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HomeMy WebLinkAboutWAT2025-00073 - WAT Application - 4/8/2025 • WAT 202,5 - o c o- jl�. MASON COUNTY RECEIVED COMMUNITY DEVELOPMENT Permit Assistance Center,Building,Planning APR 0 8 2025 360 - `7/07- 02, 78 6 415 N 6th Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 •:• Belfair: (360)275-4467 ext 400 + Elma: (360)64:55W9Akkip S tnifdlU4y 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! Parcel Identification _ Name on Applicant: A ar7 c4 i s/1ar/ct ()CCh/ Date: 3 • 2/. 25 Mailing Address: Z3/ E. f-><i//Ci-es"/ iDr. Phone: 3(d)-333 SO 6o Parcel Number: 3 20 Z2- 769- U UU s/U Type of Water System Reason for Application ❑ Public/Community Water System (2 or more Building permit connections) 0 Division of land: Individual water source (one connection), #of Parcels? SPL Et Well 0 Boundary line adjustment 0 Spring/surface water ❑ 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) ❑ 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. i:rEH Forms'Drinking Water Revised 1'25.'20)8 Individual Water Well ❑ Water well report (attached to application). Depth ft. ❑ Well 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. ❑ Satisfactory bacteriological test (attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 141-1 15I 16f 22= Water use or limitation recorded N/A = Yes 0 Well Drilled Date 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) 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: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). Reviewer's Signatures: Environ. Health: Okit' y- 41r 4dIn Date CSD Director: Date of 2 Ho Original sad Fist Copy wad Start Grd No. DepaRnt of Ecology WATER WELL REPORT- Dimond ' Dimond Copy—Owes.Copy STATE OF wASNMIct1TON r i+ Third Copy—DM/Ps(Aso Water Af4 1 P.rnrM No. 1 °w, wSI (1) OWNER: Naar. Address C/'Y W 4.36171 tt C nnq �/� I Y (2) LOCATION OF WELL: comity 4 OIP 1 t- G 12 J*.4IJ%Qla Si AnnL9 X TC21.N.pW-M. (2 ) STREET ADDDRESB OF WELL(aa.ar..t.demean) (3) PROPOSED USE D°111•15 lc Industrial ❑ Municipal 0 (10) WELL LOG or ABANDONMENT PROCEDURE DESCRIPTION E 0 DeWater Tact Wall O Other 0 FaNasriss: Describe by color. oheract•r. site of nestertul and .trsoluni, and show Ibldisese of sondes sad the kind and anew at the aratarief la.soh Odom p.Mtreted. O• (4) TYPE OF WORK:Dula s erebe of wall adah an at let Orr array for a.oh chimps of information. Of MOM than man) MAMMAL Pilots TO Abandoned 0 New moil pL Meth Dug 0 Bored 0 () 1S BDeepened Reconditioned 0 Rolm 0 � 0 ��y)e1 &O 4.)4. f ` /in R (b) DRIE481 Diameter of wad_(OIntakes. n vex / ! 0 l fOb of oanpltad we —�?—lt. � 7 c6&y `' lo ! 8` 7 20 C OS CONSTRUCTION DETAILS: ! 41� Cooing Mat+IM ____a__ A: • Diana troy +/ -n.10..L 1 -ft. E Miami War Metalled Diem hate ft.lo w. Tlreeded ••i Diem,rcer N.to ft. O PMfo.momt: YMO tisi� Q Type of perforator wed RSsat d Die doretlenne is by lw. , Vp.tforatiees frost ft.to ft. al peAsratlom heat e.to N. psi orstbe.lrara N.to IL , C) biomass: YM❑ tss� C IN IAiardsolnrer'sNaas ` Type Naomi N. _ C Claw foot■lz■ trman__ f1.to ft. - IC Diem clot size ha■ 11.10. h• L �ci Gravel packed: Yea LJ Netlw a gravel IGravel pieced hone_ a to n I SWIM*aOeh YeeVet0 Towhatd.pth?_ ILJ EMaterial mod in soul r}u ^^'ice-'�a f� H Did any strata contain usable water? No[ +� I 1 d Type of wat.r'7_ nimbi of aims-- O Melhod of sealing strata off - Q • (7) PUMP: M.rartaow.e.New. Q[i4.444 5 g Typo: e 7 U b tiP I (a) WATER LEVELS: ,. .,Ion . I- 1 O static lsysi [p 0 R.below top of well Dar. ! } LipressingArfaan pressing lbs.per sonars l agmar.Inch De O Artaaianweerboostroll.dM map.vim.dap worn atatw 19. cat+Plated�? l .to C (S) WELL TESTS: ar+wariqi is. «level is lowered below static tents Si Well.punptow mods?Ye.0 NoCS u ya..bywhom? WELL CONSTRUCTOR CERTIFICATION: E Yield: gat!min.with R.drawdosm after Ps. i CgnatrYCtt,d anon or■oCt,pt naponanDlilty for construction of this well, end its compliance with all Washington wall construction standards. IQ .. .. •• Materials wad and the information recoiled abort,are hut,to my bast Q. knowledge and belief- Recovery deli(Pair t.ksa as ttero wham pump trrrtrd of°(water level measured from sea top to wad level) r Trove Water Leven Taw Waiver Leven Tim wow Lew NM* S (Pu.DN.F . cOfMORA 1 (TYPE Address Date of tw Llcaeat,No l (sigrned) (Wail musts rat 010 wL,iwa*Et !t.drawaorre steer Contractor's rye MAIM_ gal.l ruin.wmh stem set at M.for NILNILR tk No. ' Data8— /• . 19 71 Artesian Now _ 04.m. Data - Temperature ol wow_.—Wee•chonwsi analysis made?Yea (USE ADDITIONAL SHEETS IF NECESSARY) acra■o•t-20 store» •ram 'fir Thurston County Environmental Health 412 Lilly Rd NE O Olympia,WA 98506 '� - 360 867-2631 THU 'Ty • COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County Collected 5PAM Month Day Year / :`'C� ID PM t �' Type of Water System(check only one box) 'El Private Household ❑Group A El Group B 0 Other_ Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# System Name: Contact Person:" Day Phone:( ) Cell Phone:c, ) . r E-mail: Eve.Phone:( ) Send results to:(Print hill name,address and zip code or email address) I / !r r'U-1 D/' - --1 N. •� 1. ..— SAMPLE INFORMATION Sample collected by(name): Specific location or address where sample collected: Special instructions or comments: Type of Sample(must check only one box of#1 through#4 listed below) 1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes No ❑Distribution System Chlorine Residual:Total Free Chlorinated:Yes No 3.Raw Water Source Sample Chlorine Residual:Total__Free__ ❑E.coli—GWR(A/P) 0 Fecal—Surface,G'NI.springs(numeration) Unsatisfactory routine lab number: Filtered:Yes___No__ ❑Assessment Monitoring(A/P) Unsatisfactory routine collect date: ❑Other S 4.❑Sample Collected for Information Only Investigative Construction/Repairs Other 1 LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY 0 Unsatisfactory Total Coliform Present and •©Satisfactory ❑E.coli present ❑E.coli absent o liform detected Replacement Sample Required: ❑Sample too old(>30 hours) ❑TNTC ❑ Bacterial Density Results:Total Coliform_ /100ml. E.coli _/100m1. Fecal Coliform /100m1 Enterococci /100 ml. Method Code:E 1 SM 9223E ❑SM 9222D Date and Time Received: i ❑SM9215E ❑Enterolert® y' 7(- S `�-1-,4 Dale and Time Analyzed: ; Z , Date Reported:j 12-yS ) k 11 Sampe Number(DOH number plus five digit) Lab Use Only: 0 8 0 ') L _ DOH Form 11331319(revised 11/23) • (t �Y 1{