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HomeMy WebLinkAboutWAT2025-00103 - WAT Application - 5/20/2025 WAT 2025 - 00103 MASON COUNTY Shelton,W d'Street WA 98584 074 Shelton:360-427-9670,Ext.400 Public Health & Human Services 13elfair: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/ P. • • • • •• Jason Allee 20MMay25 Name of Applicant: Date: 206-999-1471 Mailing Address: 1914 tau,Ave W Seattle WA 9811..a Phone: 2.2021-33-00060 Parcel Number: Type of Water System Reason for Application ❑ Public/Community Water System (2 or more Building permit BLD2025-00602 connections) 0 Division of land: Individ ater source (one connection), #of Parcels? SPL Well El Boundary line adjustment 0 Spring/surface water 0 Other(explain) ❑ 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'HI Fors\Drinking Water Revised 05/08/2024 Page I of 2 Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well Water well report (attached to application). Depth, 160+ I ft. El Well capacity Test (attached to application) ;,12 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. 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) x 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: A '`"PS Date 7/3/25 This form may be scanned and available for public view at www.masoncountywa.gov Pagc 2 of 2 Water Well Report For An Existing Well 41 Your well must be properly tagged prior to submitting this form. Asterisks (*) indicate required fields. Mail completed original form to: DEPARTMENT OF WA State Department of Ecology, PO Box 47600, Olympia,WA 98504-7600 ECOLOGY State of Washington Use this form If an original Water Well Report was never filed or is missing from Ecology records. *Current Use *Unique Ecology Well ID Tag Number: SR.K 115 (Domestic ❑Industrial ❑Municipal DDewater *Water Right: Dyes (if yes, attach a copy) ❑No ❑Irrigation ❑Test Well DOther: A7v)l y /tuff *Property Owner Name: lASc /T Dimensions Apo Diameter of well in. *Well Street Address: ZEai) Si �Al t. r I rh ow Depth of completed well ft.(if known) *City: .)iii0 �{{��^^*County: /r 14.iy Construction Details *Site Well ID: 1� I Liner installed: Oyes ❑No ❑Unknown �r� ,ram i . Type: ❑PVC ❑Steel ❑Concrete Liner *Tax Parcel Number: Z2U21"3.3-OI 00 ❑Unknown ❑Other: p i r *Date Well Constructed: 8 /+� �5 Perforations r Oyes ❑No ❑Unknown *Location(Township, Range, Section) Size of perforations in.by in. An accurate location of your well is very important. The • Number of perforations from ft.to ft. Section,Township,Range,and'/4,'/4 can be found on your t Screens tax parcel legal description or through your county € Oyes ❑No ['Unknown assessor's office. g Type: DStainless Steel ❑PVC ❑Other: Z i- Diameter Slot Size from ft.to ft. Township Z Rangew DEWM orDWWM Section L 1/4-1/4 1/4 L Gravel/Filter Pack cDies DVo ❑Unknown Materials placed from ft.to ft. Comments: 0 -o Surface Seal Department of Ecology g DYes If known,to what depth __ft. } ❑No ❑Unknown SUN 1 2D?5 B Materials used if known: 2 ❑Bentonite ❑Cement «. Water Resourco Program Pump ✓ Oyes ❑No ❑Unknown Latitude/Longitude 3 Type Horse Power (Decimal Degrees recorded to 5 decimal places) F-• Water Levels 1 e/EXa pie 47.12345) 0 Z Land surface elevation above mean sea level ft. . .`OD to3 Casing stick-up above/below land surface o Static Level- ft.below top of casing Date measured: Lon Itu e( am le 118.12345) Artesian pressure lbs.per square in.Date measured: • 4H (01 Well head has cap? Oyes DNo Shut off valve?Dyes DNo o Additional Information (If available, please attach) w Well Tests: Nocation marked on topographic map c Drawdown is amount water level Is lowered below static level. Location marked on air photo c Was a pump test made? Yes(attach copy)OW Unknown d Yield: gal/min.with ft.drawdown after hrs. DConsultant well report E. *Certification: The information reported above is true to the best of my knowledge and belief. A s ❑Consulting Firm DDriller ❑Engineer (,property Owner Name: (,�'V I f'It.f�i Company: License Number: Address of erson completing this form: Hill l 4VE - ",.r...,-- Signature: /�i�_Iry, (e Tala :.dh (� `( Date Signed: 3! .4'( 2,5 City, State,Zip: SE 1�-.j�A , -( t'l( r 1 vest'070-557(09/2016) Ri request A1)A accommodation including materials in a Gunmt For the visually unpaired.call Ecology Water Resources Program 360•d07- 6872.Person with impaired hearing may call Washington Relay Services at 711. Persons with speech disability may call Try al 877-533-634I :F N} INVOICE -4) _,} ailo y DATE: 10/30/2018 DUE DATE: 11/09/2018 INVOICE# I 8227-11 MEMO TECHNICIANS INVESTIGATED AND DISINFECTED WELL. COLLECTED BACTI, LEAD AND MINERAL SAMPLES(CUSTOMER REQUESTED BACTI AND LEAD). WELL CAP IN GOOD CONDITION,GOOD TRUCK ACCESS TO WELL ++ HEAD.STATIC WATER LEVEL WAS AT 130.7FT UPON ARRIVAL. RAN WELL AT 7.5 GPM FOR 15 MINUTES AND WELL DREW DOWN TO 140FT.CONTINUED TO RUN SYSTEM AT 12 GPM AND WELL DREW DOWN TO 150FT AFTER 40 MINUTES. o SUBMERSIBLE PUMP IS EXPECTED TO BE A 1HP 230V PUMP s THAT IS RUNNING 8.9 AMPS DURING USE.THERE ARE NO PRESSURE TANK COMPONENTS AT THIS TIME.THE PUMP IS c HANGING ON AT LEAST 160FT OF PVC DROP PIPE(THIS IS AS FAR WE COULD GET OUR SOUNDER EQUIPMENT DOWN THE WELL).THERE IS GOOD FLAT JACKET SUBMERSIBLE WIRE DOWN THE WELL. c WE RECOMMEND INSTALLING A COMPLETE ONSITE WATER SYSTEM(PID10)WHEN YOU ARE READY TO MOVE FORWARD o WITH FINISHING OFF THIS SYSTEM. PLEASE CONTACT OUR 1 OFFICE FOR A QUOTE. 0 O TERMS & CONDITIONS a Invoices are due upon receipt. Invoices not paid within 30 days will be charged interest at 12%per annum. o + •"We accept VISA, MasterCard and Discover credit card payments. Payments can also be made via PayPal on our we site t. arcadiadrilling.com. "' 0 L 1 1- 2 I IS Department of Ecology IIIN 12 2025 .Water Resources Program Rs Form (�RazorSync.. ©2018 RazorSync.com.All rights reserved.All other trademarks are the property of their respective owners. 10000' Analytical Report Al lia Work Order: 2505565 TECHNICAL.. G R 0 U i-- Date Reported: 6/3/2025 CLIENT: Jason Allee Project: WAT2025-00103 Lab ID: 2505565-001 Collection Date: 5/27/2025 5:45:00 PM Client Sample ID: Garden Bib Matrix: Drinking Water Analyses Result RL MCL Qual Units DF Date Analyzed Total Coliform & E.coli by SM 9223B (IDEXX) Batch ID: R10018 Analyst: BB Coliform,Total ND 1.0 1.0 VIPN/100mL 1 5/28/2025 10:25:00 AM E.coil ND 1.0 1.0 \4PN/100mL 1 5/28/2025 10:25:00 AM 1 4 Original Page 4 of 5