HomeMy WebLinkAboutWAT2024-00013 - WAT Application - 3/7/2024 a
MASON COUNTY WATCOMMUNITY SERVICES ~J \ n
\ 9udd..,Wooing rmua .l H IlhC --iry Hix
\n13��� 415 N 6m Street,Bldg 8,Shelton WA 98584, RECEIVED
Shelton:(360)427-9670 ext 400 9 Belfaic(360)275-4467 ext 400 P Elma:(360)482-5269 ext 400
J FAX(360)427-7787 MAR - 7 2024
Application for Determination of Water Adequacy
15 W, Alder Street
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 approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: l '!f CY . NA�F Data:
�- b— 7
Mailing Address: it, ki ll�(fh Iola (x/ Embone: -?L6 �- V??�
Parcel Number: W Q l oS-nraoo
Type of Water System Reason for Application ,�-
❑ Public/Community Water System(2 or moreBuilding permit at�ay^ 0022J\"�)
connections) ❑ Division of land:
PL Individual water source(one connection), #of Parcels? SPL
Ja. Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Remodel(please indicate name
If you have mom than one residence connected of water system below if applicable-no
to this well, check the PubliaCommunity Water 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:
(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.
Signature of Water System Manager Date
This forth may be scanned and available for public view at www.co.mason.wa.us.
I\6H Forms\Dnnkin8 W� R,v.d 1/25/2018
Individual Water Well
L]t-Nvater well report(attached to application). Depth y"c�4Adv "ft.
l( Well capacity Test(attached to application) k//b pm 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 lest,which provides stabilization of draw-down and recovery data, must be performed
by a licensed contractor.
�OSatisfactory bacteriological test(attach to application).
// Water Resource Inventory Area (WRIA)
Development within which WRIA http'1/gis.co.mason.wa.us/planning 14=15=16=]220
Water use or limitation recorded................................... N/AJ=-Yes_=
Well Drilled ............................................................... Date
Individual Spring/Surface Water
❑ WDOE peril(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)
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 Permits 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 its intended use for the following
reason(s).
. RjReviewer's Signatures:
Environ. Health:
1` ' ' —i Date
CSD Director
Date 2 of 2
Arcadia Drilling Inc.
P.O.Box 1790
Shelton,WA.98594
Customer: Carey Charon Well Tag#: None
Site Address: 320 Satsop Maple Glen Rd, Elma Static: 8.1'
Date of Test: 1/23/2026
TIME GPM LEVEL RECOVERY
1 Min 16.5 16.6 TIME LEVEL
2 Min 16.5 20 1 Min 21.1
3 Min 16.5 22.7 2 Min 15.2
4 Min 16.5 23.8 3 Min 11.8
5 Min 16.5 25.9 4 Min 9.6
6 Min 16.5 26.9 5 Min 8.5
7 Min 16.5 27.6 6 Min 8.1
8 Min 16.5 28.1
9 Min 16.5 28.6
10 Min 16.5 29
15 Min 16.5 29.8
20 Min 16.5 29.9
25 Min 16.5 29.9
30 Min 1 16.5 1 29.9
49 allons Pum ed D ���� v �D
BY
Thurston County Environmental Health
412 Lilly Rd NE U Olympia,WA 98506
360 867-2631
'fHUPBION COIIMT
COLIFORM BACTERIA ANALYSIS
l DeleSertpk COl Tme Sample County
D /0I1`11Pn CO BChtl Me
Type of Water System(check arty one box) to Private Houxhold
❑Group A ❑Grow B ❑Other
Group A andA a'�ndd G_m_uuppp B(S^/yetarps-Pmoideftoom�WW is F IIM lmenlory(WFI):
lot 1 V — DO y
Syelem Nanw:
I Contact person:
Dey Phone:( Cell Phaw:( )
I Email' C.104CjImEeeRhone:( )
Sentl reeulb '. nt l name,etltlnx a[dz rear emee cal
la C—1 ut�wk
SAMPLE INFORMATION
1 Sample solecism by(nam): n C n �l A(QY
Specific kretlon or adtlress whore sample ml clad: j Special lnumucbms arcornmente:
3;L0 SlafSa�clp�
TM of Sample(must check only om boxuf9191muph g usled below)
1.1FRogna D'rsldbutioh Sample 2.Repast Sample(ab,Motet rcaNrre)
Chlorinaled:Yes_No ❑Disubut'on System
Chlorine Resitlual:Tonal Fina_ Chlorinmed:Yea_No_
3.Raw Wafer Source Sample - Chlonne Residual:TMa1_Free_
❑E.m6-GWR(AP)
❑Fecal-souma.cwl=nalmawsax Unsatiefeclry mrne u kb number.
--
FiltsmdYea No
Cl Assessment Wrmin9(AIP) Unsetlsfamorymullnecol'eAdmis:
❑Other
S
4.❑Sample Collected for InformaUon Only
Inwsfiganw_ Consiuctlonlibmairs_ Other_
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
F ❑Umef k fory Town Colikrm Premnt and I R"facbry
0E.9 present ❑Ewbabsent NoColiform detected
Replacement Sample Required:
❑SamplemooM( 30hours) ❑TNTC ❑
l Baclenal Density Results.Tatel Collorml100ml Ecof1/100m1.
Fecal Coli(orm 1100ml Entemcxcs11D0mL
MWW Coda:eg SM 9223B [ISM 92UD Dat and Time aerawd.t
❑SM 9215E ❑Entesion& qfh
DefewMTme Analyzed: 5Date aepwlaG' 7'kr1
sampexumeataax nurm l+a b.apa LW Un onN:
0 8 0
Fey 131almvtlllltll SL
' IC1L reM