The URL can be used to link to this page

Home My WebLink AboutWAT Application - 1/28/1994 MASON COUNTY DEPARTMENT OF HEALTH SERVICES POST OFFICE BOX 1666 SHELTON, WA 98584 (206) 427-9670 FAX 427-8425 APPLICATION FOR DETERMINATION OF ADEQUACY Revised 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 system utilized. 3. Submit completed application, with attachments to the health department for review. PART 1: APPLICANT/PARCEL IDENTIFICATION !li ll iliU llI IIl Rili EiftN N!i!i S!I!S:i L':i!ii:!!ii!i�il(i�I!!!Eiii ii!i ilii ii l�i fjl,IU III EI1I11111I1111N Ii/iIN III II IEDIIS;Ii ll:i:iifilii iliiii tiiif1111E11 il1l it❑IIINIIIENEISUI NAME OF APPLICANT 111bbY__A f.lF )n Nl'L �Q'S I l e DATE MAILING ADDRESS � ,WK I� TELEPHONE ( JD6 ) Z7s-49S7 iIY k)C . ere> me_a ma_L ASSESSOR'S PARCEL NUMBER 2� �o —�Y� '.C(NY 23 .J— 1� ' II ,c. cep. SUBDIVISION (If Applicable) N LOT TYPE OF WATER SYSTEM (Check One) REASON FOR APPLICATION (Check One) Public/Community Water System Building Permit, Single Family Res AIndividual System, Drilled Well Building Permit, Commercial ❑ Individual System, Dug Well ❑ Building Permit, Replace/Remodel Individual System, Spring Land Use Application ❑ Name Individual System, Surface Water Type Individual System, Other Other PART 2-A: PUBLIC WATER SYSTEM Ill iillil ll 111 111 it lil 111 ll it ii it till iliU UliUii::aia IIIIINiiI II IIII IIII II IilI it 11111IIU I11lU Iti:!:a lilt 111 ll lil iti it ll illl llll liil llil ll:IlU liIN::IIlill illU!il ili NAME OF WATER SYSTEM WFI ID The water purveyor for this system has previously filed a certificate of avatar adequacy with the health district. I an manager of the above referenced water eimbes. me wares Mt® naa rcm approval for _ service connections, with connections Drooently in use. The applicant has approval n connect to this at. system. service of water to the applicant for domestic Purpoaea is consistent win bath the Water ay-tea plan and no water right permit presently in affect. Water lines are available to no applicant's property line, or the applicant has made eati fartovy arrangements to extend the linen. 9IORATOA£ OF 9Y9TEf M A06R Dnrz W-7 PART 2-B: INDIVIDUAL WELL l ili ili it iiiliiliSl Si Sl ii iiti it iitilili it ii!i ilii ills ii ll iiliitll it iill!n!ll it lill ll iill iln!!Iiilli illl llliil l!I IIIII II II III III II IIIIlIiIIl Woo I ICI II II III III II it lilll WELL DEPTH l.5 o I A Ft WELL CAPACITY d 1 Gallons/Minute Gallons/Day Well log is attached to this application Well capacity test results are attached to this application mares: well capacity testa are often performed by the wall driller at the time the well is con- structed. Teat results from these teats are noted on the wall log. pmeults frae these testa will to accepted by the health department. If a wall lag carrot be located by the applicant, a wall capacity teat rest he performed by a licensed Contractor. Baler or pump teats ass acceptable, provided sterilization of draw-down has been msasurei and redorded. Satisfactory total coliform test is attached to this application. PART 2-C: INDIVIDUAL SPRING OR SURFACE WATER iiiiiiiii!iiii!iiiiiiiiiiiiii!liiiiDS!S!S!3!i3i!iii!L'I!1!Sll!!S[!1!!illi3!❑!31llSi!!11!i!1S!0N!SIllIt3SiSit!!liiihii!iiitii!iiiiiiiiiiiiliuunif nunnuunnnn:: NUDE permit is attached to this application I have reason to believe the spring proposed as 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 NOrs: In addition to prosining the above mtatepa.t, the applicant will need to arrange an an-aitn Inepsotion by the health district prior to dotezminatlon of adequacy. PART 3: HEALTH DISTRICT EVALUATION (Health District Use Only) SATISFACTORY DETERMINATION: Applicant's water supply appears adequate to meet needs of its intended use. Note: This datered.tion does not address adequacy of the diatributidn afar., guarantee an adequate supply of water indefinitely into the future, or guarantee compliance with all applicable mox water resource regu- lations. 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 /i2�9y Face Original and fYa!CovY with Application No D Parriaent of Ero.a WATER WELL REPORT U.j Second Copy Ow.er'e Cop> _ (1)'andLWNERIONOF'�WELL. Cut1YGIA95ua . ..�ATBOF-WAAdre.l�14Y.�fi&Lw.at4xL.SW. 4S�PY0YTCermit NT.a.a'N w.._l W.M. � .dng end distance from..lion or subdkvlAlan corner (3) PROPOSED USE: Domak. 0 bdakkd ❑ Murdabl el❑ (10) WELL LOG: Irrigation ❑ Tat Well ❑ Other ❑ Formation:Describe b color,character size of material bad Atraeal nd shore thitkrwa of ayuvg on .and the kind mr t Hato.at the mate I in a.h .am Ow ere numb of well .e. prostrated, with at least e entry or W each change of fmation (4) TYPE OF WORK: Rt more than net. . _... ... ... MATERIAL FROM To e s New wen ;❑ Method: Due ❑ Sore t ❑ T` Deepened ❑ Cable 17 Driven ❑ -)1Cun--con ILA1a>Yatsl_---- ` Reconmaoned ❑ aatarr❑ faked b k (5) DIMENSIONS: et of well � b. ar.n. Drilled _ it DepthocomPleted well L 2 ..... T{raIwn YI`I�MII, wva]y erld weter _ 10 a+.- (6) CONSTRUCTION DETAILS t � llwt�lrntr Q Casing installed: (y..... Diem from ._...v._.. tt. to to .__a- l 2 _ n. Th readed❑ .. Diem fl from ... - ft. Weltletl[] J' Dlam, rose, rib _..__ ft. l Perforations: Fee❑ No IS Nediah !noun cl a th Cevel Type of peOcrawtor lYed SIZE ofperfo.tl.N .. ...._._ W. by ...... _ tn. Redieh brinit clay with r ..._._............. petlorakov Irom _...._..._..___. n,b __.__..___.... n. and watee[ '.. _...___............ .rlontloN (rose _......._......__.. ft. to .____..._._.._n. ,.... .>. {}[{ - perforadoN ��from . — n b . -. ft.. t 7 Screen. yeeb NO[] fl'- { TYPe Rill¢a9Q..._. D1 ......... Slot After .5/ !rose .LJ*).. tt to In_..n DI .............Shot aka .. from ........_ rib Gravel Packed. Ya❑ Np4j Mae Of treed:.._ .. _ ff Gravel'Me"from ........... .. ...k.to... ._._ __ft Surface seal: yes 11 me ❑ To what depth? _48-252-- n Mat H.1 Used 1 .el —. -- yDid Y strata co wi abl waterf ye,❑ No p! f Wetter? . . Depth of ek .e l.allg t ta R .. ....... ._. -" ex S (7) PUMP: Menyf.atura TYPe. BDlrlle.CalDl.! ....._.._ ( ) 8 WATER LEVELS: L o-auto. I R D aba a mein w 1 ei k. Attic le ft. below tap re well Data a( Arteels� p e __-)Ire.per square Inch Date i Artesian water is controlled by - 1CaPv 1 t I (8) WELL TESTS: Dwdown 4 mount water level v —. lowered below static level Work sta tetl .............19 ___. Covent tea .. 19q{ We.a pomp test model Ya❑ Noll] If ya.by whom, -...r... Yield: gal./mW. wIN n. enwaown attar hre WELL DRILLERS STATEMENT::. ' This well wall drilled under my Jurisdiction and this report ill true to the beet of my knowledge and belief. Recovery data (time taken As .ro when pump boned eHl laaltt Wet mAssured from well top b water level) NAME.....UUYAS �t1.1.11.).{u; .. t •• firm M ndohl (TYP c f 1_r Time W t Level Tlme Water Laval Tbhe Water GPfI (person -n^ y ..... .. Addre...Raifeit 9a, 902£ ....... ..................... . /Dot f tde __. .. ... ._. [9lgnedl..._. 5 ..... R.ue. tart Z. s 1/ I lm .1Q.......t dnwdowp .nee_.__..( _ha, ArtetlLt aore.d.'... ... _..... ..._l.vID. Date. .. . .................... ........ 1''' Liceaae No.(1f11� �� Dale.... ! lB d^ TeR�atu i of water.._ Was a andelchl aNl>de medal Yea b Me - h— ttl all r }� 4i (USE ADDITIONAL IF NECESSARY) 'r� elg?p.s STATE OF WASHINGTON i DEPARTMENT OF HEALTH WATER BACTERIOLOGICAL ANALYSIS SAMPLE COLLECTION:READ INSTRUCTIONS ON BACK OF GOLDENROD COPY n ImwolbR..n not 1611 .1,.."m WIN IN I.o. ' 7olBY e�q NAME OF SYSTEM SPEOFlCLOGMW WIEAE SW.PIE COILECIm TELEPHONE NO. YL �;II IrIL �rCf. DAYIJ'Cl /., GJ EVEN-0 SAMPLE COLLECTED BY:IN./m.I BYSTEM OWNE W)" :(Nw-) ( ,i�. SOURCETYPE ONOUND WATER UNDER SUREACE INFLUENCE ❑SUf1FACE WWELLRELD ❑SPRWD ❑�RIIIIES®a ❑w�°N SEND REPORTtt):IPdd WII .AddreM.M]1P L/A./ H � FTINE rE(NWI•^„Y aIW w t❑DAMnaIed lRaYdul:_TdM_Fm.) WATER"A--+AMPLEddam presence Lob. Dew 11RCE WATER Sous M® m ❑TOW LaRam ❑NEWCONSTRUCTIONw REPAIRS ❑ aaN ❑OT1ER(SpKm REMARKS: �.. ILAN iNUT DIWKMIU WATE RESULTS ❑UNSARSFACTORY,CD -preeed SATISFACTORY, oMlame abed 8REPEAT ❑ E.Ca l,N Nt ❑ E.CNlebeenl REWIRED ❑Fein M. ❑ierel opeed OTHER LABORATORY RESULTS TOTAL COUFORM_ILDD w E.COU_RDDM FECA-COLIFORM_RONW PLATECOUM_Ad ANOTHER SAMPLE REOIMED SAMPLE NOT TESTED BECAUSE: TESTUNSUITABLEBECAUSE: ❑ SanpM boats ❑CmlluenlNroYAh ❑Wmnp amwNlar ❑1NTC ❑h1oAaPww IOInI ❑Tu cWlure SEE REVERSE SIDE OF GREEN COPY TOR EKPLANAnON OF RESULTS Mg _ MTE,TIME NECRVED RECEIVEDHY WTE IEPOIRED ( LIBOMTg1Y: