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Home My WebLink AboutWAT2025-00159 - WAT Application - 7/2/2025IIIMIW WAT,909, - OOi4i � MASON COUNTY 415 N.6th Street ■ i ; , `, Shelton,WA 98584 ■ ■ 4 ` I Public Health & Human Services Shelton:360-427-9670,Ext.400 '-s"`; '. 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: nes4wjahe hoot Date: —1a,/g0 Mailing Address: 70 SE Se(/s 7 • a Phone: jl/1ce0I-z(gp—Reno Parcel Number: 3/90g-4/3-437(70a02- Type of Water System Reason for Application tip pru1/cj Public/Community Water S stem (2 or more Building permit ,�DI,e2oa5-oa�1ve connections) (2-py- ,_)c I-,ev SJ.S e"I 0 Division of land:--E)If1 26Z'5 -Ce21146 ❑ Individual water source (one connection), #of Parcels'? SPL ❑ Well WEL g0A5-0vD33 ❑ Boundary line adjustment ❑ Spring/surface water 0 Other ex ❑ Other(explain) (explain) ) ❑ 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 01S' p 00-1,3 Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: / VtAiv -ril�'1- W"yI m/ ,sys+'eiyi Water Facility Inventory (WFI) Numl9,er: j`../ (write''none"for two-party) ,,21 1 am the manager of this water system. The water system has been 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 IA 4, Phone -36C LI `q b'Z9 7 0 Signature of Water System Manager • Date -t_{_ 7A 7`--;- This form may be scanned and available for public vi w at www.masoncountywa.gov J:\EH Forms\Drinking Water Revised 05/08/2024 Page 1 of 2 Group Systems Water S stems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well l Water well report(attached to application). Depth 108 ft. ® Well capacity Test(attached to application) 17 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) O 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). RA S Reviewer's Signatures: Environ. Health: Date 9/15/25 This form may be scanned and available for public view at www.masoncountywa.qov Page 2of2 rilmigillialliiiiiimonimismiummommumm....,.....................,.........--... WA 1 R W e L I. R R P 0 R T • ::Kgeee,Gird N0:.: 045351 STAT0..Of KASHOp9?OM anniU iter Right Peri& No. wawam..mrm..=■■...■■■ssrrw1lerrwA¢Aaa • marrarrarie .- ' 9&5E4• waa.w...Rm■Name LINKS, .RRmeC■sa3sYe'r ROB Addr'saa RE 3$90 LUCK 1�:,. LTU, 4/ (1) OWemmm NeAtit.LINKS, u0►; osolmo war semeNo meiiprwrxwasx=m■aus.mossxxs■xY.*NoNoawaomsR mosomoaa. (2)■mLOC■TIONAO ELL: County KA■OHRxisw ..55 1/4 NE 1(`4 aet.1 T 19 N. R 3 DK WO (2) E OF ADDRESSWELL: County(or nDN e) SS 3a50 LYNCN'P4' erg i■G.iFwlt2_.. itiaa cilrac�lars..a.. . nwasa-ra: (2a) STREET aaa OF WELL nee r W=rrxra,a,maarwa . NOM a>sar.w=.sx.eKxwm�la>m■i•xasR. (101 WELL i.00 (3).PROPOSED USE: DOMESTIC ,�,�■■rxa..wrxwarwruWrrr w. Q WO*Klm*gm" Formation 4escribe by color, character, eiza.of material (4� T1fPQ OF 1i011K: Met ROTARY of Welt,. and structure, and show thickness Of-aquifers and the kind i.�.. (if then one) treted, with 1 NEW WELL (if moree ROTARY ifld nature of the aratari c in enSe Infer .p e .rs:Y„w gcasm.wmx m.se vat resat one entry•far weh change in formation. • !.. S t!!tr t�I (;, ��a �, , FROM TO (9) DI'- .`. I,:, Ii1lTER.tAI 0 16 l hi t Ir !i-3 t c CLAY AI.1AliD.. 16 22 • r AILS.. [ CLA'!Z GtiAVEI: 2z 100 t4) r� ION OI TAI LS Fc,;'Sy) J`:1 • RW CLAY...... 100 100 ;Il.t.i( :illf sl 1_'•••••• f�;. 4X E:•, COURSE V*L I IIMER ,„ 11 pit. from fC, to ft. PerfOt*i.0tl$, MD Ty i'3.:perforatar used. 1n. by 1n� SIZE`Ot perforations ft. to ft. • liri perforations from ft. . perforations from ft. to perforation' from ft. ... .f`e ill Streenss NO • Hrnufecturer'a Mama NodaF we. Type Elam. slat size Eras ft. to ft. . Disco. Stet diefran. ft. tb • Gravel plwked:NO Site Of gravel CD Gravel ptit.d:from ft. to ft. .t"�.. 5urfsce scale YES to mhot depth? 0 ft Material used in seat'EEMTONITE_ • Did any strata contain unusable water? NO • Type of water? Depth of strata •ft. OS method of seating strata offrrrssa+�wrrwrestwWp+ ' wNoe■xfr saiaxasv■w:tawmx.. .momm.:. (h') PUP: Nenufacturer'&.H r H . armsnr. !� »�"a 'x, "'!a`mosooseosoosoNossoommermseemasesess L$r+d"aurfaGe elevation• (R) WATER LEVELS: above mesh sea Level .,: . . ft. ft. below top of Well Datw'04/03/91 tbs. per square inch Data ' tilptir Controlled by Work started 09/03/91 Coeelpitted 09/03/91 llrtsst .. Symtrair0Qaw4.tR■aexCO...mY a.i...e.■nm.s It R.Cim.■■A 3a rwiwrluir�wsmw rssiilrw..t 79 t11011: stawdoionticL is i/pynt wrt4r' Levet la Lowered below WELL.OitRUuci C5E�lorIGo a7raxponallila:iiao.Kithoa i . esatia Level. atructlon of this well, pRi#::its throe yge.a.pimp test pads? NO If Yea. draw down hrs. Washington weft cocetruptfop standards Matertala used Yfeltls ti•t heiA tllth ft. drawcioun rafter and the information reportid above are true to my beet y� knoWlodge and belief. Q R�COVat Y.dat1! T•�Irs; yatiel!4svgl lima Meter Level ,?tab Water Level NAME (Pouon,Dfirm, or corporation)Plc. (Type or print) . ADDRESS S/O/��?0 R PARK RD Date of test /../ rs. l8IONE010 41...°A .1 License No. 0950 t� IIrR11 ' ;C; �Civd' ', Oata ontreotor's a oats Q9109/91 0 + iat rat iort No. ARCADD 147K1 /9Yawar.eww■= Teepere#ura of.water iNi�0 t1 1tl ly msook ...R ...... ....x......vs.4...mw.w.11witaarx»rw a smt.aarx.a...astia.■x • .. • • . - .. .. Printed From Mason County DMS Printed from Mason County DMS .:.i.ta•-.. .. Arcadia Drilling Inc. P.O. Box 1790 ,� Shelton,WA.98584 Customer: kit S '/`" '1 rr�� Well Tag#: Kp►ct ' Site Address: 70 S'c Se//S \J✓' Depth: /6 8' F.. Date of Test: (,//Z 2..5-- Static:GS'.4 Pump Set: y,s— TIME GPM LEVEL RECOVERY 1 Min !p IPG. O TIME LEVEL 2 Min 10 LC._ Z 1 Min 4 4.7 3Min 1d t,t.,z 2Min G St , 3 4 Min I p LG.2 3 Min 6,Y. cr 5Min /0 (o4.2- 4Min 6, . 4 6 Min 11 Cr S. q 5 Min teG:1 7 Min 11 GQ,,.? 6 Min 4s; `/ 8 Min II G Q,U 7 Min 9 Min f 1 GC. 4 8 Min 10 Min 17 (,, . (. 9Min 15 Min 1? (of. L 10 Min 20 Min i'? 61, L 11 Min 25 Min I'1 li. G 12 Min 30 Min I-I 6.9. I. 13 Min 35 Min 1? (oy,[, 14 Min 40 Min (7 (o f.0 15 Min 45Min 17 GC- L. 16Min 50 Min )Z G f.L 17 Min 55 Min f 7 4 f. (r 18 Min 1 Hr r 7 4f. G 19 Min 1 Hr 10 Min 20 Min 1 Hr 20 Min 21 Min 1 Hr 30 Min 22 Min 1 Hr 40 Min 23 Min 1 Hr 50 Min 24 Min 2 Hr 25 Min 2 Hr 10 Min 26 Min 2 Hr 20 min 27 Min 2 Hr 30 Min 28 Min 2 Hr 40 Min 29 Min 2 Hr 50 Min 30 Min 3 Hr 3 Hr 10 Min 3hr20Min 11 i 3 hr 30 Min 3 Hr 40 Min go� / / 3 Hr 50 min / D 5 74/ c // c 2vv yli, 4 Hr Printed From Mason County DMS Printed from Mason County DMS 44, e; Vanguard Laboratory .. 2635 Parkmont Lane SW • Olympia,WA 98502 360.967.7010 VAMGUAED Report of Laboratory Analysis LABORATORY Collected by: Jim Avery Matrix Drinking Water 360-490-2970 laboratory ID: V250602-8 Sampling Address: Date Sampled: 6/2/25 15:30 70 SE Sells Dr Date Received: 6/2/25 16:08 Shelton,WA 98584 Date Reported: 6/3/2025 Sample ID: 70 SE Sells Dr Analysis Result SDRL MCL Units DF Date Analyzed Total Coliform&E.coli by SM 9223B(1DEXX) Batch ID:V250602-8 Analyst:AF Coliform,Total Negative I 1 MPN/100 mL 1 6/2/25 17:24 E.coli Negative 1 I MPN/100 mL 1 6/2/25 17:24 Notes: MPN:Most Probable Number ppm:parts per million nd:non-detect Reviewed by Dustin Newman,Laboratory Director on 06/03/2025 n/a:not applicable SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 06/03/2025 DF:Dilution Factor 17025:2017 MCL:Maximum Contaminant Level tTEnrrEn L��! tanoruTonr 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. 2635 Parkmont Ln SW,Suite A,Olympia WA 98502 I Office:360.967.7010 I testing(c'anguardlaboratory.com www.vanguardlaboratory.com 1 f 1