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Home My WebLink AboutBLD CD Environmental Health Review - 1/10/2022 N5ON COON �� ti - Public pry. Health Doti .. P` 1� �` `\ C� Always working for a safer • healthier Mason County `` e5 �� 415 N.6th Street,Bldg 8,Shelton WA 98584 WI or C,e' 360-427-9670 or 360-275-4467,extension 400 �aS Application for Determination of Sewer Adequacy Instructions: 1.Complete Part 1 of application. Permit number may be added at later date. 2.Take application,Site plan,and any other associated information with the proposed development to the Sewer System Manager or Designated Employee for approval. 3.Submit completed application and information to Permit Center or Mason County Public Health for review. NOTE:You must supply the System Manager with a site plan for the project,showing all existing or proposed sewer components and lines in relation to proposed development and property. Part 1: Applicant I Parcel Information Applicant: der)D60 c eSly'h 4- Kttitl() L-.L C Date: 1--10 2,3 n Mailing Address: 17()(a F rp i, - S I- . t{ 3 City,State,Zip: L,�il()e)-\ 1 W/7 1 g Z 611 Site Address: T 13 f Phone: 366 - 4 L.7 - i.5 7!1 Parcel Number: 1 L Z-Z 0 J 3 C 3 0 0 i Permit Number: J3 I.-. b - L O 1-\ U I S O 9 Part 2: Sewer System Information Name of Sewer System: 140( h1 ?)(1t -- El Site Plan attached? Official use only: Sewer System Manager or Designated Employee is to complete. ® New Connection: I have reviewed the applicants information and have no issues with Mason County Public Health approving the corresponding Mason County Permit. ❑ Existing Connection: I have reviewed the applicants information and have no issues with Mason County Public Health approving the corresponding Mason County Permit. ❑ I have reviewed the applicants information and have determined sewer connection is currently NOT available to this property. ® Please add the following conditlon(s)pp the correspondingMason Coun Permit: optional) / ZZ‘, /-t'!(pct) u✓E2 �Ir\JPS! ✓lam'-)f LdK.3 /iLUr .r L`T�Cic!` *;,,,,. .„2,_ 2 7 s\ r).-..'ri(f.i'v". t f/t/I al V(,)1 /5‹./ ..,--...-I-----._.._. O I i ail 73 Printed Name of System Manager/Employee Signature of System Manager/Employee Date ....--1 Part 3: Mason County Public Health Review/Approval -. (-- Satisfactory 0 Unsatisfactory %" Signature of Environment Health Specialist Date This form may be scanned and available for public view on the Mason County Web Site. REVISED 10282015 -f--- --'-. '11 I\_v` k.-'\--c -- c-yi"`-,'<" ' I o k n Lu itl n S'ril.C; ("►r'a-4 I. L.c WAT W , ? - DO OQ 0 /a 415 N.6th Street Shelton,WA 98584 MASON COUNTY • — •1511.1. COMMUNITY SERVICES Shelton:360-427-9670,Ext.400 Belfair:360-275-4467,Ext.400 `•�, ''` A Building,Planning,Environmental Health,Community Health EIma:360-482-5269,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 on Applicant: John Wynstra Date: 02/15/2023 Mailing Address: 1706 Front St#443 Lynden, WA 98264 Phone: 360-927-1578 Parcel Number: 12220-50-63009 Type of Water System Reason for Application i ( Public/Community Water System (2 or more Gd Building permit connections) ❑ Division of land: ❑ Individual water source (one connection), #of Parcels? SPL ❑ Well ❑ Boundary line adjustment O Spring/surface water ❑ 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: Port of Allyn Water Facility Inventory (WFI) Number: 68790X (write"none" for two-party) Ef I am the manager of this water system. The water system has been approved for 136 services. There are presently 15 connection(s) in use. This will be the 16 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. Print Name of Water System Manager ewman on behalf of Northwest Water Systems Phone 360-876-0958 Signature of Water System Manager4' /v � Date 02/15/2023 This form may be scanned and available for public view at www.co.mason.wa.us. J I i I Forms\Drinking Water Revised 4/27/2021 Individual Water Well ❑ Water well report (attached to application). Depth ft. O 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. O Satisfactory bacteriological test (attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planninq 14_ 15 16 22 Water use or limitation recorded N/A Yes Well Drilled Date 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's1 j Signatures: �� Environ. Health: �)"� J Date `1 Z(/ This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2