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HomeMy WebLinkAboutWAT2025-00234 - WAT Application I WAT 31 Dd p2 /eaMASON COUNTY 415 N.6'h Street Shelton,WA 98584 • Shelton:360-427-9670,Ext.400 ; . 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 Name of Applicant: 1-��J � ,t��. evU� JY5 \ ate: Mailing Address: / Phone: 31ED, I,A 1-13`\ 1 Parcel Number: 2.2 g...51-000Zoo Type of Water System Reason for Application ` rn Public/Community Water System (2 or more >4 Building permit e��96-�` Z'`D connections) ❑ Division of land: 4 X Individual water source (one connection), #of Parcels? SPL X'Well ❑ Boundary line adjustment 0 Spring/surface water 0 Other(explain) ❑ Other(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 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. 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 Phone Signature of Water System Manager Date This form may be scanned and available for public view at www.masoncountywa.gov J:\EH Forms\Drinking Water Revised 05/08/2024 Ng,: I 42. Group B Water Systems ❑ Satisfactory bacteriological test within last year(attach to application). Individual Water Well ® Water well report(attached to application). Depth 71 ft. El Well Well capacity Test(attached to application) 8.5 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 ;I by a licensed contractor. El 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) lN SatisfactoryDetermination: 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. E! 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: StL Date 12/16/25 Environ. Health: This form may be scanned and available for public view at www.masoncountywa.gov rage 2 of 2 • e —t WATER WELL REPORT zO ""` EPAR1MENT Or Nod*aofl'ftaatNo:y t6S1a . ECOLOGY Unigweeo*Well ID Tag No, BLV426 Type of woekt State cl Washington Site Well Nerve(if mote thanono well): 111 Commode* ©Daoonr lwba .Origami Iandli MITI N.. M81 W14 wade light P11m(UCatUic a No. Prgl.Miba 11110011014 QIeM SId 0 Mu.Mitrsi Propotywns O Name;PETER CURT M0 bDt sWa$ D f Soo CITuI Will CI Otha Well Stied Add 3740 E MASON LAKE OR ounty.MASON Nw►411 q AMwutoo 0 Denote 0M Jowl 0° cTsi C C qFdelealdw 0 Parr. ,_ . d Oat a Mr' ❑Mndd<oary Tad No. 2210541-0D02U • 'Wrewiwe MameOtrodig,f. by*1161...—g, War a vrrienee approved for this well/ CIO Yee 0 No efearopsoaad well 7t5 it If YIN what*litho variant*foe? coNtilflidlitlyi vomit MWIt loaded ldutAgQ coesameiled wel 50*IA tf9m0+C°°tdd 6O hlit . Datsl Wanly To Neiman Sad PVC WmldM Tbreed ®! au❑ >a%w µ,it a tea. • I n O I 0 Location(we*auctions on$$e 2). £WWM or 0 EWM Cl 1 ❑ in. — ISW.yr14 of the_fig_IAA,Section _Township 22 Range- - ❑ l ❑ In. is 0 I ❑ ❑ i ❑ Latitude(Example 47.1234S) - CI ! a ..._.le. — —l6. ❑ i n n 1 ❑ Longiuide(Exempla:•I2D.12345) Ptrl4allw ss*talc 0 Yu 0 No Typ'.tp r wed brIller'a ter' '"a" tin PrOtedert No.otpstiontkos Siff ambush* ILbY- __M. F WM b eai mite,manta, alit orimai�l a m*l ea +e,sad Me kind and Min*tom t a ft Won psi NOWT none&is dun igyer puma*filth ot lows ono may for fink mange of 6meN 11 Yen CI N. a Wacker Deck_t• iabr Uasaddflimni rhsmo if oraetuy. t1 Material from To Maa*igtfaot's Ntn a.I I nIX i b 1 Dboo r6..,,in, sot tint AL {a tom Vol* mad Kittle ri.b S, 1 11 Dioaagor_„-in. !fiat do la taro 1.to_.___P. 1311,0 17 29 etrowfti 44 • t sdlfdrr polio A Yfi ❑No Stop ofpwk atraaaYl +ISrrovott NM pan 29 29 44 MMlisedi;pMlod tons,..,.�IL to'__t 'eef�-rzi $.tees 6telt ID Yes 0 No To mar d se1.L..P. BrOVIl1 56 e2 sl Mewls!hood Mewl !frown dWWater 62 72 Old eery Brass wain aaeanble wane! 0 Yea 0 Na • Type Munn? Depth ammo Method of Mdiae weal oft Pools Mnp6otma't Nam,____.—'IYPr---,...-- H.7._Pump bake deptk..-_P. Desivni Sore nano:"_da>m Waver LaUst Lanne r9a devotion above Ilion m Ironer_P. 5dcJ .p amp*hull adat P.—Name su*os Ratio wen low'_I. 4.below asp anon cooing now W1W201$ Anal+prWattil.-.—bs.pot squats loots Dot Attune weer is aoatrollod by__ __---(offwive,etc.) Watson Wee s pumping teat pwlbmtod?O Na 0 Ya C=> by whom/ Y1s14 Wtn web__,ft dnwdewn star__Its. Yi.14__.Wm web_it dhwdown slat gm. yield_ *pm*WI_A.&,wdown amp, hrs. Recovery dsa(Sane•aro*bon pump is mood elf-tutor level maeotod boa eel I tI topaowswkwt) Timm Warr Ian! Time Wear Wei Time Wan Level __. ___ Dam or i I — — ptmrgiet fit BMW wtl_.-,Wet with i n-dnwdowa otw las. • Alt as pm with man at it --,-,_R Ara.-_.,.hrs. Cow Matt— . Amnion flow_„-,ape ���aaaaaaaaannn Template's Outer'_�'F Wu a dunks!sosiymY rods? C)IN C No Suet 1 or poi o Completed,Deco OB/1 19 . , . WELL CONSTRUCTION CER IFICATIONl I aauttruet ad ant/ordaaept radponibilil 'toldturrtIcn of this wll,and its compliance wish all Washington well oonstntotlof epndtnb,Materials wed and the irdlomedlon reportsd'Bova so true)to my iMowladys and belief. C Driller RI Trainee n P14-Pent Name Doug for CM Command moon Drilling,INC SiPitivfik U eN .32e8T Cry$ispsxlp POROrdlafdLWA98365 IF TRAM6i;;Spmiot'g N�2 --•..--- �' $ �,Y� No,NICI I0W1370M ego 06/24/2019 boraces sSisnatsali ECY 050.1-20(Rev 1 I/18)If j om seed this doormen In as aileron please call the Water Resources Program at 3604107.6872. Person whh htartmg lots can nail 711 for Washligtors Relay Sento. PstioW with a tp ech dtsabIllty cant call877-833-6341. Printed From Mason County [)M Printed from Mason County DMS 1 , --, # NICHOLSON DRILLING INC. Nang NAME: Rata(DU* DATE I June 27,2019 . k SITE: 3740 E Mason Lake DR W TIME I Grapeylow,WA 98546 WELL peril muij Feet WELL DIAMETER PUMP MAKE ellti PUMP MODEL inlialMill1 TANK MAKE TANK MODEL . . *itiole depth Drpoi -Rae The 'Depth Draw• R M io iii ..„7: .,... tiii OM To Down gptn to Dawn gem Down _. 11 Water Sc . ..752 0.0 . 40 . 16.5 .. 1.3 ' IIILE111111111111111111U111111111 i -.. • , • 2 • 45 is",6 1.3 10 - iiii.kliiiiii MOM 1 . •- i.. r...1 • . 4 , ..0 16.5 1.3 7mmummup ' 1_,. i . .9, • 60 leis 1:3 111,E111111111111111111111100111111111 • • 1 I ' ' 0 • • ••• 70 16.d 1.§ .. IR1011111111111111111M i ' di 4, . i ..: • so 18.6 1.3 -• iii.,...1 • b.,. .- NOM WM ie. I. . .... . so 16.5 1,i IIMMIIIIIIIIIIIKEIIIIIIII 7 18.3 1.1- : • 190 9.0 KLE. imilouis s 16. i4;, • ' do 0,0 . 1E= IIIIIIIIM 9 16.• „1.1 .. • 150' 0,0": RETZ2)NUM 11111111E011111 10 183 • : i.i. .,."., 150, Co ii.E.721.1 L________. 0.. 11 16.3 1.1 ,, , ' 219 6.0'. IliE311111111Ni111111113 12 16.3 I.( - 240 0.6.' ea-aqiiiimismosim 13 16.4 '11 110 0.0 iiii=ammiNEE 14 18.4 1. .8.5 300 0.0 . iiMI1111111111 . 0 i• 16.4 1 380 • 0.6 RELT..)111111111111111111111116 ] 20 16.6 .1.3 420 b.b KLE!]111•11111111 MEM , 26 18.6 1.3 : 2(?‘ 04 EliBmmum 0.0 30 16.6 '1:3 . 6.0 IMMINIMMINIIIIIE 35. 16.5 1.3 A i RE, a.o all.:AummemiLli ge•ygp. The Deeth IMIr 'Time Detrh '-Draw Down hi, erto: Down 'raw to Down Water , Water star 1 15.6 ,04 11 0.0. NO 0... 2 16.6 0.4 1.4 IKE 0.0 11110 • imEE 3 16.6 ,0.4 ' 0.6 ,„o 4 16.6 0.3 14 0.0, Mlik.1111111111 0.0 6 15.6 0.3 15 ' 0.0 OWN MIIIIMINEE 154 0.2 20 0.0 . MO, 0.s] '1 15,4 0.2 26 0.0 6 15.4 01 30 b.& IMEK11111111111111111111111a.' 0 16.3 11 36 -b.o 111‘011111111111111 0.' 40 15.3 0.1 40 _ 0.0 MEI m SIGNED BY: Alan Myatt,Hump Sueenhor Printed From Mason County DMS Printed from Mason County DMS i - . ll Thurston County Environmental Health ` ,�r,,��, 412 Lilly Rd NE I Olympia,WA 98506 i • _.�f 360 867-2631 • THURSTON COUNTY COLiFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County Collected l01Zk1 11 • Uo• ❑PV(A�, iM Ss Month Day Year Type of Water System(check only one box) 0 Private Household 0 Group A ❑Group B 0 Other _ I Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# -- -- — System Name: Contact Person: _ 1 6, ,., • Day Phone:( '31) 60i A_ ')'>C1 t Cell Phone::(5 E-mail: Eve.Phone:( ) Send results to:(Print full name,address and zip code or mall address) r ' ._._....w..1_.4.P......w./.. Gr.,S-_:e.,1,,,, ...C..1..Uhz__..._..._.._ _ .-... SAMPLE INFORMATION • Sample collected by(name): Specific location or address where sample collected: Special instructions or comments: `l ku C.,,-Avesig w 1,-,'k il r r oaf cD4-.A.A e..v i t W w ii- 9esoft Type of Sample(must check only one box of#1 through 44 listed below) I,-VR-outine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes No 0 Distribution System Chlorine Residual:Total Free Chlorinated:Yes No_. 3.Raw Water Source Sample Chlorine Residual:Total Free f ❑E,colt-GWR(A/P) ❑Fecal-Surface,GM,springs(numoraton) Unsatisfactory routine lab number: Filtered:Yes No ❑Assessment Monitoring(NP) Unsatisfactory routine collect date: ❑Other / / L I f -.I 4.0 Sample Collected for information Only Investigative Construction/Repairs Other LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Collform Present and Satisfactory ❑E.coll present ❑E.coll absent No oliform detected Replacement Sample Required: • ❑Sample too old(>30 hours) 0 TNTC ❑ Bacterial Density Results:Total Collform /100m1. E,coll I100m1, 0 Fecal Coliform J100m1 Enterococcl /100 ml, ' Method Code]8M 922'3B OSM 9222D Data and Time Received? -"r ❑SM 9215E ❑Enterolertt tU'lev 2`5 V3-c.) Date and Time Analyzed: tit• L.1- 'j.5 Date ReporledkV'30•")..5.X1 � Sample Number(DOH number plus five cl ls) Lab Use Onty: 1 DOH Form 0331.319(revgad 11(23) —J