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HomeMy WebLinkAboutWAT2025-00167 - WAT Application - 7/17/2025 WAT Ai'.,*; , - Ck)l Lel i em , M Sheth Street .6 98584 Shelton:360-427-9670,Ext.400 :•'.- .0 Public Health & 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 L Name on Applicant: r�e_t!, ( ,'C L.-i Date: � .1L- ' 1-7- 2U ) Mailing Address: 11 l 1.Xyl ciA CL+I� Phone: tf lQ-iti✓Q.._ Wet_ Ci 5 3/-4- Parcel Number: 0.Q - y, - i „362Q "14 21 - —74 61-41 rs ``- Type of Water System Reason for Application / Public/Community Water System (2 or more 0 Building permit-602625' qq connections) ❑ Division of land: ❑ Individual water source (one connection), #of Parcels? SPL ❑ Well ❑/Boundary line adjustment O Spring/surface water ,( Other(explain) Aett L 2L�`7 •3 14 ❑ 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: i Public, Water System re- Name of Water System: U' i I C� Lear,.0_,Water Facility Inventory (WFI) Numberr:Tilbr�t (write"none" for two-party) fl lam the manager of this water system. The water system has be,.../eq approved for services. There are presently I connection(s) in use. This will be the 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 by state and local regulation. Print Name of Water System Manager �1 Phone �„ArG'"74(s=-c;�t;� Signature of Water System Manager //�--"""---4i Date b —,/9-2- This form may be scanned and available for public view at www.masoncountywa.qov J:\EH Ponns\Drinking Water Revised 05/08/2024 PaeL! I of 2 OWb Group B Water Systems 0 Satisfactory bacteriological test within last year(attach to application). • Individual Water Well 110 lA Water well report(attached to application). Depth ft. 51 Well capacity Test(attached to application) 15 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. RI 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) 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: � SU�I Date 9/22/25 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 earl Cord 1144 0 Rio Oriente and Rya Copy with WATER WELL REPORT0.0-1...nt et Ecology MOUE WELL CD,Arrefir if0-7 Seco*Cow-Owner's Copy STATE OF WASHINGTON , Runde No.Mite Copy-)Omits Copy Weai4Tt aPK a OWNER: memo 0 .. - tlt tttS..a. T...... ...2t.R % (*.INAS. re (2) LOCA ION OF WELL- Com (�,} STREET AppHE$8 OF W®1 w resew adls.s!�1� J47 Za't_1C /2o, S.JEC7t1' J u • (>!a) WELL LOG or A� oESC W11 + l' "cm*" Top me G U writ snow RhldsnM d agAnm 43) USE: Fann.as•:Dace*My.olor.wtaa.r..Fe.drawee we Mvtu..wn a w err entry for word C motto* Teal me U osier U astl to Old owl town d Pne s al lel h arrdr�ea/hh psMt11s4 in G OM** drams a eeonssaon. _ S (4) TYPE OF WORK: Qhw1.r a rvrti.r of hwe! IM�1 hr1011 t O (N rlror.otPwt ah.j - C Abn+drr+.d C Nsw vnP Medhe4.Dug C amid w Q �I L/i . ./ r i ._. 11 Gab*OIL C Wind rodC Rotary kited • ' _ .rt?'i:I1sL i►ell "//Il 13 (j OWIENSIONS: Otar*wrd'•W 4 !Q 04y6 tow C.vd+d completed well 41a R. i 1t SI►/ I �Q I ($) CO JCTI0N DETAILS: t / l if-. _L 01 i Ja R b LL / 0 liiAsllsd: It XE:- f4 a It. e Polo,rrone: She 0 N d INN d perha►+ot wood ... .� _. - 'p aaE a p«wreeore k C ll- le — ewe R to perlortforw Mom It:to it pearlier*bars 4 b R. 'i ' {" ) Se : `IY.® NG - (.s. p` t ICa _ Mods No, Lam+ 6#h)haahate.Sid tams_„4121.1"—Ram p 7 _• C Dam. Doi are___ from k to- -- h w tame pecked: it❑ No�, Soo d gavel - A Grail placed Mom it to . Sit Oak Vas Nit❑ To who de la?___1_Q R' 0 AlsYf O dread Yt fon Ztab any eras comae unwed*NNW? vas❑ 1 o$ Typo al motor, 000 Wets _ N d Be 1blrod a mare skim oll (7) MAW: Mod sari Nam. -- N f. - gl (i) WATER LEVELS: Lanowgime asivalon Vibe SWIM 7.-zio-45 ,tit CAVIIPM1100-7--z 1.---c_t_JS., ...11 --pp rR © ear.e66" WNW tab d wr Dos f+l� WELL KommtICTOR CERTIFICATION: W Aegean poessum W.to wets even oar I mrtpaccept pr uc*d w accept hot oonitnrceorh of eta well, andesmean saw s aonrot.d by _ Pre vim.eici oonphenee with al Witan i0n mei aonstrucdon standards.hiataiMla wee end 416 Ids ironnelion nomad above are Ina to my best knowledge ledge eV beta _ (a) WELL TESTS: Dewey...is recur*water level la arrow!tweed.stele Wed �-a�/ �_tf?" -- tJ_R �� Wes.pump 1.a made?Yes Na❑ t r.a by*boon? . NUM *imam MI 4.dyardoen atter�- hrs. tt - - .- Ae JA_4 t� 1+ LTV /CO' ,ram ,7VAI C.v » .. p f �s tiwnN No�r U - love r..sshred tan wee (Sp1wr -— �1 Recovery data gme teen as sere when pump homed se)twee(L] T b mar ana Valet Level Taw Weer tr.. Tessa Wo.r i�M1 CortrageOrl d w � hiha227-75 .to �._ (USE AOOITKINAL SHEETS IF NECESSARY) Nos asis Sew ad Z.IV go.mill.will 0 R.er wd.wn tiler il M Eater in E0711 Oppo1ltlntty and AllkR1:NIV4 Atdlorh etth l6l.FOr tfL1 Airltel /mar.with stem eat et_-. R.for t1r'. Olei scoo Nn'Dt Ion needs,coved the Weser Resources Program at(�) Arlleiafltlow• aldareiedar►etywCmesa YM[a ;_}3, 4078600.The TDd number i(2bB)4Q78006_ PrIntectefIviriVir pay°t°'i'e tU from Mason County OMS Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA.98584 Customer: Lori Fey Well Tag#:AEG607 Site Address: 71 W Rustic Ln, Shelton Depth: 110' Date of Test: 718125 Static: 95.9' Pump Set: Unknown TIME GPM LEVEL RECOVERY 1 Min 15 96.9 TIME I LEVEL 2 Min 15 96.9 1 Min 95.9 3 Min 15 96.9 4 Min 15 96.9 5 Min 15 96.9 6 Min 15 96.9 7 Min 15 96.9 8 Min 15 96.9 //��,,, 9 Min 15 96.9 ...lei/ + 10 Min 15 96.9 15 Min 15 96.9 969 /PO% L1&2 15 . 20 Min �d 25 Min 15 96.9 30 Min 15 96.9 , 35 Min 15 96.9 40 Min 15 96.9 45 Min 15 96.9 50 Min 15 96.9 55 Min 15 96.9 1 Hr 15 96.9 Total Gallons Pumped: 900 Gallons I Printed From Mason County DMS Printed from Mason County DMS Thurston County Environmental Health 412 Ully Rd NE I Olympia,WA 98506 ' • ifiVr.„ ..... ... f.. , r.`„„eL-, 360 867-2631 TiiireirxiCoutrrY . .....m ... . " ;, COLIFORM BACTERIA ANALYSIS. Date Sample Collected Time Sample County Collected 06i Ati J1615. 1 3 .-A 0.:, tiorlt 0•7 Year • 0 PIA tA S Or/ Type of Water System(cheek only one box) Kt.Privets Household 0 Group A 0 Group B 0 Other Group A and Group B Sys -Provide from Water Facilities Inventory MR): Da _____ System Name. Contact Person: Lo Qi ce- f Day Phone.( 440 (I tto-50.f.")(1 1 eel Ph":(.3416)a10 EmaliOf l. -e,.t&ed wo I i'ate. elatonc( ) Send re& be:(print Ili name.*stress and zip cork cx am ai address) fOrto e.,(5.:PeriLoo,--clioexts:i. call _ __. SAMPLE INFORMATION Sample collected by(narne). i . LAO Q. ct,-,Y Et'A Specific location or address wive sample collected: Special instructions or comments: 11 tofJ 1.1.$4-s'e../..ei JUN 1 6 2025 51-1/4e t#1,6,tioA qr5s‘y RECEIVED Type of Sample(must cited only one box of di through fla led below) 1.0 Routine Distribution Sample 2,Repeat Simple(after urisat routine) Chiorinated:Yes_ No 0 Distribution System Chlorine Residual-Total Free Chlorinated:Yes NO 3.Raw Water Source Sample Chlorine Residual:Total Free i 0 E.col-GWR(A/P) 0 Fecal-sursoi.owl lovas evorissemi Unsatisfactory routine tab number I 0 Assessment lAondoring(MP) 00ther Unsatisfactory routine collect date: SI I 4.Eir Semple Codected for Information Only investigative J1_, Construction I Repairs____ . Other LAS USE ONLY DRINKING WATER RESULTS LAB USE ONLY 0 Unsatisfactory Total Coitform Present and tlstactoq 1 N) iforrn de 0 E.co/present Cl Ecoll abeent teded mipt•coment Saws Requinod: ['Semple too old(>30 hours) 0 WIC - 0 Bacterial Density Results:Total C4Mum1 /100ml. E.cof /100int. • Fecal Coliorm /100ml Entsrococci MOO ml. Method Code:ril, 92238 0,9.4 92220 Dale and Tree ReeeMedr ...0 1 SM 92158 0 Elutes. kstg.-15-, U12- Oak and Time Arelyaditit.Z- Daft RIVOtted 4 14i X.S tr." solo Nabs!PC*1 mobs ptus 69b) tab the Osir. -N I ., • '1 rinted From Mason '' • 8•! . ... • ;, Iti - — -- . Printed fi-om Mason Cou4R. tag-% 9,4V3Cb