HomeMy WebLinkAboutAPPLICATION FOR DETERMINTION OF ADEQUACY - WAT Application - 9/18/2015 •f
Public Health
Always',Norton or a safer ► healthier Mason County
PO Box 1666,415 N 6a Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 + Belfair.360)2 5 4 46 gext 400 + Elma:(360)482-5269 ext 400
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Application for Determination of 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 system utilized. .
3. Submit completed application,with attachments to the health department for review.
Part 1: Applicant! Parcel Identificatio
ScUtyk i,1wl GT'\ � it 0015 [
Name on Applicant: )�1vsi y -- Date: e Q
Mailing Address:1)0 e )c C1( 3 tjQ�filIV A Phone:: ?j 620 -z 1 - D�1,
Parcel Number:: 7-7-?.??...)0" " J(•-) - w 26
Type of Water System / Reason for Application
Public/Community Water System(2 or more l Building permit
connections)** 0 Division of land:
1 Individual water source(one connection), #of Parcels? SPL
_ Well 0 Boundary line adjustment
0 Spring/surface water 0 Other(explain)
0 Other(explain) 0 Replacement(please indicate name of water
If you have more than one residence connected system below if applicable-no signature
to this well, check the Public/Community Water required)
System box.
Part 2: Water System Information
Complete the section appropriate for the type of water system being evaluated:
Public Water System
Name of WaterSystem:RYNiCA-kk 2 'pay wQ , ,
Water Facility Inventory(WFI)Number:
(write"none"for two-party)
I am the manager of this water system.The water system has been approved for 2 services.
There are presently t connection(s)in use. This will be the 2.- connection.
0 I 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 bye-state and local regulation.
Signature of Water System Manager,i(.L ���i/ Date
Revised 712013
Page I of 2
This form may be scanned and available for public view on the Mason County Web site.
Individual Water Well
tzi' Water well report(attached to application). Depth 21.1 ft.
EI ell capacity Test(attached to application) gpm gpd.
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 by a licensed contractor. !1
`4_ �x Satisfactory bacteriological test(attach to application). .X I Slinti ' ,
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ I 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 statement, the applicant will need to arrange an on-site
inspection by Mason County Public Health prior to determining adequacy.
Departmental Use Only: Do not write below this line.
Part 3: Mason County Public Health Evaluation
Satisfactory Determination:
Applicant's water supply does appear 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 in the future, or guarantee compliance with all
applicable WDOE water resource regulations.
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
Keviscd 7/2013
Page 2 of 2
This form may be scanned and available for public view on the Mason County Web site.
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1:4
/15/2006 10:55 13602757501 TOP DOG DRILLING CO. PAGE 02
n py.W. • : . .: 'A TERM WELL REPORT . UN1Qt1EYVELLI3 apt
.COPY STATE OF WASHINGTON W'lef •Far, A<>�1 .._._
TN"Copy-orinarf . Na• -
(1)OWNER. *one MABx..Y. R4Q.• • Addreaa •
.(2)LOCATIO1i1 O WE=i.):: -�•tom-••+.• _
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TAX PARCEL NQ -:' '
.(3)PROPOSED GM :' Mom' t :D ;]Mt
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L j kriipoi -f?Tat Wiiir C Othdr ponanac toicke byiatia.cimAlgar'ins ormatorir aril and In land and •
• • ••' '��,O�Mfarr;':' •' :. fttxs d ehs anW was• s►a1401 +h.tsl.q rest at tidal aria ui* fir Mob amigo. .
a dsomufiort Vidlcpts.h rarer srrosu trsa'
(4)TYPE OF INORIK:' *ones n+ttacir 6r+ (t OWe than oft) %_— __: --� _
• raw W,$', . ,. ••••.frldi.sd; yNTER1AL: . ,FR TO
•
• . aapeimt!•'; •,i c . Ueosed BROWN BAND AND QRA L • b - 5
: ltlacce ef* :' , cable • .$)R CLAY G EQj---__ 3 •05
• c?JMesa' BROWN CLAY AND_SANO'�D 05., 147.•
••. (5)'Di1 ION8i- .o)t,Qtitecoftre1 .. ....,_ }X.__. __�_1_wow,. •BROWN SMD.QRAVEL AND CLAY CEMENT= 147 - 240
9,6e4 •299 � Oey�are�n punfe wilt r 293 �, �_/t• •DROWN SAND AND GRA'EEL WATER Br.ARIIIGI '240 ' 299 .
(6)CONSTRUCTION DECALS. •.•• •• ' I__________
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Cas�g Irretallath _ - ".`
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federation,:• 17fes XNo •• : ' • —..._ • •
•Type or perKxator usee` ,.
SIZE of p12000o0 - - .ray. l" r •
pertocnitunt<•A•ofrh ' dLiO _. -..__ _ •
_—. '_- pir�oragottstt�di+�i �, ''.'r'1Lb ..---_..__....a
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' • .a Screens; • [�Yae !No. 1Gdraci4 n'. . • •
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Dam. Slot size . fiats►. - R.to R. .. __. . �.... i
Grar.uFyn�a.�r paidc B!l i+a'`�'.s a s#iiw�r+e~ _ Y ' • • : • • • • . •
'Mneild P�'ltarrf ' ' . • RAP --.---
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lAstfotl o/saepnp iae:of •
Cr)MAW; Muttstec rirs Name eE$SaE'Y„ _::- - = -- . •• • .
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(8)WATER LEVELS � R work •
started 1/1512003 .: • ,1t1.'Contpuiea� ,tti..,_„ ,
above Mean See,ole!StaSe 1"31• . 237• ' • _:R t,e1011op.d>adi • Dels 1 3_. WELL CONSTRUCTION°rERTIFICATION: ' '
nnesaut txd w e . 1�;e•: • t�ecs i ecrudr eked end4or accept tei.ponsid9ty for dentin ction of arse eti.rota.
'Median water*oororonea ley _ . .. eampAaneta WM all W niasldnstete'well co nIc*on steedenia..R!laiartata utiao
' - t"- and the information reported*love'ant true t io my best b mts ps and belief,
• •
• (9)WELL TESTS:,p aIs srnculis%to't j,la.lew.red bstow-.- - i.vai • Type or Pilot Name Noy c j Juggyt�NIST _ License No. 2147-
• wait a pump teat rneida? 1LlYeu-i)Ne•.f.i ii,.ihtia401O7 . µ eroded Dili rnpkteet ,
• YteM; gailfr rt with•' • : dnttidoesssefts!r _. m Menge_ hie- Treinea Nae No.
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RecoyerY dads lliaie tartan as'siro sedan Ptut'tp*oil oliks Peter level tmeestaed . , 1 • C •
. . Pram' • top to WalWrlsvet) . (Strad) �1,14.- , r ' Llpense.t'►o• 2147
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•• Time Weber'Uhler '.. Time Weli f.41 i Water Level •'• • '
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Address ytlA. 0650 .
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