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HomeMy WebLinkAboutWAT2026-00021 - WAT Application - 1/30/2025 (2) WAT 202.40 - 00021 MAS �h Street - COUNTY 1Shelton,WA 98584 Shelton:„,360-427-9670,Ext.400 Public Health 8t Human Services tilirV:Ilig467,Ext.400 15 W.Alder Street 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: C4 i- A,"49-46 1 Date:Mailing Address: 35,c, A ee �Iseiv Phone: 3#,(9,-' .-- 5'72 Parcel Number: 2'P17— '. .—()t0 5=' Type of Water System Reason for Application ❑ Public/Community Water System (2 or more 0 Building permit connections) 0 Division of land: Individual water source(one connection), #of Parcels? SPL l Well 0 Boundary line adjustment 0 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 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. ❑ 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 1 5 Group B Water Systems D Satisfactory bacteriological test within last year(attach to application). Individual Water Well Water well report(attached to application). Depth 9 7, ft. Well capacity Test(attached to application) 6 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. in 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) E `.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 Applicants water supply does not appear adequate to meet the needs of its Intended use for the following reason(s). Reviewer's Signatures Environ. Health: ' Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 Figure A-2. Example Water Well Report for an Existing Well Water Well Report For An Existing Well .a `' Your well must be properly tagged prior to submitting this form. Asterisks(')indicate required fields.Mail completed original form to: '''',:''-r'r VA State Department of Ecology.PCT Eox 47600,Olympia,WA S8504-7600 ECOLOGY Use this form if an original Water Well Report was never filed or is missing from Ecology records. < 'Current Use -_ 'Unique Ecology Wet ID Tag Number. social a4 Dtxrr?stiC Clirds.^satal OlAracipal DC water "Water Right DYes(if yes.attach a copy) ( No Dirrigatan ❑Tesi'A'et CIOtr•e' Dimensions 'Property Owner Name: owns a eN sea Diameter of Wet 6 in, 'Wet Street Address: ?S CA4212 tmr es Dept of completed wet ars It.(if known),r 'City s„A, 'County M •: c. Construction Details a Line-rinsated: [ayes ONO *Unknown 'Sife Wet ID: run r- Tom:OPVC (]Steel DConcrete Liner 'Tax Parcel Number: a0f:•'1d•0°s° C►Linknown Deter: ra 'Date Well Constructed: Lb.,. Perforations in Dyes DNo r t Unknoatn 'Location(Township,Range,Section) } Sae of pericratcns .by in. An accurate location of your well is eery important.The hurtoer of perforators __ ttcm R.to r Section.Township,Range,and'A.'4 can be found on your o Screens tax parcel legal description or through your county s DYes DUo (fflUnkrtcam assessor's office. O Type,C1Stan�Steel D'ti`C t�Citter._.._ v Diameter_Sct Size from ft.to It Township 20N Range 3W DEA.M or(E\'t.Ytil z. Grave4FNter Pack sec'on 11 SE u4-114 SE 114 o DYes Oro ®Unknown Materials placed from t to t Comments: {' o Surface Seal �� E�Y E© To Dyes a known.to;!.teat ceps ft Mate ®untn )ept Ot t-cotoey $VVI�a r aterals used if krta wn: o 4- DB+er'«Crtte DCerrtte 24Feb26 pump ,°Js ® © ' Dtsrkmar, 3f2 Latitude//Longitude T S""'A"'s° Horse Powe (Decimal Degrees recorded to 5 decimal pieces) Water Levels Latitude(Example 47.12345 Laux waters elevation aye mean sea ,� st �� ) L Casing stick-ups abovelbetow land surface 0 stalk:Level 0sft.be:cw top at castc Date measurer!: Longitude(Example 118.12345) Artesian pressure_lbs.per square yr.Date measured: -}n.°' W l" 'rrei ma,'has cart": Elves Dino Shutoff ether DYes Otto O Additional Information It[avertable.please attach) Well Tests: OLocaticn mailteo on topographic map Dlrawdbirt is amount v,�s8r:evrel IS'o-t,�rtd below static;Cv?t. DLDCahCt1 n`3:t(eC on�lr Photo co o was a pump test mom?®Yes touch copy 1 ONo D Unknow a '9 "CM; gatnain.with t.dra down a':r rrs, DConsuttant Ikea report oo 'Certification:The information reported abase is true to the best of my knowledge and belief. U j Consulting Firm ( Orilier ©Engineer OProperty Owner O Name:CoOY Johnson Company.Arcadia DMins Inc + License Number:3411 Address of person completing this foam co 21 W Westfield Ct e s Signature: !? E c Date Signed:2113 6 city.State.Zio:Shelton,WA 98584 a. a D I." ,EAP081,Version 1.2 Page 20 Uncontrolled copy when printed Arcadia Drilling Inc. P.O. Box 1790 Shelton,WA.98584 Customer:Chris&Michelle Schreiber Well Tag#: Pre-tag Site Address: 180 E Agate Loop Rd,Shelton Depth: 37.5' Date of Test: 2/4/26 Static: 23.9' Pump Set:29' TIME GPM LEVEL RECOVERY 1 Min 11.5 28.1 TIME LEVEL 2 Min 11.5 29.3 1 Min 26.7 3 Min 6 29.5 2 Min 25.1 4 Min 6 29.8 3 Min 24.3 5 Min 6 29.6 4 Min 24.1 6 Min 6 29.5 5 Min 24 7 Min 6 29.3 6 Min 23.95 8 Min 6 29.2 7 Min 23.9 9 Min 6 29.2 10 Min 6 29.3 L 15 Min 6 29.3 20 Min 6.8 29.3 L. 25 Min 6.8 30 30 Min 6.8 29.8 35 Min 6.8 29.9 40 Min 6.8 30 0 45 Min 6.8 30.3 O 50 Min 6.8 30.3 E 55 Min 6.8 30.3 O 1 Hr 6.8 30.3 1 Hr 10 Min 6.8 30.3 L O Total Gallons Pumped:465 Gallons v d c v L L Z .v 0 O u LU 0 c a a d .s F , II ..N.\.\ lltrn-hi)n t"�tirnty f twirc+rllrrr,lli.al I{r�rtU}t '' '., ..: X11+I illy Rd NI 6 Olvinril.WA'ltd`.;III ""' . •\ tr,t1 J;t,1 1 f,tt {,�uft: xr ..! i \ • , n . (lrlt [3C (t� BAC BACTERIA LY I llllli!ctngll+bs rnnnty {r iP in i ii}iP 6�}Ilpr!�xf tsm .-\I t L-1, f l t:l t,'° r 47 l�1 f i`�0 tee err,, f aH i;,.,'.$4.:III ieflo..cik oaly l nu hoc)_ 1C IPrivate I loilcohold • 1(rou r, ❑croup t3 .—Olltmr.,__.... _..__......._. . a;n I. f,,,,}, .t;r0-,vr,S Systems—Provide trots Water Facilities Inventory(WFI): i 5'si'r.1 Na/ms \Contact Person. CIV15 sc37I Day°home:{�) CI Cell Phone: (fir )q90.M•3`). E-ra'ilger1'1(,Q,,t' V C Eve.Phone: (�� )4 5�I 5 1 Se,M resells to:(P)ini tut name,address and*code or emelt address) i I r SAMPLE INFORMATION I Sample collected by(name): I Specific location or address where sample collected: Special instructions or comments:LbofAti S .c itotu W I G.i's -1 • Type of Sample(must check only one box of 111 through#4 listed below) 3 1, (Routine Distribution Sample 2.Repeat Sample(after unset,routine) y r Chlorinated:Yes, No , _ 0 Distribution System 1 ( Chlorine Residual:Total Free___• Chlorinated:Yes No 3,Raw Water Source Sample Chlorine Residual:Total_Free•_ 0 E.coif—OWR(NP) - , 0 Fecal—Surface,GWl,springs(numera on) Unsatisfactory routine lab number. filtered:Yes __No __, ❑Assessment Monitoring(A/P) Unsatisfactory routine collect date: 0 Other S 4_ Sample Collected for Inforrnatfon Only i "-"---- Inuestigarive.r._ Consiruddon l Rspairs)_ Other LAB USE ONLY DRINKING WATER RESULTS LA 0NL B USE Y 0 Unsatisfactory Total Coition Present and Satlafactory 0 Evil/present ❑Exalt absent No Col(form detected Replacement Sample Required: — --- 0 Sample too old(>30 hours) O1141c Bacterial Density Results:Total Colitorm ~�— ---____..1100ml, ':--------coti� ./100mI Fecal Coliiform --._J100mi Enteracocci _— _1100 ml, I Method Code:WiTre— 3t)t gM g22pD-"— — ---- 1 __ __❑BM B215BDale and Trma Received i)760 O Eratorolertrt� ��© Data eel Tara Analrzea ...f.------___f � — 1.S 1 +{wr.;ciz ipy��num...0 v,Ui;u j""'--------- --R—...: 0 a 0 Lab Uss Only;`r,--1:11----4°2------S '' I i