HomeMy WebLinkAboutWAT2026-00009 - WAT Application - 2/9/2026 WAT - j' �
J�AS O 415 N. Street
N COUNTY
X O/ Shelton,w 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: ec S•\0pt 4- takDate: 'f31/ 2-02
Mailing Address: \Gj11i L c. t 1V S Phone: • 3(Qcj 58t "')-OLJi4 c--
Parcel Number: -tlei 3 19 Oct - 42-aoOGO
Type of Water System Reason for Application ,+�l
pi_ Public/Community Water System (2 or more ...1k Building permit&1 �j�� C. t,, UD
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ Spring/surface water 0 Other(explain)
❑ 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 See
WEL2025-00021
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: lh.> `7`-,,G'"rU \tAvv\rA/A `'-'+"•-1 Water Facility Inventory(WFI) Number: non Lam.. (write"none"for two-party)
lio 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 :2. 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. •,60 f5e zo14.42
Print Name of Water System Manager kN' S N.,17 Phone Z1`1 52-q&
Signature of Water System Manager 1 L'�'� Date /3/ cz —
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 oft
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
lil Water well report(attached to application). Depth 143 ft.
>400
l Well capacity Test(attached to application) 30 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)
❑ 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:
IRAtitrimtoW`IA-
2/9/26
Environ. Health: Date
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
Application No. ... ...
WATER WELL REPORT peruiiL Igo No. ......
Vila Original and T(rst Copy with ,((
Department of Drillers
CopyThird COPY— nal% OF WASHINGTON /a �!�/
ei
Second Copy Owhes COPY x.�� �1,_........................... ..
{1) OWNER: hams _ c. .. ..
County,.....- ... ?__ e w ` .. .
(2) LOCATION OF WELL: ���:_
Q d distance troth section or subdivision corner ,-_0__-_ �tar�.*y k"1-407
• BlaY1N( iln ►1 LiwiJ iN l.: ----------C4.-""1 y!�4Ad
Industrial [} Y- dial'� i101 h color.Character,tits of mateand stela.,la.,
ID Domestic •orrltat2on:Daacriand tAa kUtd and yaturs o1 the tnatstYat in rack
rt ($) PROPOSED USE: 0 Test Well 0 Other 0 ems,1Atelin.ar o1 a net Mast on' rntrli f r taco change of !fit°^:
Irrigation Q oration psnetroted,w FROM TO
tdATTrRy►1• O
} TYPE OF WORK: pwner's number of well....._....,._..._-••-._.......-..
} t F) [f more that)one). Bored O 1- --
-
Kew well x Mothod. Dug n
N Cable Q Driven O y�(,
peepertad O Rotary C1 Jsa+ed ❑ -.•'� Rerondltlaned ❑ - ��.
t.+
_ _ 2ncAes. ---- --- ,fop ' �
Dialneter of well _.
O (5) DIMENSIONS: feted well,.... . .... _._-tt — _
C Drilled_ ._.._._..---•--..._it Depth of comp 4011-4 {6) CONSTRUCTION DETAILS.,
ITiam. rrvm ._..Q....._ ft. to f!�-n- �.,
instal
Casing installed: Dtao�.
/
Threeded O n. to .,__._.__.
O Diem-from.............._ s
y Perforations: Ya O N° _.__.,.. _..._._.. ,,�_—_——
_ c Type of perforator
n.to_ ..__...._....-
pertoratlons front ......._,....._..,.... �_�—�-
O
� perforattons Isom ..........._._..
t4 r— --
el Sereena: Yes C No ( -....
•
agaAutacLtr+e s Naane ._.�.____.__._.._ Model No-....._.��.__... —
CI
stse
t slot s2zs .. .._.._. tom ...._...... �_'' I
Illam
a.r — sue of snivel
>+ prays) par Iced: Yes L3 Ya to _ tc +__�
C preys)placed trot°--.__ �....._ _...._-
t.. Surface anal: Yes To what depth? ._.
fR VS N 1
used in seal-. i �Ci-ire:.-..._.........- .._._.--lie-- '-
.� Did, O� unusable water t Yes U -_ __
A1d aof r? .-.fain
aura Depth of stmt+----__—_..•...-..- ��...--
H �..._
Type d Rater?....—._ ---- r�
O
Z - -
N {7} PUMP: hr's N . ........ HY. _ _r_
. elevatto� .
O l,.nd-"riac sdt legs).... __._ - ---- —
(8} FATES LLl'VP3+S: e LuD of �w wt.� -
• static leytl -. ---___._.._. wr%Loch .._ •
....-.._._-.. , J__
______ins per e9 _.�--
O Astastan water is controlled by-----"(Cap.va3w, ete.l _
O
WELL
Oersted
wn is amotu+t water legal Ls ---
V.I (9) 17r.ua' TESTS: orawritOweed Below atauC level
'� mode Yee O No D U yes,by whom?.._..._._-- _...�.._. WELL D, t ER'S S'I'ATEMBN'I`
Q Was a DttmD test ti.drawdown after hrs. ton and this report is ii•E ual./min. with This well was drilled under co jurisdiction
nd dbictio
Yield' ----'~ of tttY knowleda
— ' `' true to the befit cD when pomp tyrtted of!) (water lave) leik ...,4711.eZ- .
data i NAME orstLon) Mint or ptrtet)
L Racov.ry m wtU top to w tar level) a Water bassi (T o.
a tttiasJred fro [ Time water Level nine
al a Ttmt Wattr utw / p ,x'`._A2;4104,04.,..... . ).
Q ..^,.. ....L_'.. ..._....--......._...,.--.. [Signed (v7 D tar) _............
Dote of fast ..- 19 ft drawdown ester._.....• f�9
��j with_.. .. _.._..
Saliertest+�"`F......_. al,/ -,..._........,__ _" t',�,�__d.Kn�U-?6D,.te-- -•
m. Data
Temper �*'o__-.__.......____.Was a_r emltai sttaiyais made!Yes C3 No O License Ob 7
Temperature of water-.._...._... .� /�j► J
/e/ i,� �-;Q f /.27 /6 coax AOD oNm..SHrrrs a tacrssARY1 '
$K i7S3 *EV- n.tii. / y
Printed from Mason County
M
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' T1',,'-'or' Cc kkx,t' e
a r
r ., `,„• g t�
: .'* 7 1'rl�► lS1 �g 1.)110#,p e
111 ik...muirlIate.i.tit."y!►
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COLIFORM BACTERIA ANALYSIS
'. -,, ,a.,4, Dew sarnpio CJd cWI1 'v+M ..a4-- t
�-'` `�"''- '•, 4+ .w. 7 0CA a., I
,
-�'*: Typed Weir Sin Oh* one boo 0 Pt+«x0►
•_ . ❑Group A Q0io*,8 ...n. \11..%)bil
, ' - G A and Eacup 8 Brims-Pfevitie toe War Facilliet Inventory 4
$.
_ y . ,, System Name
- i Contact Person° � .
"� "- .,••nA_syu'15 h, i 1'rnr hd� n �-'?'"
`. .w.. _ — •z• "" ,y , .. \ 2.+ Se__ k---y,,.,'' �_ -�
' -"-A- IIQ.Aki...,--lel LL) •"' ct c .c._ 'LA--
SAMPLE INFORMATION
~'' •-.;;:,.= Sample collected by (name) ATZ-WQ-All
.,� -.art`• . --4"'s ��
:� ,, _;- ' .„••• Specific location or address where sample collected. [ alinstructionr
••>,�... _ .
� "`�` Type of Sample (must check only one box of#1 through#4 listed below)
- •__ 1. n Routine Distribution Sample 2. Repeat Sample (after unsat. I
`'= - - Chlorinated: Yes No [ 1 Distribution System
„� --,.,
Chlorine Residual: Total Free Chlorinated: Yes o_
' 3. Raw Water Source Sample Chlorine Residual: Total
'- —AZ,- ...c" -_ (-1 E. coli— GWR (A/P) , . .. ...
.: M �-._ ( I Fecal — Surface,Girl,springs(numeration) Unsatisfactory routine lab nu_
-_' Filkered: Yes_ No____..__. -
- - [� Assessment Monitoring (A/P) Unsatisfar4ryout►n `°
,•-• nOther / /