HomeMy WebLinkAboutWAT2025-00167 - WAT Application - 9/22/2025 W AT (1 T - �'►11"
•
• MASON COUNTY 415N.6thStreet
Shelton,WA 98584
Shelton:360-427-9670,Ext.400
�r: 17;: P Public Health & Human Services Bclfair: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: k !�" L.,; Date: —1' I-7- 26 -6.
Mailing Address: 1 l ROc,-y i_ic.:[ al)1:--, Phone: .1,,-) -Lk" ivt_. 1 i) 't_... qE') 1`t'
Parcel Number: q tJ - `_+`"i - (a[) (.G i :3t., ,o _.[.12:7 - -746r 1
Dbl.!4)ry• L1.1C4-$6 ? t t-it tS --3
Rea
Type of Water System on for Application
Public/Community Water System (2 or more/
0 Building permitj� 20G�J' �� �
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water Other(explain) 'kat 2L Z..`7-•Le6 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:
Public Water System
Name of Water System: /r)ULE+I _ Let'h x
Water Facility Inventory (WFI) Number: not ir (write "none"for two-party)
I am the manager of this water system. The water system has beapproved for services. There
are presently j connection(s) in use. This will be the f _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 -JG'-4tc43 7.MeNt!mei-- Phone .36-' .' LC'4-4 7
Signature of Water System Manager 4/�`. Date -/ cam 7r
This form may be scanned and available for public view at www.masoncountywa.gov
J:\EH Forms\Drinking Water Revised 05/08/2024 Page 1 of 2
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
•
Individual Water Well
IA Water well report(attached to application). Depth 110 ft.
ElWell 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.
l Satisfactory bacteriological test within last year (attach to application).
Individual Spring/Surface Water
O 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
e •
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.
D 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:
RANYYYuPS Date 9/22/25
Environ. Health:
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
Re*WM and Rrst Copy with
Dapertment of Ecology
Sableol Copy—.0aesses Copy
TWO Copy—Wee*Copy
WATER WELL REPORT _—
OW Cad HP.47741466
STATE OF WASHINGTON mow mem roma 14:41QuE wELL ID'. 8121- 1°7
I
• (1) OWSER: tiontw ,a_t_ _. Adam's 14 1 14. a
re (2) LOCATION OF WEL: cam_Ll 1„.56- 1,4secii I 16 - I_
Ti S"'"' (2e) TREET MOREE8 OF WELL or normerdestio), -780 2Le-.4 il_D. S tt-170AJ.‘4,44, 91.•=1-/
(3) PROPOSED USE: 0 OtwaNg Indus C Akeldpsi 0 (10) WELL LOG of MIANDOPRIENT PROCEDURE oascpurnot4
C trIpsdon
4n C DesVeW Test Well CI Oyer 0 Forrooket Dernonse by mac*macaw.dos dense.and au ..end Wow isklesese of seders
and lo kind slot main of Or notonsi ks own wart oenornosa sds%et lead ow v*y for 011eh
chaps el siorreelort
Z (4) TYPE OF WORK: ilors"1101400(r
C _IIATVIAL PIM To
Bored 0
O Abandoned C New wet ,IE %Wino:Dip C
Owiponed C Cabe Ilk DO '/Lotc.4 -1-4990.11 6 J
C flecondeoned L.; AY C „Wed C:1 ./IOLA.") ,4,„,. .......i_e:or
(5) DINENWONS: °wow crow_.___.4 kola. dip i I. .114'&eV .S4"601111". 4. A6. * _
RS MOM 1 i 0 feet Depth of coryleted well 412----__S. A ' 11—r",
....--------------........,
i <4.) COMMOTION DETAILS: i —ea .. // /0/
4.—
C Ceming Inalfilkid: 49 • Dem rtoretl__IL V__. .._IL
... / — loi
0 taw irelseer _. • Co -tons IL to ____—___kit 4_more,jez. —
lltreadled • Darn.km t to
*a
8 Parloralbne: Ye 0 e No44
Typo al perknoor used _. _
.0 SUE of poilotetonrn . _ _ hi.by __ M.
C
CO ______ perforations km t lo----R-
S perform:ono from IL so t
El ___ parlondlone barn ft.lo It. .7r:
... : .,
, 4
13 f r
saws: Cm S No 0 7
El aiOZCO _ .
S 7Ts , ___ mod.,No. _
6#....44,--- -..... _flg„ fra./D7 -it
C Dew Sol eise _ cm IL to IL ,'"• .
CE
ii.. Omni poseltad: Yes 0 No r. Sem d Wad----
fa. .
CO Orval paced km ft to t .-71
--4 .
. _
Ilwriaeo oltalt Yee No 0 To ape?___L8 pt.
-
-
okielorld weed In IS - 4
Z Oki any wets coolers unusable wow/ Yes 0 Noig4
VI Type of weer' Depth of sem
8 method of swam crew cd
--- — •---
M PIMP: Marrnstwourera Nemo_
_____________
Wok bibiof.7g).__,so composy0 —1_,Ik_REA_. ._ ,if—
01) WATER LEVELS: Latollkoallo•ofv*kr
7-7111-4-
O VIEU.CONSTRUCTOR CERTIFICATION:
Ill AntaAan P.."'" lbw por woo moo Dor
mow wow to orwarolied by 1 coneirucled sandlot amyl favorable?for oortalniclion of Ibie wet and Rs
46 Ow veto.eicl oancientie with all Vtisslarclon well oonsIniaben mandarde.Mewbile twee and
Ilw inkornedion wiled dm"are Sue lo my beet knowkidge andbelief.
•wi (111) WELL TEEM Dewclaw I craw*grow looi bi bolPOO bolos sulk Wei
C
W Wei a pump sot made Yes 0 No0 lir».by*IWO poloAttraliAlitikeykiiiittaQ --
@ —.6.1t psi min.with tt drowdown Ow____rim
"— " " Addrws054#i 1.4) t4S.604,449tt 40' 9/a/VAI g.s..
21. " .. " " iSlanadaethil":" License No-Vie
8 ni....nido,tilme Wan ea wooden pump Weed od)tweet ewe nwesured kern web
lap la aim Web
Tire. Ws of toed Thus Wow Lows warn Wow Level
W Conlisolor's
= _
1""' 112.9M—kra l›Ziigek,__.Cialo-7—2 7-96 ill
(USE ADDITIONAL SHEETS IF NECESSARY)
Cris WANK
Baate lad ZS./ pi min.with a IL drandorm IOW ii ,..
AM* Wines,orbs went est at IL br " Ecology is an Equal Oppoduniy and Affinnativa Potion employer.For spa-
Artisan Sow op tn. Dew_ dal accommodation needs%contact the Water Resources Program at(206)
• 407-0600 The TDO number is(206)407-8006-
Pr T"r""""n"—""e 4wwila.."9"3111Y0 i 141114
,.
;:ti from Meson County DMS
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: 718/25 Static: 95.9'
Pump Set: Unknown
TIME GPM LEVEL RECOVERY
1 Min 15 96.9 TIME LEVEL
2 Min 15 96.9 1 Min95.9
3 Min 15 96.9
4 Min
6 Min
15 96.9
5 Min 15 96.9
15 96.9
7 Min 15 96.9
8 Min 15 96.9
9Min 15 , 96.9 ✓�� I
10 Min 15 96.9
15?Ain 15 96.9 96.9 4 .., i g,
20 Min 15 'le
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
1Hr 15 96.9
Total Gallons Pumped: 900 Gallons
10
I
I
Printed From Mason County DMS
Printed from Mason County DMS
I
} Thurston County Environmental Health
412 Ully Rd NE Olympia,WA 98506
360 867-2631
THUltitiet . tr
MININNEIVIINH
COLIFORM BACTERIA ANALYSIS
Dale Sample Collected Time Sample County
Collected
0&' t ld " I uses
Type of Water System(cheek only one box) R Private Household
❑Group A ❑Group B ❑Other
Group A end Group B Systems-Provide from Water Facilities k entry Mon
t0#
System Name. t
Contact Person: t,,v a ( ctr�(I--
Day Phone:( ,,l L Z(o - S�5(1 Ceti Phone:(3(P'LL)Z
E-maAlt)f 1,sc e,f e&i U:Q,j k`t it(5_ r"'° ( )
Send resits to.(Print Minaret aka sod zip lab x anis edam)
for 2u� ewCLt►- t)�e .
SAMPLE INFORMATION
Sample callected by(name). 2.4 c
Specific baton nx address Are sample collected: Special
instructions or canmenta•
1 l W 1 -Lt.5
UN 2 6 2025 He(km,WP Qnc (
RECEIVED Type of Sample(roust check only one box of r1 through*4llaed below)
1.❑Routine Distribution Sample 2.Repeat Sample peter onset.routine)
Chlo naiad.Yes No_____ ❑Distribution System
Chorine Residual Total Free_ Chlorinated:Yes_ Na
3.Raw Water Source Sample Chlorine Residual:Total Free_
❑E.co i-GWR(AR)
❑Fecal-sarize.cM eer+4f two^) Unsallifiactory routine lab number:
Filtered:Yea No ._ — _
0 Assessment MorelorinO( Unsatisfactory routine collect data:
0Othe 1 1
, S I
4.QSample Collected for information Only
Investigative for'f Repairs . Other_
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Uneetisfactory Total Coltform Present end ��
❑E-c+allpresent 0 Exc.absent
Replacement Sample Required:
0 Sample too old(>30 hours) 0 TNTC 0
Bacterial Density Results:Total Colgan 110prnt. E.00fi 1100mi.
• Fecal Colaorm .--.--.J100rnt Errler000ca /100 mt.
Method Code:jtSM 92238 ❑SM 92220 Doe and Tyne Rewired:
SM 92158 ❑Enbrolerte &wl LrI .
•
are and Time Analiaed(Q 1S Dole FMQabd b`l c#... iZc
sample wrier low weer s*eobt Lab Use Only:
rinted From Mason • .8 • - g __-
.tt�
Printed from Ma; Ca i , ch 9aect
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