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HomeMy WebLinkAboutWAT Application - 5/15/1994 N.NSON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX 186 SHELTON, WA 98584 (206) 427-9670 FAX 427-8425 APPLICATION FOR DETERMINATION OF ADEQUACY INSTRUCTIONS 1. Complete part 1. No determination can be made until Part I is fully completed. 2. Complete only the portion of Part 2 applying to the type of water system utilized. 3. Submit completed application, with attachments to the health department for review. PART 1: APPLICANT/PARCEL IDENTIFICATION muummuuu�umnuuumummumwumrmuyu/uumuunuuumumuuuuummumnmumuunummmuuumummmmuumw NAME OF APPLICANT M]0V � '1\A{LGti C�-{c!^� DATE � 15.1 ,r MAILING ADDRESS r)tay_ 11yU TELEPHONE Si�c.LGnaR_ u.:h 9ssz.€; ASSESSOR'5 PARCEL NUMBER Z Z'3 02 - VZ O D)qO du 1_1! —42.f, SUBDIVISION (If Applicable( LOT Leo?' a ` S,P �Zf] TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Check One) Public/Community Water System Building Permit, Single Family Res Individual System, Drilled Well Building Permit, Conmercial Individual System, Dug Well C1 Building Permit, Replace/Remodel Individual System, Spring 11 Land Use Application Cl Individual individual System, surface Water Type Individual System, Other Cl Other PART 2-A: PUBLIC WATER SYSTEM uuuuunuuuuuununnnunuuuuuuuunwnnnuunuuuuuuuuuuuununuuuunuunuuuuuuunauuuunuuuuununnnuunw NAME OF WATER SYSTEM WFI ID no wur pdrve}vc for faie system oae Prnlwely flied a artlficate of or. ado mac, vim Me aemlm dleuici. em emoNer of Ne eDove mforencad Water rysfem. me wur ayrtem oas = app[wal for rn wnlee cn.rric., Win cpM.cr3wN presently n ... The eppl3 Cani n4 rpploo.1 'L C®nant rd rile wr.r syetr. yrvlcs of vataf r Ns epPllcanx :or darCc purpow .e cwairrsnc win onto '_f'a wur System Plan and no rter :pgbi amit presently in sCwS. water tines ars avel Lille w me applicant, prdpsrty line, or No a1Pllcant 1. noti.fectory arrengrenn to noun _ne 11nw. 3ILNA1VAr OF SYSTE*I X ALA JA1? PART 2-B: INDIVIDUAL WELL uuuuuauuuuuuuttuttumunuttt:HtNtNttttttNttttt:uNt:uuutwmunuuuhnuuunuuunnuwhuununuunuuuununuuuuhnhur \ WELL DEPTH Ft WELL CAPACITY Gallons/Minute canoes/Day well Log is attached to this application well capacity test results are attached to this application ayes: VLL3 upmiq ul[a tl• o[tm prfa:eee q tal wll lillla[ +C [el [3> tel wll L Cm+tlecttl. Tr[ [vault+ [sa cNr au Y� mW m tL wu :aq. prulu [rw cLr cry vlll ev a¢pW q W erlu llgc•�lvc. If a wll l q cmmc w, 1e tw q ry +ppliclv[. + vl1S upvlq trc .mat Y PH®e q + llcrutl wvcreccs. BLLm e[ pay tsu +ca +¢y[Wl+. piwlar +upilli+yee a[ eia�r-EWv eva 9re y+u[+e am .-+Ct¢yC. Satisfactory total coliform test i, attached to this application. aft A'crWAE)b Lt--rrkA- [mom UA41,0 W&LL, DCtwJOr— PART 2—C: INDIVIDUAL SPRING OR SURFACE WATER uw:uuuuuuuuunnrnuuu:uununuNtnn:Nut:mHtmmtuhhmutnhhnmhuunnuuunuunuuunhuunununuuuhuunhuuunt WDOE permit is attached to this application I have reason to believe the spring proposed ae the water source will supply adequate water its intended purpose. This belief is based on the following observations: AUTHOR OF STATEMENT DATE RELATIONSHIP TO APPLICANT soap xv +amuoe m ptwleinq N+ +eevl +uts[, tel +pplluvc olil vr6 to +czavgl r m-vlu 1n�pmLten vy ul urlte eL[[Sa p[So[ u e�tus{v+t1m e( tlyv+ty. PART 3: HEALTH DISTRICT EVALUATION (Health District Use Only) ununnuonnuuunuuunnnuunnutnuuunuuunnunuuuuuuuuuuuuunuuuunnnuuuuuunuuunuuuuunuuuttunuuuuuw SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to meet needs of its intended use. lea: This erl[mimclm er_�mc tla s vrgo+ry of W lLccieucivv Mcr, gu+[mrw m +a.qusu +apply of wu[ Sval[SVSCLLy lam cal [vcui+, or gr[mtw mlpll+vcl wlu LLl +pp11eNL VN6 wuc amum taqu- Ldml. UNSATISFACTORY DETERMINATION: Applicant's water supply does not appear ade— quate to meet needs of its intended use for the following reason(s) : HEALTH INSPECTOR DATE i - Davis Drilling, Inc. NE 340 Davis Farm Rd. Belfair,WA 99525 275-5367 To Whom it may concern: Having drilled several wells on Toonerrville Dr. I do not anticipate any problems in finding an adequate supply on the property of Randy Speece located on Toonetville Dr. in the SW 1/4 of the SE 1/4, of SEC 2, TWP 23N, R 2W, in Mason County. Attached are some well logs from neighboring wells. Thank You, (� Mike Davis w yas F1.1 Cepr wnn WATER WELL REPORT Deremer-1 of Ecdlpg' Around copr mww:s copy STATE OF WASHINGTON Tend evy Dr iei a Copy Wg•r Rp I'Wad Xo 411 OWNER: won. �. ,I) LOCATION OF WELL: LanM IA.. - Y,1 n7ns T�0..R-2Lai (]a) STREET ADDORESS OF WELL for«rrrg ada«s) NE 580 TOO11eryi]Is Ur Be If air 6'A 9852' (3) PROPOSED USE: }7 Domestic IMugWI ❑ Municipal❑ (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION ❑ Initiation ❑ Dewerr Test Well ❑ Other ❑ Famigeni D••olow M paor, eared.. w+e a m•terirl aria gmnure, end •how Mlekrge of epuMm«d this Was rand return in the IMrrul watch•iota.P•«tnled, (4) TYPE OF WORK.mDe m Iwnariewxa•.'t- a..d der rtwgaR«Wrwerarauroaartwmetlen. IM ) WTEIyI FlMr M Abandoned F] Newwell ❑ Method: Dug ❑ Bored ❑ Deepened ❑ Cable o. owns. ❑ Reconditioned ❑ Rotary,❑ Jatied ❑ :;; "]O:arT e l' 4 (5) DIMENSIONS: DlemWerof.01 wches. Drilled feet. Depth ofcompleled well '47 X. .ri 4 (6) CONSTRUCTION DETAILS: -;k+ f 'nd it raYCI )gijil Vatcr ]: Caabgbudaud: pla-man, wi ER _• DMm.hcm n.m X. Sa:rl & gravel With Wntcr 140 147 LewrgrMa S ylmaaa a.m.wm n.m n. Perforations: yw,U wkj • TypralWrtaatx«ad B�aprgxgl«a. Y.M w _ q.atlroM M1dn X.Ip 6 P•rlartia4 hpn X.1a n pMdNlmhan X.se n. 1PCraaXa: Yas Ne LJ WngMwYa Bela• :.«'-. • Type ,.L^. - •<•". Wdgw ■' Dlue Sm Wr fi L4L X.Ie- -4 c Drm Bbtraa r.M Orawlpladurd: Y« w NMofraa grsMplresdhan n.lo h. Bud.Beal: Y«13 wo Towwl drpw0 X. Mali it b«N 'tom Dm gry atnm eWr«s«Warn Y«0 w© — Ty,ent"t n +"^rhaie �. wlMd a«al«W.I.M (7) PUMP: wngegxrfa Nun• is' _..� ._ —__ TY«: NP I i (e) WATER LEVELS: ib wearmiwarlwag�ie�.a�--__ W snlb M«I t n.UMwtopawn Deu M•Wnprr«xr b.px«wm rgl We Ana•Mn wgx r wm.are by Vey.w«..e WM•Mnw ) �- •_p_.( tan M 1� 'll/'-t ,lp_ (9) WELL TESTS: DrawdgWPbsm nl wrtx Nw.lY b.xMlwlo.anicww wssspemptagmso•TY•e w ny«.bywhae> WELL CONSTRUCTOR CERTIFICATION: YWd «I.ImN.wtel fi.dmwduxr rnx M_ I congructed and/or eccepl Mspongbilhy for construction o1 this well, -- arm Xs compliance with ell Washington well consbuaion atrudreds. Materials used and Ma information reported above are tree to my beg Recorery wuDm Mr«rr+xowMnpumpw«a eMlWlx wgm«•wa0 Lnowrdge and babel. fmmwaulapmwgx MMD tw• W.I.L. I. wanL•rw fax wx.Ewe i�t'LF Driiillk NAME Ort+uaR.rwr.a Cplpolmntyoro RyE os own) Adds« litllaiC WA 90526 Daeal«l iekl6 Bella lag «I.Imb.weh ]_�' n.trswdp«snn�M• OOrHrag0!'a IwEU DRUEuI /JnM MI.ImN.w.halam Mg h.la M• r' phobbIW L_• M J1( .1' ].olr Data Muin«w _ppm. 0W. No. ` (1 i. freer) fr wgx_wae.rn.mm.LnrMg.m.aev r..h' N.G� (USE ADDITIONAL SHEETS IF NECESSARY) 40 , EcroEoero'Uu en .mge- .�•+ pan capnewn, xx .'s Caps with WATER WELL REPORT Dp•nmea a EcapQy Tare raP cop�yoPY STATE OF WASHINGTON Wale,papa Oxmn Nast (1) OWNER: Name Aas..• �.-. LOCATION OF WELL: couay _._n.Sed . T_N..I If (L) STREET ADDDRESS OF WELL(a«..•eerw) (3) PROPOSED USE: L7 Domestic Inlaetdst ❑ Municipal❑ (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION Irrigation D•WI.r Test Well ❑ Other ❑ Formation Daewoo y edx, axna.r, aka a sonabol was ahead, an snow nwn—nureps,an ew I tNGkn•u a«une s omal thekM.M mlae a tM resistant k«cn nnton assassinated, ( ) TYPE OF WORK: to ma.m.n ore) wnn.tWuta«xroyxx«cn wtw.aaam.ml,. Abandoned New well ❑ Method'. Dug ❑ Bxel ❑ eNllwleL �a M Deepened E Cable ❑ Drivan ❑ Reconditioned G Rotary ❑ dental ❑ (5) DIMENSIONS: Oiameterolwed wlchae. Drnletl feet. Depth of completed wall M. (6) CONSTRUCTION DETAILS: CPWtpine ; OWm.xam n.ro n. Wele•a 1q� U.m.sore n.a n. tow y - Townson Li pkT han n.ro n. PwflwrwllPlM: YM 7 No - Typaapxlanxlx« M OPMornbse M.y 4 p«fxnWm nom n.ro n Imdx.tbn.axn n.ro n. pMonllxx More n.to n. se . Yeau W MMWeNrvsN•ree ' T". M•MNe Own Iwl W. R Orm abtam R« n. Orewl palial: v« Np ' wMgtPeeN Ore.•IPIeueOlrpm n.lp X. BDIIepe Mwl: Yp❑ Ms❑ TawNte.pml n. WIMaIwMlnw•I Db eul'Mn4 MeleWxWpW xMM Y«❑ WO Type a wetM— a exn. so.11xe ae•slpaMseX (7) PUMP: M.MscNeYa Nam• Tram: X.v (8) WATER LEVELS: •eaw-IIWi�w Wixom n. 81•Ik pastel X.ylw rop•twN 0•Iw M•Wn Wax• p.preawa NN Per.— Msei•n wslxkcaama«py IS) WELL TESTS: Or..ap W. P,1«tx Mwlbbwx•e ykwxnk4wl Wxn...-atest « «— i w•.aP«slMm.en Y«LJ xnLJ Yr«.ywhasev WELL CONVIRICTOR CEFMFICA71ON: t YYtl: 0•I.1mF.ran X.6ewlpwn•nx M. I and Its compliance wnn/Pr wcaaPl Washington well connitudlon of this well, and Na Daland thpa he i HI Wellington wall con or. hue o try res. Materials wledglad all ms Mlgmxnbn sported above ere Irua to my pan aeons1op to*at ,Wr•I)sLstro Men pump tvn•l aDlvlxlMlfeeswM Mov/la/peand pallet. Iws w.iw Len. ire. wnwLM now W.wtxY NAME Pmed.aw,w cproJiutlop Itrna m tswn AGlnss D.bpn..t Ma•rtnl P.I./repast waa X.er•wUewn M•r M. (Signal) LIwnMNo . Coanoror'a M(xYu�)AH«t y1.Imin.with nstm M•t RM ar•. fl'°�`M��t)L17,�nrri : . 4 ry •F M•Wnno. g.c.m. GN xnaxn M) No 'T w"tx_Was.awnlule«ens m«eT Y•s❑ W❑ S va'nno"m none .1. tp,s .ni (USE #DDITIDNAL &1EE