HomeMy WebLinkAboutWAT2025-00252 - WAT Application - 12/19/2025 WAT 2025-00252
a _ 415 N.6th Street
CIO
MI TY Shelton,WA 98584
Shelton:360-427-9670,Ext.400
'tirt6,, Public Health & Human Services Belfair:360-275-4467,Ext.400
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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: MIRANDA ET UX ROSALIND LOPEZ Date: 12/19/2025
Mailing Address: 131 E DELANTY SHELTON,WA 98584 Phone: 1.360.490.6681
Parcel Number: 320301390022
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more M Building permit BLD2025-01353
connections) ❑ Division of land:
M Individual water source (one connection), #of Parcels? SPL
M Well O Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
O 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)
❑ 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.qov
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
Water well report(attached to application). Depth unknown ft
N/A
❑ Well capacity Test (attached to application) N/A 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
by a licensed contractor.
ll 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.
II 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:
12/19/2025
Environ. Health: Date
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
i
.er
t .---,-
- - Water Well Report For An Existing Well
Your well must be properly tagged prior to submitting this form. ''v, „,
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,
* uy *Unique Ecology Well ID Tag Number: L.CISS
x t
Ctyt�'rent Use q
Domestic Dlndustrial ❑Municipal ❑Dewater *Water Right 'es(if yes,attach a copy) ❑No
Dlirigatidn ['Test Well D0ther:
*Property Owner Name: t-6 -61/
Dimensions 1
Diameter of well in, *Well Street Address: C'
Depth of completed well ft.(If known) ��j�,���
*City:';, *County t
Construction Details
Liner Installed: ❑Y s ale DUnknown *Site Well ID:
Type:DPVC eel ❑Concrete Liner
❑Unknown ['Other:
Parcel Number:;2,030 -I 3'-'7�U��--
*Date Well Constructed:
• Perforations
es ❑No ['Unknown *Location(Township, Range,Section)
Size of perforations in,by in. An accurate location of your well is very important, The
3: Number of perforations from ft.to ft. Section,Township,Range,and A,'A can be found on your
s Screens / tax parcel legal description or through your county
c DYes DNo 1 6nknown assessor's office.
v
c Type:DStainless Steel DPVC ❑Other:
o Diameter Slot Size from ft.to ft. Township AO Range , DEWM orDWWM
v 114-1/4 1/4
E Gravel/Filter Pack Section 3 = I
Qtes ale DUnknown
c
Materials placed from ft.to ft. Comments: Department of Ecology
s.
0
�- Surface Seal
5 DYes If known,to what depth ft. JUL 1 7 2025
DNo DUnknown
Materials used if known:
s QBentonite ['Cement Water Resources Program
+-
4- P� yytnp
3 (ZJYes pliNo gLlnknown / Latitude/Longitude
I: Type9'�o Ut?tae'f kt :Horse Power g
3 (Decimal Degrees recorded to 5 decimal places)
Water Levels
O Land-surface elevation above mean sea level ft. Latitude(Example 47.12345)
:2• Casing stick-up above/below land surface
1 Static Level ft.below top of casing Date measured: Longitude(Example 118.12345)
• Artesian pressure lbs.per square in.Date measured:
g Well head has cap? MYes DNo Shut off valve?Dyes DNo
0 Additional Information(If available,please attach)
t i Weil Tests:
y- Drawdown is amount water level is lowered below static t vel. ❑Location marked on topographic map
c Was a pump test made?[)Yes(attach copy)DNo (2 Unknown DLocation marked on air photo
Yield: gal/min.with ft.drawdown after hrs. ['Consultant well report
i I
am
*Certification: The information reported above is true to the best of my knowledge and belief.
❑Consulting Firm ['Driller ['Engineer ❑Property Owner
I-
Name: Company:
License Number: Address of person completing this form:
Signature:
Date Signed: City,State,Zip:
RCN'O7O-557(09/201())'lb request A\l)A accommodation including materials in a formal for the visunity impaired,call Neology Water Resources Program 360.417-
6173.I'co on wilit ingtaitt•d hearing may call Wn hington Relay Soviet's at 71 I. Persons with speech disability may call'I'l'Y at R77-533-6341
ig
Arcadia Drilling Inc.
P.O. Box 1790
Shelton, WA. 98584
Customer: Rosalino Lopez Well Tag #: Unkown
Site Address: 155 E Delanty Rd, Shelton Depth: Unavailable
Date of Test: 6/23/25 Static: Unavailable
Pump.Set: Unkown
TIME GPM
1 Min 13
2 Min 13
3 Min 13
4 Min 13
5 Min 13
6 Mirk 13
7 Min 13
8 Min 13
9Min 13
10 Min 13
15 Min 13
20 Min 19
25 Min 19
30 Min 19
35 Min 19
40 Min 19
45 Min 19
50 Min 19
Total Gallons Pumped: 830
Arcadia Drilling Inc. `
P.O. Box 1790
Shelton,WA. 98584
Customer: Rosalino Lopez Well Tag#: Pre-Tag
Site Address: 155 E Delanty Rd, Shelton Depth: 201.5'
Date of Test: 10/14/25 Static: 161' i`
Pump Set: Approx. 195'
TIME GPM LEVEL RECOVERY ii
1 Min 20 163.1 TIME LEVEL `'
2 Min 20 163.1 1 Min 161.7
3 Min 20 163.15 2 Min 161
4 Min 20 163,15
5 Min 20 163.2
6 Min 20 163.2
7 Min 20 163.25
8 Min 20 163.25
9 Min 20 163.25
10 Min 20 163.25
15 Min 20 163.3.
20 Min 20 163.35
25 Min 20 163.35
30 Min 20 163.4
35 Min 20 163.4
40 Min 20 163.4
Total Gallons Pumped: 800 Gallons
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( Date Sample Collected Time Samgte ` County .
Collected -
DiUi . . _
lfx�,lr Orr. Yew , —_D PM .
Type of Water System(check only one box)
. D Group A ❑Group 1 -0 Other
`Group A and Group B Systeti s-.Pro+hde from Water Fai es Inventiy(WFI): i
(Dp rI .
System Name 11vK tti {)JZ(,l,
Contact Person: 0.,.0s1 ltirc.v 1 s-t,, /
Day Phone:( ) ' Ce.1 Piiorle:( .)
•f iyt� 0eoditO ,�nQ:(3C'6) Ile)40/ • ... . . .• -
Seal resiOe(4:(Print karats, rrE4v Prd ai code M IZ
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Sample elected by(name) .
. SpeciF.cfcraEcn Mere sanipte'callected: ' Sr.'eclainstructonscrocrnrt:t-nfs
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i.0 Routine Distribution Sample.(ANP) 2.t]Repeat Sample(A)P) '
Chlorinated:Yes-• No (tom cu*511.ufvn system e..Er piset rmO o)
Chlorine Residual;Too]_Free; Um far#ory rout'ne lab number.
3.Ground Waler Rule Soure Sample • "—
I Unsatisfactoryroubneco&ctdate:
S
I. — =1 /
Chlorinated:Yes No i
El Triggered(NP) Chlorine Residual Total Frees
Assessment(NP)
1.
, 4.SrirfaceorGYllRa Source,%YaterSamplz(E.nuresratcn) + I
(]E.col []FE al Fs"re i Y No S __ l�--1
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0 Uns2iisfacto yToialCctlorin;Presentand' ''''.. '( Safisfigtory"'
❑E 'co;pi4ent ❑Eeodz"ent
Bacterial Derisrriy Results;Toil Ctaffouin 5 •J1(Gml.Coy . /1Cirml.
Fecal Co''qun ' ..JIOCml . ' HOG . •li ml.
Replacement Sample Required:. D TUTC • 0 Sample too'btd '
❑ Sarppte Vr urno ❑Darn.gel Ccitlelee: 0
I • Da ralR see lab re.x43ticmhv
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06/19/25
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