HomeMy WebLinkAboutWAT2023-00308 - WAT Application - 11/21/2023 WAT�3 -0030e
!� MASON COUNTY
F COMMUNITY SERVICES
l 1
Building,Planning,Environmental Health,Community Health
•!IL 1,
415 N 6th Street, Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 s• Belfair: (360)275-4467 ext 400 •:• Elma:(360)482-5269 ext 400
FAX(360)427-7787
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 approved building site plan must accompany this application.
Part 1: Applicant/ P cel Identification
Name on Applicant: obe Y f C lose Date:
Mailing Address: F.O- (30X 5t 1- LW/y11 1 Phone: — 2 -41 q
Parcel Number: - CO0,
Type of Water System Reason for Application qq,
❑ Public/Community Water System (2 or more L'>� Building permit ,:�23'o1g-. /
connections) ❑ Division of land:
Eg Individual water source (one connection), #of Parcels? SPL
!$] Well 0 Boundary line adjustment
0 Spring/surface water 0 Other
❑ Other(explain) (explain)
0 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 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)
0 I 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.
❑ 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 by state and local regulation.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised 1'25:2018
. . ••f' ..,
Individual Water Well
❑ Water well report(attached to application). Depth LOCI ft. c�,f/
❑ Well capacity Test(attached to application) \_/ gpm ? DO 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.
FO
11 Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://ois.co.mason.wa.us/planning 141 1 15U 16*220
Water use or limitation recorded N/A ]Yees) � I
Well Drilled Date `(l� /(l
Individual Spring/Surface Water
O 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
•
•
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:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: (41711 Date Kt- C(Z-----S
2of2
CSD Director: Date
---
rile Original and That Copy with
DeIlklIRNIN of Ecology WATER WELL REPORT ApplIcrillun Nu. . .
Second Copy-Owner's Copy
.TIord Cups,-Driller's Copy STATE OP WAIIRDIOTON Permit No . .. •. ..
ii (I) OWNER: Name...1*tas Agnes. Bergquist ........ dereu_Stsr-Rt.,"lijkss-1024.11nian liA ---
h.
• (2) LOCATION OF WELL: county . Mason _ . .......1/4 ..... IA Sec.3.51# T.-Zali..R31414
a.
O Bearing and distance from Mellon rj
or subdivision corner .4_24 Jo itI, &is y ZII 14 .cR
Ce '
(3) PROPOSED USE: Domestic X Inchurtrial 0 Municipal 0-"q10) WELL LOG:
CD • ! :994,9;9019 a rest Welt 0 Other 0 irornsation:Describe by color,character.etre of material and structure.and
show thickness of aquifers and the kind and nature of the material iii each
stratum penetrated, wart at least one entry for each change of formation.
US (4) TYPE OF WORK: Owner's number of well ======== ===.-
MATERIAL FROM ' TO
New well - • Method: Dug 0 Bored 0
Deepened 0 . Cable -X- Driven 0 - ----• •4 -• -DrAwa eXY &-SERVele_bard n 1.5
C Reconditioned 0 Rotary Q Jetted- 0 Brram. cl Ay WI rh grAvpl• IS 10
O - -ease. little water 3fl 31
C (5) DIMENSIQNS: Diameter of well . . 'If__ Inches. 31 __50
Drilled.. 4? 888WsZU2 water • • —
= ft. Depth of completed'well..........(4.--ft.. , Dagker brQwn_.aitxv.itb_sam"rjnto,
-9
sone water- SO .59
E (6) CONSTRUCTION DETAILS:
. .Brown clay & gravel, weror henrIng ria _69_
O Casing installed: to .. Diem. from .....4?...- ft. to. 112..1 ft.
hi.. . .
'Threaded 0 ..... ___.."Diem. from .-. - ft.to "
C -
Welded IX ..i......_': Diem.from-:. ....- ft. to -
_ ._
IP _
-
.0
Perforations; yea c1,3 No K. .. . . _ - - -- . - _. • - -
4..
a- Type of perforatoi used__......___:.:_...........___-• ___!......,........— . . . . - - .
O SIZE of perfaratiOrW ....--......7--... in. by ......,.. ... _____
a,, ..... _
.0 . —
C ...._. .. ____perfoiations Born .,._ "ft..Vs
r3 perforates:a front ft. to- -
--•
co screens: yes 0 Now-. .. . _.. . - - - '
Ci . - - •. .
Manufacturer%Name.--.-..-., . ._--.----- • • •
. . .
al No .
ZDiem. ._____.... from ........_.... ft.to—.—. ft.
Z4 Diarn. ..._.........Slot also....,....— ft.to .-- ---?. tt-
- . • :
- - _____-;.---X---' - ..r- s.k4 - " . —
C --,
Gravel packed: Yes 0- No A- Sire of gravel:-.-.-.....--,.......
1.. - • •
L. --
CR . , -
.. f j iji 0 5 1219
Surface seal: Yes 0( NO ti Toetrhat dr2reptk? _41:— ft. , . • _
•
Material used In:seal••••73C10?-0 '
Did any strata contain unusable water? • " Yea El: - No .. .
bk • . •
0 Type of water?. -.....-..-_-.....-Dmitb'of strate..-...------t-
Z ... - . —
• _-.. .., .. ----
Method of sealing strata-off--- - ....._-___........._:___ .,—.' . - .-
cn •.
8 (7) PUMP: stanueactum .. Natne- ..."1".7.iel...................... :. ... .. . _ . ..
13 Type: .6..C4-Eir.A112-4.7.0.14:7-,. —......„..,_ X.P -7..i......- — • •• •. - ---
i' .2, . • .- , ?"-sr I :. --" '.-- ' • --- "'"" '
_
>41 (8) WATER LEVELS- -LiTicsuri-aCe elevation
CDe... 1 i—r- .11bilvli Inean sea level.... ...........r.......f...p. •.: .
.. . .:"•.- -
O static level ••-••?2,>.y .-.A.below top Oi well.-Date.--.4././..kar7.-• . . - --- • -
O Artesian pressure .......... ............lbs.Der square melt Date.........--L..:.---
0 Artesian water is controlled by.........__. . . . • _____ ---.-
LLI 't dap-.viii:iii:iii.)- . .
.
a... - •
O (9) WELL TESTS: • Dr
lowered iiitansla°tItIrer level
- -----.7--- : -
.. Work started--4111113-7-----.Iraq- Conipleted-j4Ma-12----. lYi--
C Was a pump test made? Yee 0 No ILI1 yes,by whornt..
111 Yield: gal./min. with ft. drawdown after hrs. ..WELL DRILLER'S STATEMENT:
E - • . -. . . . - This well was drilled under my jurisdiction and this report is
I- .. .• • - true to the best of my knowledge and belief.
3.. Recovery data (time taken as zero.when Wm) turned off) (water level .
9.) measure d from well top to water level) . NAME. Indratio :Drilling. Corp.
CI Time Water Level ?Time Water Levet I.Time Water 141Vel (Pelson.firm. or corporation) (Type or print)
if .........._.............-......-....
address 1653..Sn...-9541,--Tacona.,..LIA..984.44...---_-_--.._
I—▪ - I__..................................
,/-7,.. _ isisn•c---114,41, 1 SJI/Ir,m0211--
Bailer test-.1.g!:......gal./min.with-A- ....-ft.drawdewn after.sitr-i-r-Aire. (Well Wilier)
Temperature of water was a thank&analysis made?Yea 0 No St Limnos No ,/,il3 . Date-June...LI .is.7.9._
Mall ADDITIONAL Sinners it NXCESSIARY) 4111111,$
ECY 050-340
•
SPECTRA Laboratories -Kitsap 26276 Twelve Trees Ln NW Ste.C
...Where experience matters Poulsbo,WA 98370
60 Phone: (360)779-5141
www.spectra-lab.com
Spectra Labs- Kitsap,LLC (Poulsbo)received samples for Davis Pumps on Tuesday,March 21, 2023 at
2:40 pm. Unless otherwise noted, all samples were received in good condition and were tested in
accordance with the laboratory's quality control procedures. A summary of the samples received are
outlined below.
Sample No. Description Location Sampled
224884-01 Bob Close-Hwy 106 Outside Faucet 03/20/2023 16:30
This report package contains laboratory sample results and any attachments listed below. If you have any
questions please call (360)779-5141 or email us at www.spectra-lab.com.
This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other
than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at
360-443-7845 and destroy this report promptly.
These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced
except in full,without prior express written approval by Spectra Laboratories.
26276 Twelve a
Trees Ln NW
Ste.0 I'' SPECTRA Laboratories - Kitstp
Poulsbo,WA -nitre t;nrrsace arorecri
98370
(360)779-5141 COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected 1 Time Sample I County
J 2� I cos t o 0141 1\-kPL. J\
//r Dal Yea r M �
A�nY -
Type of Water System(check only one boot)
❑Group A ❑Group B Otlter -__ _ --
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
ID# /�
System Name:�vb CA — j`G Co
Contact Person: (
Day Phone?�;�,•0gC - \L. 7 1 Cell Phone:
Email: I Eve.Phone:
Send results to:(i Arn S address and by cods or entail above for sMetronk copy dnuns)
0 .,0t, SPuvr.s Vt.0
SAMPLE INFORMATION
Sample collected by(name): le4._ -
Specific location where sample collected: I 'al instructions or comments:
Type of Sample(check only one box)
1.❑Routine Distribution Sample(MP) 2.❑ Repeat Sample(AIP)
Chlorinated:Yes D No❑ (from distribution system after unsal mane)
Unsatisfactory routine lab number.
Chlorine Residual:Total_Free__
3.Ground Water Rule Source Sample Unsatisfactory routine collect date:
I S I I I I
Chlorinated:Yes No
•
❑Triggered(PIP) Chlorine Residual:Total Free
• ❑Assessment(A/P)
4.Surface or GWI Raw Source Water Sample(Enumeration) I S I
❑ E.coli ❑Fecal pirered Yes__No•
S..Sample Collected for Information Only.
LAB USE ONLY DRINKING WATER RESULTS TLAB USE ONLY
0 Unsatisfactory Total Colilorm Present and factory
I 0 Ewa present 0 E.co6absent J
I Bacterial Density Results:Total Cotform m,N100m1.Ecoi mpn/100mi.
I Fecal Coliforrn cfull00ml. IFC . rddlmi.
Replacement Sample Required: 0 TNTC 0 Sample too old
❑ Sample Volume 0 Damaged Container 0 _.---
/ ` Lab Reference Number
D i e Rrelyt
! ).7 Lt < Lt -t7.l
Receipt Temp C: Method Code:
SM9223B/OT-COUNT/SM9222D
n..wa.......w..r�a..o.•.�a mv�rm
Da":
1 a4Nnpp�-� 7•• thaid.tltMredbMUO.amrignd.k..c.hrbo.
�'�/l�1 �'liil\ �- �OC•. Yerdef redplslYuW4aAad gym how trcabed Hs rtgMn
drag fir'cal prary%-
DOH tat-Sanmple#
K�J L/C-2) Theo rwebrrrr ore/Dtlaawesbd rdeAareeemes
Q1A-V Y `� / ra it Wee sir al h'Speare L^Ev°e"
Davis Drilling
340 NE Davis Farm Rd
Belfair, WA 98528
275-5367
Test pump for: 8262 Hwy 106
Pump: 1/2 h.p.sub
Well Depth: 71'
Static Level: 22'
Date: 03/25/2020
Well ID:
Draw Down
Time Water Level Flow GPM
0 min 22' 0
5 min 45' 12
10 min 45' 12
15 min 49' 12
30 min 49.1' 12
45 min 49.1' 12
l hr 49.1' 12
2 hr 49.1' 12
Recovery
Time Water Level
0 min 49'
1 min 39'
2 min 33'
3 min 29.9'
4 min 27.5'
5 min 25.7'
10 min 22'
415 N 6TH STREET,SHELTON,WA 98584
MASON COUNTY SHELTON::360-427-9670,EXT 400
BELFAIR:N 360-275-4467,EXT 400
eigg,11, ELMA:360-482-5269,EXT 400
Public Health & Human Services FAX:360-427-7787
ENVIRONMENTAL HEALTH REVIEW OF BUILDING PERMIT
(...01U7j1/
CLOSE ROBERT J (.0
PO BOX 517
UNION, WA 98592
Applicant: CLOSE ROBERT J
Parcel Owner: CLOSE ROBERT J
Site Address: UNKNOWN
Primary Parcel Number: 322344300102
Permit Number: BLD2023-01299
Permit Description: NEW MFG HOME
Permit Submitted Date: 10/26/2023
Permit Review Date: 11/21/2023
The above mentioned building permit has been reviewed by Environmental Health and found more information is
required.
After the Fact Asbuilt created by B-line shows a 500 gallon septic tank with 44 ft of linear drainfield trench. If the trench is
3ft wide, that is only 132 square feet of drainfield. The typical sizing of drainfields prior to 1990 was 120 square feet per
bedroom, thus this septic system is undersized for your proposed 3 bedroom home. Please work with a septic designer
on a septic system upgrade or resubmit a building application for a one bedroom home if your designer can confirm there
is 120 square feet. A one bedroom home of this size may require a Certificate of Residential Use: Limitation on Number
of Bedrooms to be recorded with the Auditors office. If the existing system is to be used, it will also need a satisfactory
Operations and Maintenance inspection within the last year. Thank you.
If you have any questions or concerns let us know.
Sincerely,
4_ --- Rhonda Thompson, EH
te
cialist
360-427-9670, Extension 581
rhompson@masoncountywa.gov
[ ] Jeff Wilmoth, EH Specialist
360-427-9670, Extension 543
jwilmoth@masoncountywa.gov
[ ] Dave Anderson, EH Specialist
360-427-9670, Extension 353
danderson@masoncountywa.gov
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