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Home My WebLink AboutWAT2025-00093 - WAT Application - 4/28/2025 WAT 2025 - 00093 th leigk MASON COUNTY 415 Shelton:360-427ton W,E 400 Shelton, .6 Street 98584 Public Health St Human Services Belfair:360-275-4467,Ext.400 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/Parcel Identification Name on Applicant: xjZA .((r 5 C y �2 Date: - Z — Mailing Address:9 3 2.0 S T£v'f/uf`4`T LAW? Phone: Z S3 -35-3 ' 9 6 3 5` GJ.t Parcel Number: 32 0 25-cc - 90 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more Plr Building permit connections) ❑ Division of land: 12' 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 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. Print Name of Water System Manager Phone Signature of Water System Manager Date This form may be scanned and available for public view at www.masoncountywa.gov 1:\EH Forms\Drinking Water Revised 05/082024 Page I of 2 Group Systems Water S stems N,A t1 Satisfactory bacteriological test within fast year (dttdc.II to applicatiun). Individual Water Well ld Water well report(attached to application). Depth Z l 9 ft. • 12t'''Well capacity Test(attached to application) / 0 0 gpm >400 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. it ❑ Satisfactory bacteriological test within last year(attach to application). 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 • • Part 3: Mason County Community Services Evaluation (staff use only) 0 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. 0 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 Signatures: 6/18/25 Environ. Health: S Date This form may be scanned and available for public view at www.masoncountvwa.gov Page 2 of 2 11 WATER WELL REPORT CURRENT Original&t"Copy-Ecology,I"copy-owner,Ye copy-driller Notice of Intent No. WE29$41 DirmIrMil F 0, ECOLOGYrgw}ee Construction/Decommission("x"in circle) Unique Ecology Well ID Tag No. Erin 747 f+.•. ® CoustruCt?on Water Right Permit No. ❑ Decommission ORIGIN.91.INST 4LLATION Property Owner Name krtip Scher -____ ____ Notice of Intent Number PROPOSED USE: ®,Domestic 0 industrial 0 Municipal Well Street Address 305 SE Snider Rd 0 DeWater 0 Irrigation 0 Test Well 0 Other_ TYPE OF WORK: Owner's number of well(if more than one)_,_._ City Shelton County rr__ ® Nevi well 0 Reconditioned Method;❑ Dug 0 Bored 0 Driven Location ttwl;4-1/4 $.E1/4 Sec Zf Twn zoN R g} Dam❑ Ci Dtteperiscl. 0 Cable 0 Rotary 0 Jetted (s,t,r Still REQUIRED) or DI1MENSiONS:Diameter of well inches,drlle4222 Ii. Wwnt t3 Depth orcbm*leltd Well 2 11. 7. W4TTQ<l»ETA.ns - Lat/Long Lat Deg LatMin/Sec ' ,, ®Welded 4.° Duns.6udor,+1_IL to 219.A Long Deg_ Long Min/Sec ipafelled: ❑Lirier h iitiUa om•d,„„,,_" D from_R.to R. lJ Threaded ..-, Dian.From_ft.to ft. Tax Parcel No.(Required) rto2s-so-90543 4 .peeforatioot 0 Yea El NO- •tyfpebrperforiuiortucd - - CONSTRUCTION OR DECOMMISSION PRQCEDURE' ' Et of parrs___Us.by*h rood M.b _from—i•10 .� Formation Doti c by color.character,size of material and structure, ll the)and and ' Ststaas Q A* Tia N0, q� Liettiac nature of the material in each stratum penetrated,with at least one Wry breach change of inrormatieu, (USE ADDITIONAL,Sl-EETS IF NECESSARY.) Sfi>inidactufeYsHlal►e_ _ "Model No. MATERIAL . , , FROM., .Nil_. •...,, :.. �_ _ Topsoil.rotas 0 .. t d7jgto.,— 1Rtsice_fronr_ti;la, ft, :; Dt}tm. 31a:ha from ft.to ft. Clay,silt,sand,gravel ? brown/Soft I .. heir d Ypa .�$1p •Size ofgravel/sand_ Clay:sl7t,sand,gravel _- ' 1s --.140 .91 r'v t. gray/stilt 12. --_- 19 Siv6tteSt:alt]$ Yea L1 No TO delal4-l8 `. Clay.gray/soft 19 .. triSNl µlst 'sarolostitC. -. Sand,silt,gray/soft 339 ,1kd lay strips remain unusable warm? 0 Yes 0 No Sand,coarse,some gravel Pe of rime 1 Depfb of saata gray/soft 39 . 44 Dielhodot.sealiKgstiuto# - , Clay,gray/soft 44 61 a :. • ::_14P ees$11.-wo-Wk. -. - - Sand,silt,gray/soft 61 ' type: 65 - LL--. Clay,wood gray/hard 63 83 'WA'1•Es UMW:,Land•s,sfateetevatioa shove Mean sea lewl_h. Gravel,some sand,some silt Static.16Yxl,_M&br,low OP of welt Date 2LIIL2Q.1.L -•. gray/soft 83 10 Altman Prgpprc.lbs.per sgoatu inch Date Sand,silt,gray/soft IOS 127 /irteslao water is-controlled by (cap,valve;etc.) Sand,silt,btown/soft 127 135 • Sand,Cure,silt,wCt . 'Fl 1..L 131 J x prawdown is.am°u water le*is/q d below satin la'ct gray/soft . . 13$ ..1r71 14s.as ;itsttaade7 Q Yts El 1,10 lf Yes,byavhom? CIaY;gray/soft In .... ._. III tetit with I.dmdrdomn a tee his: CrtaV4l sOnte send some silt, .r .. t itf* tom!-3t t vaiawa after:.___JI: "gray/Soft:WI) 211 _. s• . Aruov! ei rauriokeo Peerowlyrrrpvmp(arnedoj? Purer level mta.mredfnm `- RECEIVEDaill{op ro wutz Ienv11, _. "1Ym8 Sager.„,.. Tithe Water Level' Time Water Level --• •_ r' JUN 08 Z018 -- - - _-. nueoraio li 'Den ttti eftt of C olcigy --- •= �, ' ._-- 114t n-.ogeb•`R.drowdeweaBa,TSgr I.Veli Chitlins(Vim- . . . j4nest .lit tli)ittpia. hear-net srJI a'fat . , •Attisioutov?r.-.,401•Dgtt ` pal64:6f —.WafaiMinimlanalysistaada 0 Yes ® No . a. WELL CONSTRUCTION CERTIFICATION: I constructed andor accept Start Date 2tt St2018 Completed Date 2l162oi8 tespanikllitY•,fbr, drthhis well,and its compliance with all Washington well mdstruclionstanda'ds..Mat.lals used arid the information reported above are trim to my best lmowlcdgc and belief. . _ ( .Driller lataginetr D Trainee Name(Flint)Chris loner Drilling Company Moeike&Sons Pump and Diiiling .. r Driller/Enfants/ft./Trainee Signature L 4—' 5'`*+-... Address 1162 NW State Ave _ Drill&oi't al*, Li¢4tse?No:2213 City,State,Zip Chehalis , WA; 98532 . 7E TTr.4RdEEAkiller`,a LicetONo: Contractor's e atlAeritts' _-- Registration No._MQERKSPO32N5 Date 2/16✓1018 ELYDSO-I ZO(RtV Q2.20I0) To request ADA accommodation including materials to a format for the visually inipaired,call Ecology Wafer RtSOAYaethQBtam 0 q 7;2;Per**00 unpaired FFegrim htpy call WashinglOn Relay Strike at 712. Persons with speech drsabriiry mayr4Pl TTYat 677.83.1-a. 6..,e, / Vanguard Laboratory • p i a': , 2635 Parkmont Lane SW y .... M Olympia,WA 98502 °fil Q•o 360.967.7010 VAN GUARD Report of Laboratory Analysis LABORATORY Collected by: Moorko and Sons Matrix Drinking Water 360-748-3805 Laboratory ID: V250416-16 Sampling Address: Date Sampled:4/16/25 13:40 365 Snider Rd SE Date Received:4/16/25 14:45 . Shelton,WA 98584 Date Reported:-4Tf /2025 Sample ID: 365 Snider Rd SE Analysis Result SDRL MCL Units DF Date Analyzed Total Coliform&E.coil by SM 9223B(IABX� Batch ID:V250416-16 Analyst:AF • Colifot•m,Total Negative I 1 MPN/100 rnL 1 4/16/25 15:13 4 E.coli Negative 1 1 MPN/100 mL 1 4/16/25 15:13 I j I Nitrate by Bach Method 10206 Batch ID:V250416-16 Analyst:KS t Nitrate(as N) ND 0.50 10.00 rngfL 1 4/16/25 16:51 . Notes: MPN:Most Probable Number ppm:parts per million nd:non-detect Reviewed by Dustin Newman,Laboratory Director on 04/18/2025 n/a:not applicable SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 04/18/2025 DF:Dilution Factor / ?�4 - 17025e2017 MCL:Maximum Contaminant Level �,0r; worwrom: Samples were received in acceptable condition.The result(s)in this report relate only to the portion of the sample(s)tested.All analyses were performed consistent with the Quality Assurance program of Vanguard Laboratory.Please contact the laboratory if you should have any questions about the results.