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HomeMy WebLinkAboutWAT2026-00165 - WAT Application - 8/7/2026 WAT 2026-00165 MASON COUNTY don,INA8584 Shehon.N'A 9R584 Shelter.3GW?7-9670.Est 400 Public Health & Human Services hclreir: 360-27 -44ezL,t 400 Application for Determination of Water Adequacy Instructions 1. Complete Part I. No determination can be made until Part us 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. Patrick Dower Date: 7/9126 1100 California Ave SE Phone: 760-224-5738 Mailing Address: WA 98166 Parcel Number: olr»F 70-00120 Type of Water System Reason for Application ❑ Public/Community Water System(2 or more 0 Building permit connections) ❑ Division of land. 0 Individual water source (one connection), #of Parcels? SPL O Well ❑ Boundary line adjustment ❑ Spring/surface water O 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 F er System. Inventory (WFI) Number: (write"none"for two-party) manager of this water system. The water system has been approved for services. There ntly connection(s) in use. This will be the connectionmanager of this system. This connection will be to upgrade or change the use of an existing n 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.masoncountyrwa.gov 'FFI Forms'Drinking Water Re'ued 0A0R6024 Page I o12 Group B Water Systems ❑ Satisfactory bacteriological test within last year (attach to application). Il Individual Water Well ® Water well report(attached to application). Depth 216 ft_ >400 ® Well capacity Test(attached to application) 16 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. ® Satisfactory bacteriological test within last year(attach to application). Individual Spring/Surface Water ❑ WDOE permit(attach to application) ❑ Method of disinfection O 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) FAdequacy ctory Determination: ermination does not address adequacy of the distribution system,guarantee an adequate supply of efinitely in the future,or guarantee compliance with all applicable WDOE water resource regulations. ended approval indicates requirements of Sanitary Code.Title 6,Chapter 6.68.040-Determination of y for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter RCW.isfactory Determination: t's water supply does not appear adequate to meet the needs of its intended use for the followingreasos). Reviewer's Signatures: 8/7/26 Environ. Health: Date This form may be scanned and available for public view at www.masoncountywa.gov Page 2 oft WATER WELL REPORT U DEPARTMENT OR. Nolee0rmmhtwo. E62706 ECOLOGY Unique remogy well IDTogNo. fNMea2 type orWerkt Stem ofWashington Site Well Name ...than one welp>. CJ Doco.wtion Water Ri tYerml1/Cenificmv No. _.__.__- QUewmmuelon �? Original i;wWledenN0l Nv. Bn Proposed Use: M Domestic ❑bdroord ❑Municipal Properly OsvnerNhwn T6TRlCvnnsn ER --- ODewaterSg OIMga600 ❑Test Welt 0 thher__�_ Well Sheet Address 510EBURGUNDY RD — CuvalrvetlovType: Method: Cil SHiyT_ON County MASON _— Newwell ❑Allemtion 0 Driven ❑Jetted 0 Cable'root Y ❑Jkepaning ❑one U Dg IN An, ❑Mud-Rotory Ta Percol No, 220257,900120 Dlmeolom: Diameter ofbming 6 n,En 210 R. Was o ,eianee approved for this well? C1 Yes I]No Depth orcpviplalWwell 216 h IfYCS,what was the variance fos'r Conetrnmon Detaue: Well __-_ Casllg.Liner Dimnele Form To Thomas Stwl PVC Welded rioted —_ Qe WWM or❑EWM 0 I ❑ e —in. +1 206 .205 In. IB I C © 1 C i.ocation(see ins octlons on Page 2): ❑ I ❑ _{n — — _in. 0 I C C 1 ❑ NW yn-Ynnfthe SE 'ASeelion 25 Township 2 NN Range_,? DID — — _ in. ❑ ❑ DID Latitude(Example 47.12345) 47.190518 ❑ ❑ - — O ❑ ❑ ❑ 12D 874612 __— Longitude de(Examme47.[2345) } - N'rorWiona: ❑Ye,n®No Type orperraretor WOO -- DffRer'sLog/C0n lrlle ton or`Decommbsrnn Prneedntt No.ofperforadons_ Sizo erperromtimu_in.by_in, votmaliole:gescribe by color,ohamIXm,size ormaterial end structure,and the kind and Performed from—ft to_h below ground surface vanes of@e meredpl in ctch4W pemuetsi,with at least one entry for each change of Sereem: ®Yes ❑No &Pucka' a Depth__". iuformntion. Use eddnio;ml slams Wueeamy. Muvuf elamr'e Name________________________— Materiel Front To Typo 6TANLESS !_ Model No. CLAY&SAND BROWN 0 200 Dismncr a in. Slot sip 12 in.from 206 0,to 218 R SAND H2O BROWN 200 216 Dinmeler— in. Slot size_ in.home—6.to—_it -- SaW/Mher park;CJ Vea [Na Size ol'pack motorist—in. Maleness plxmd from,, ft. _— gnrfEeSeaI: IMYee 0No To wlml depth?.2t_.ft. Matetiel used in seal BENTONITE Did pity stratacmttainuowabbOwmM ❑Yes No Type of water? Depth ortlreta_ ' -- Method ofsealing nreta o¢__ Pump:Manufacturers Name GOULDS 'srpe; SUB H.P.±1 Pmn,Slake dephl200 ft. Dut&;ed low rate 10 goes Water Levels: Land-rmfnroelevaliaaabove mean sea lmxlft. SticNupoftopefwelleasing 1 R above Pmmd s;efiw Smliowaltrlevel 170 ft.below tap Orwell caning Data &25-26 Artesian ptnsaurl—ha,per scNareinob Date __ Aslesim water u controlled by (cap,valve.etc.) Well Tmm Was a pwopfng teal perfomwd 10 No m Yes b by whom? Yield 16 how with 7 A.dmwlown afler4 ben. Yiold_¢p or with__ft.dmwdowo after_tug. Yield_.gpin with_..It.damsdown after—ben. B4wvey does(time -zero when poop is tomll oil—water level ownropd flop won top N water level) Them Water Loud[ Tire Water Level Time Water Level Dale afp;Mping lest Baileril_Bpm with m n.amwdvwn seer .Ire.} Alta__gpm with stem et at. .__,ft.for ,, .hit. Dale Armsnilow__gpm lemperetmmrwmw_"P Wmn chemical analysis made? OYes No grant One.6.8-26 _Completed Date &-21-26 WELL C0NSTRUerr0NCERTIPICKHON: [consltoGwl audtor accept responsibility for eonsBucllon ofthis well,and its compliance with all Washington well contmchon slrtdmds.Materials use4 and the inferhont oh reported above are true to my best knowledge end belief. Ce Driller Lahore❑Pr— ante CLAYTON PITfS Drilling Company COOLWATER DRILLING,INC. Addi ss 10921 NW HOLLY RD License City,Seem Zip BREMERTON WA 90$12 Licmue No_2518 — IFTRAINEP'4 0r's License Nn _— Coatlactots 3 pmor'x Si attire Reg V ton No COOLWD1941QM Date 7-7-26 ECY00-1-20(Rev 11118) Ifyou need this dxnmenNnan ahemamJ.nmt,please call/he Hulot Rleeh disability Program at 360-407.68]1. Persons with bearing lest can cai(]l/879-g3J63sln Rulgv Service. Persons wRFaspeeeh disability can call 26276TW01vn x. Tu ba NW Rfa L�� �Ql� l�dq ltflP poula ,WA 98370 ,y FORMS OtERIA ANALYSIS FORM (360)779-5141 4 _ Tina Semple mAty pare Sample ColBated CPlhcled It I To2C L ,H/� P J' vest .1r 2liwl won pm —ale- Typaoi Water Byalam(abecyoelY e�9 ❑BroupA ❑ -.�-- Group A and GmuP B Syslmma-Provide from Water FacMSS invemory(WFI)'. hyatem Noma: /y.��/ . dOWa< _ COTt VIP n' coat frJ4JI Dayp . ---^— fell Ph honm 360 830 90o K m* soot uaF,+[0/U'66LM�.. Crlornd%-__�;«'.__. _- sempleco rndy(name): L'ae.e"" " spsolelinsUdbm Or �b� vzGu!y y�_! Type of Semple(check��ryoeb O Repeat Samgo(NP 1.O ZNIne OIsWhugon eample(NP) 2.❑ p° IImm alsmbWm getem eke wwt mubiw) chbdneled:Yes O No❑ UnaeWfeCoryiouSnabb number Chbdoc Raaidual:Taba a.BTound Water Rule Source$ampb Uneebefacm7rougnecoaecldate: L.....L—LJ _—J _-J------ Chbdnafed: ❑Tnggered(NP) Chbdna Roo Tolz(_Fina—. ❑ 4Su�aoAs oThn1(AIPI eorBWl Raweoma Water SanmN(EnumeadUU) S ❑ E.tau ❑Feaal mm� •t_—. only 6. s plowanmMmcmmeuan oary'. la»mmRMderee Ug°"°n ' N °.. _ (A9. 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