day Phdn ,(W )42 330 Cal Fhunw( )
Etllwl: Eare,
faMtnuhb(Pnn,lull name,atlGaas am zipweebre.mal)
.ret.®amwem,lllnsram ABpienn@arrabmanragmm
SAMPLE INFORMATION
Samoa alleded by(name):
Spedfiobmtimwhem sampe mlbcbd'. SpaeWnabwyonea.1a:
Well head (Tag ALH985)
Type of Semple(sale]ady one We of sample ham types 1 thr ugh5 below)
1.❑Routine Dieldbulion Sample)A/P) 2.❑ Repeat Sample(AN)
alomated.Yea—Na— (tmmeinNttA..nwaakrumYmaline)
Unsabafaday mutne lab numbs'.
Chlorine Resdual:Total_free_
3.Gmmd Water RUN Soule Sample — '---
lMsahsbdary mu5necdkd dale
ChbAnaled:Ya No_
❑Triggered(AP) C Wm,RmNud:Told(AtP)
Free
❑Aaaecamenl —
4. BudaceorGWl Rew Soulce Water Semple(Enulreralbn)
❑E.,.# ❑Feral r,ieee rea_w_ B
5.0 Semge Gale d W Inlpmanm Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
Cl Unsatlstietnry Total Cdgomt Resent antl �Satlehclory
❑E.m prmwll ❑Ecayament
B.Wdel Density Remhe:Tbtal CoBam 11gan1. Ems /1OOmf
Fael Wk. invent HPC »ml.
Repleument Samplelbelubei: ❑TNTC ❑Senglebodd
❑ Sample Vduma ❑Damaged Container ❑
DWIFw U Relawea I
10to 30-11
Rmvd Twnpc: .7 2 "etlpOC M 2233
D naeaaeebD ub uee onry.
DDR Laeaamdeu
285-03011