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Home My WebLink AboutWAT Application - 3/9/2023 WAT V �\ MASON COUNTY RECEf r I' COMMUNITY SERVICES U MAR 0 9 2023 Building,Planning,Environmental Health,Community Health ob.iiriv � 415 N 6th Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 ❖ Elma: (360)48)-499v,,��// exAlAer Street FAX(360)427-7787 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 on Applicant: V N A►- 2 Date: \•6' 20273 Mailing Address: P.0• Box $o- Phone: • •—] C3 I2 Parcel Number: 2Z\I D - 32. ck 0 2-2- Type of Water System Reason for Application ❑ Public/Community Water System (2 or more 0 Building permit-3Id -OO2-2l' connections) ❑ Division of land: IEI/ Individual water source (one connection), #of Parcels? SPL d Well 0 Boundary line adjustment ❑ Spring/surface water 0 Other explain) ❑ Other(explain) Replacement r Remodel (please indicate name If you have more than one residence connected o waler sys em 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. Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Revised 1/25/2018 Individual Water Well ❑ Water well report (attached to application). Depth V V\F-i1AM'' ft. E7 Well capacity Test (attached to application) \-3 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. 12/ Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://qis.co.mason.wa.us/planninq 14 15U 16022U Water use or limitation recorded N/A, YesiI Well Drilled Date 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) ❑ 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: Environ. Health: eiWvv Date 2°f2 CSD Director: Date Spectra Labs - Kitsap, LLC (Port Orchard) SPECTRA Laboratories -Kitsap 1786 SE Mile Hill Dr. ...Where experience matters Port Orchard,WA 98366 Phone: (360)443-7845 JessicaD@spectra-lab.com www.spectra-lab.com Spectra Labs- Kitsap, LLC (Port Orchard) received samples for Davis Drilling on Wednesday, January 25, 2023 at 2:49 pm. Unless otherwise noted, all samples were received in good condition and were tested in accordance with the laboratory's quality control procedures. A summary of the samples received are outlined below. Sample No. Description Location Sampled 136971-01 Private Well Head Hydrant 01/25/2023 13:20 This report package contains laboratory sample results and any attachments listed below. If you have any questions please call (360)443-7845 or email us at JessicaD@spectra-lab.com. Attachments 01) This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at 360-443-7845 and destroy this report promptly. These results relate only to the items tested and the samples)as received by the laboratory. This report shall not be reproduced except in full,without prior express written approval by Spectra Laboratories. 01/30/2023 Page 1 of 1 Davis Drilling 340 NE Davis Farm Rd Belfair, WA 98528 Test Pump for: Duane Golden Address: 731 Mason Benson Rd. E. Grapeview, WA 98546 Well depth: Well Tag: Static: 79' TIME WATER LEVEL GPM 5 m 79 13 30 m 83 13 1 h 83.2 13 2 h 83.2 13 RECOVERY 1 m 83.2 2m 80.0 3m 79.0 4m Sm 30m Trees Lrt NW 1) Ste.0 !( SPECTRA Ltibort+torics - Kitsap Poulsbo,WA — »W1kfn=pi.twcnlaadulrr, ' 98370 COLIF(RM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County 1251 2 o 2-3 Collected ?o°`va frVi et ao iZ month Dfy Y.a t$'PM Type of Water System(check only one box) ❑Group A ❑Group B kf&her Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# j "�f `>p) E. System Name: in y ri _fie c Contact Person: IL iy 1-e ?hill, Day Phone: Cell Phonr3/OJ?O 1 -26Y. Emaft:{,jay..rp(r i/4w,,14){,a� - i/ Eve.Phone: Send results b:(Print NA name,add sss ird rip cola or mall above for electronic copy of roe utt.) Petvf Pti( ,ry SAM1LE INFORMATION Sample collected by(name): K7 le. ph,/I;1's Specific c location where sample collected: Special instructions or comments: 1" 11 Seat,( hycIr'?'d TypapfSat pte(diedconbprtebox) 1.❑Routine Distribution Sample(AIP) 2.❑ Repeat Sample(AIP) Chlorinated:Yes ❑ No❑ (from distribution system after unsat.routine) Unsatisfactory routine lab number. Chlorine Residual:Total Free_ 3.Ground Water Rule Source Sample Unsatisfactory routine collect date: ISI I I I I Chlorinated:Yes No ❑Triggered(A/P) Chlorine Residual:Total_Free ❑Assessment(A/P) 4.Surface or GW1 Raw Source Water Sample(Enumeration) I S I I I ❑ E coil ❑Fecal Fatred Ye. No 5.�Sempie Collected for Information Only LA8 USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and 10Satisfactory ❑E.cofi present ❑Ecoli absent Bacterial Density Results:Total Coliform mpn/100m1.E.coll _ mpnil0Oml. Fecal Conform cfu/100m1. Replacement Sample Required: 0 TNTC ❑Sample too old ❑ Sample Volume ❑Damaged Container 0 11-7 l Arnim 17nceAL Receipt TempC': Metho Code: !'�J�� SM922381 OT1AUNT/SM9222D nn ..{�..lA� R itlOR Wt: 1lNr *lad so*bu4 w.d:rpa►n v oavirrit PI r+nrdt.A...wd Mrs.awraa v a.aw...alter U,r,a IM N JAN 2 6 2lddte,a. t�l� .=alp ,h yleee.rolfyM r.dr kw.OaM r7B0•K178tl end tio DOH labSemple '0 0010 fl lh..►rirollio Wyk.V*boa Wed.ndH.rryYfgr JN11:_• :or bytrtmrry.lbtnpat NW Vonepode>.d.na.pl n d4 eArr pin apewe.ftl.n.ppaer h soya►.t.arrafea DOH er,�a3,a ro tAthre WV)