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Home My WebLink AboutWAT2023-00015 - WAT Application - 9/20/2022 (2) WATc9.z - C (S _ °,,, MASON COUNTY r •r) COMMUNITY SERVICES yy Building,Planning,Environmental Health,Community Health 415 N 6th Street, Bldg 8, Shelton WA 98584, Shelton: (360)427-9670 ext 400 Belfair: (360)275-4467 ext 400 Elma: (360)482-5269 ext 400 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 /01)-Name on Applicant:/f1 eACDtnn p.ire Ois .4S Date: 9/9.0 Mailing Address: Po 130)( l q10 S�/v,iI WPr Phone: 360 - TU(7-5533 Parcel Number: cap )33 GI (,OOoZ0 Type of Water System Reason for Application Cl Public/Community Water System (2 or more ❑ Building permit Corn 20•LZ 'OO)D 5 connections) ❑ Division of land: 0, Individual water source(one connection), #of Parcels? SPL Well El Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) p❑ Other(explain) T`, 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. Signature of Water System Manager Date This form may be scanned and available for public view at www.co.mason.wa.us. d_11 1.onus Drinking Water Revised 1/25/2018 Individual Water Well ❑ Water well report(attached to application). Depth 10(). ft. ❑ Well capacity Test(attached to application) 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. 14- Satisfactory bacteriological test (attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://qis.co.mason.wa.us/planninq 141 1 151 1 1e1 j 22E1 Water use or limitation recorded N/A Yes I Well Drilled Date Individual Spring/Surface Water O 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) '?C 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). 9 (�� Reviewer's Signatures: Environ. Health: ✓� Date l,v( A' ..-3 CSD Director: Date 2°I 2 Thurston County Environmental Health -. T 2000 Lakeridge Dr. SW • Olympia, WA 98502 _Aiewq- -. ,!_.p.__ 360 867-2631 THURSTON COUNTY 5 ti 1 NITRATE TEST PANEL N' A \ G T 0 1 Since 1852 Report of Analysis Date Collected: (MM/DD/YY) p CI / i Gf / a '�.. System Group Type: (circle one) A B ther: f4.e_scksifm Water System ID Number: System Name: A44 Lab#-Sample#: 080 --360 — — — County: pA Sample Location Source Number(s): (list sources if blended or composited i 41 E P,Y,jkerrkcN . r a.,S%e,1 Jul) (A./6- cles ——, — —— — , Sample Purpose:(check a propriate box) Date Received:(MM/DD/YY) QL / ,-)C) / as RC-Routine/Compliance(satisfies monitoring requirements) Date Analyzed:(MM/DD/YY) _��/ L T./ — C Confirmation(confirmation of chemical result)* Date Reported: (MM/DD/YY) / l ( / arD_ ❑ I-Investigative(does not satisfy monitoring requirements) Sampler Comments: ❑ O—Other(specify—does not satisfy monitoring requirements) Sample Composition: (check appropriate box) Sample Type: (check onel Pre-treatment/Untreated(Raw) rig, S -Single Source [' Post-treatment(Finished) ❑ B - Blended(list sources in'Source Number(s)'field) ❑ Unknown or other ❑ C Composite(list sources in'Source Number(s)'field) Sample Collected by:(name) 11/. 11 A Zt fires ❑ D- Distribution sample Phone Number: 360-•e2aq $7 30 Send Report to(maili g or e-mail address): Bill to: (client name) n'z,jopersr&) e,v,,if . offf- EPA REGULATED AND STATE REGULATED OR REQUIRED DOH ANALYTE DATA RESULTS UNITS MRL SDRL TRIGGER MCL EXCEEDS METHOD/ # QUALIFIER MCL? ANA�,YST O,5 (X if yes) ` ; 0020 Nitrate-N `�t - mg/L 0.5 0.5 5.0 10.0 SM4500 NO3D/ TIDE NITRATE LEVEL IN YOUR WATER SYSTEM IS: •�In Compliance" *10 mg/L is the maximum contaminant level allowed. ❑ Out of Compliance NOTES: *Confirmation:Include the original lab number,sample number,and collection date of original sample in either lab or sampler comments section. DATA QUALIFIER: A symbol or letter to denote additional information about the result. mg/L: milligrams per liter or parts per million. MRL(Method Reporting Limit): The lowest quantifiable concentration of an analyte. SDRL.(State Detection Reporting Limit): The minimum reportable detection of an analyte as established by the department. TRIGGER: DOH drinking water response level. Systems with compounds detected at concentrations in excess of this level may be required to take additional samples or monitor more frequently. EXCEEDS MCL(maximum contaminant level): Marked if the contaminant amount exceeds the MCL under chapters 246-290 and 246-291 WAC. Please contact the department's drinking water regional office in your area to determine follow-up actions. Lab Comments: ac a 33 \o Thurston County Environmental Health 2000 Lakeridge Dr.SW 0 Olympia,WA 98502 - 360 867-2631 TI IURSTO COUNTY COLIFORM BACTERIA ANALYSIS Date Sample Collected Time Sample County Collected oq / 1 9 i A), I :O0 FRpm Ntas&.\ 1 Afonth Day Year Type of Water System(check only one box) ❑ Private Household , ❑Group A ❑Group B 0Olher R Y c1.L4 Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# System Name: Contact Person: 016- 1 l" Zi p, Day Phone:(3 b a ) (3.019 873 O Cell Phone:( ) E-mail: 3—z-ivereci9 c4,4,&. % Eve.Phone:( ) Send results to:(P t full toame,address and zip ncode or en,. adidrress) CP4 , Sl�/1 F i.A /L ______ . .PQ —151-1Q eL1 4 J - g8'584 �f SAMPLE INFORMATION Sampl)e 11- by(name): K Specific location or address where sample collected: Special instructions or comments: KOCkt 12-A S�kK Type of Sample(must check only one box of#1 through#4 listed below) 1.[ Routine Distribution Sample 2.Repeat Sample(after unsat.routine) Chlorinated:Yes No x El Distribution System Chlorine Residual:Total Free Chlorinated:Yes No 3.Raw Water Source Sample Chlorine Residual:Total Free ❑E.cob-GWR(A/P) ❑Fecal-surface.GWI,springs(numeration) Unsatisfactory routine lab number: Filtered:Yes No ❑Assessment Monitoring(A/P) Unsatisfactory routine collect date: ❑Other / / S Sample Collected for Information Only !? Investigative ,. Constructo errs LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY El Unsatisfactory Total Coliform Present and 1:1 Satisfactory CI E.coli present ElE.coli absent o.•liform detected - Replacement Sample Required: El Sample too old(>30 hours) ❑TNTC ❑ Bacterial Density Results:Total Coliform /100m1. E.coli __/100m1. Fecal Coliform /100m1 Enterococci -1100 ml. Method Code: SM 9223B OSM 9222D Date and Time Received:�J�� SM 9215E ❑Enteroleri0 q-ao- 3, ea Lr Date and Time Analyzed: `r�-a2 Date Reported:q-, C(,� Sample Number(DOH number plus five`digits) Lab Use Only: 0 8 0 1 a DOH Form 0331-319(revised 0r/re) K ^ P 33 I