HomeMy WebLinkAboutWAT2023-00005 - WAT Application - 1/5/2023 RECEIVED
jIVD WAT aaa3 - OOt O
JAN - 5 201
415 N.6th Street
,/ I �; MASON ( UN YStret Shelton,WA 98584
!
COMMUNITY SERVICE N V I RO N M ENTA elton:360 427-9670,Ext.400
lfatr:360-275-4467 Ext.400
Building Planning Environmental Health.Community Health HEALTH E1ma: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: Juro Mrsic and Jacki Campbell Date: 10/23/2022
Mailing Address: 2231 180th St SW Lynnwood Phone: (206) 359-1115
Parcel Number: 32021-56-05050
Type of Water System Reason for Application
X Public/Community Water System (2 or more X Building permit LOab T - t0009
connections) 0 Division of land:
❑ Individual water source(one connection), #of Parcels? SPL
❑ Well 0 Boundary line adjustment
❑ 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: Shorecrest Estates Water Company
Water Facility Inventory(WFI) Number: 78620-1 (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.
XI 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: Existing Connection - Building Permit
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 Krrstie Hutchinson Phone (360)426-0773
Signature of Water System Manager Date 10/23/2022
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised 4/27,2021
Individual Water Well
❑ Water well report (attached to application). Depth 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.
❑ Satisfactory bacteriological test (attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htto://gis.co.mason.wa.us/planninft 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)
r1 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 ( l' Feb 20 21
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
SITE NO. I /iMI4IQ L- f r—A. *ADC - -Apt so
4
MASON COUNTY HEALTH DEPARTMENT FOR DEPARTMENT USEONLY
ENVIRONMENTAL HEALTH SECTION DATE BASIS FOR FEE AMOUNT RECEIPT
428 WEST BIRCH STREET • SHELTON, WA. 98584 - NUMBER
PHONE (206) 426-5561 a -
APPLICANT SIGNATURE , '
ADDRESS -. ;,.-
s,f.- S-Cr 7'/_ -- �� y� R SITE: PP V 0 NOT
ice/ 71% lv /� VED
�pROPERTY OWN R ( `2 z___ BY
ADDRES.S� -. 'I ��/Yp1 9 4 &I '-• ///I& DESIGNED SYSTEM REQUIRED
LE
SEWAGE SEWAGE T
CONTRACTOR` , /J VaNER SEWAGE: ARO D • A ROVED
LEGAL DESC TION ..
BY:
/% • ► 3 ,S;67A,0ci , /
SOIL TYPE r("; ' r' ' f
TYPE OF NO. OF i LOT r!Il fra�46- A•
BUILDING BEDROOMS % • -- SIZE 9+�P • DEPTH TO WATER TABLE PERC. RATE
SINGLE RESIDENCE PUBLIC WATER Q�GQ�'Q 'Es74 7<fs ���p- /GAL
WATER SYSTEM ' • SYSTEM '� NAME 44 1 G' SEPTIC TANKS}-f� PUMP REQ.
COMMERCIAL ONLY S-Z- FEET
LIQUID WASTE G.P.D. DISTRIBUTION TILE TOTAL
DIRECTIONS TO SITE: FILTRATION AREA ,29 0/6 SQ.'FEET
QUANTITY OF
.O 1047- �i L• , 44 � /r r} ige•ti.Si4.0E' .& APPROVED.STONE CU. YD, SAND • CU. YD.
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Di - GR It i G 4 r., 7 .4.Af l FILL REQUIRED CU. YDS.
1-�l,E /,L Ns 1°� ,`Tr .�- a FINAL INSPECTION .REQUIRED:.BEFORE BACKFILLING
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P-r tted furs Ma oti 1.t'iuniy DMS • THIS SITE PERMIT EXPIRES
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MASON COUNTY .HEALTHTDEPARTMENT OCT 2 s r�z
428 WEST BIRCHSHELTON, WASHINGTON 98584 ~ +kasa
PHONE (206) 426-5561 - ril DBp,D7•-ry
RECORD OF FINAL INSPECTION OF YOUR SEWAGE DISPOSAL SYSTEM OWNER,„__ h k u) R O G R S ADDRESS S , - / 6 I JD/Cr J Q 41'Ily , p 1e
THIS RECORD IS NOT A GUARANTEE OF PERFORMANCE. LEGAL � • / � / ���
A SEPTIC SYSTEM IS NOT A MUNICIPAL SEWER. HOWEVER DESCRIPTION / I, hot 33 diet A
WITH PROPER MAINTENANCE AND CAREFUL USE OF
WATER IT CAN GIVE MANY YEARS OF TROUBLE FREE SER- '
VICE. MANY PROBLEMS WITH SEPTIC TANKS ARE CAUSED SOIL -
BY FLUSHING EXCESSIVE AMOUNTS OF PAPER, CLOTH COMMENTS •
AND. PLASTIC MATERIALS DOWN THE DRAIN, OR BY SITE FIELD X .
LARGE AMOUNTS OF WATER FROM LEAKY FAUCETS OR NO. SIZE
FAULTY FIXTURES. DEPTH TO MONTH
THE SEPTIC TANK ITSELF SHOULD BE CLEANED EVERY WATER TABLE OF YEAR
TWO OR THREE YEARS DEPENDING ON THE HABITS OF THE INSTALLER
FAMILY, THE NUMBER OF FIXTURES IN THE HOUSE, AND
THE AMOUNT THAT A GARBAGE DISPOSAL IS USED. CLEAN- SIZE �� O o S q,� ,
ING AT THE RIGHT TIME WILL AVOID THE RISK OF INJUR- SEPTIC TANK ( } Z5 6?
ING OR DESTROYING THE DRAINFIELD DUE TO SOLIDS DRAINFIELD f FEET
LENGTH t„
CARRYING OVER INTO THE DRAINFIELD. CALL THE TRENCH AREA , SQ. FT.
MASON COUNTY HEALTH DEPARTMENT FOR A LIST OF 3 w /d/f - ,25-1(
LICENSED SEPTIC TANK CLEANERS IN YOUR AREA. THE.
CLEANER CAN SERVE YOU BEST IF YOU SHOW HIM THIS DEPTH -%TILE C��� K.CORRUGATED ❑ RIGID ❑ CEMENT
RECORD WHEN HE COMES.
HEAVY TRUCKS OR EQUIPMENT SHOULD NEVER BE CU. YDS. !ROCK f�•••- Y p 5 DEPTH i� /2" TOTAL
DEPTH
BEl ow
DRIVEN OVER THE TANK OR DRAINFIELD. CONSULT THIS SPACE RESERVED FOR
RECORD IN CASE OF ANY BUILDINGS, DRIVEWAYS, REPLACEMENT DISTRIBUTION FIELD: SQ. FT.
SWIMMING POOLS, OR EXTENSIVE GRADING OR FILLING
ARE LATER CONTEMPLATED. _• t ; •'":""-!•"-
_1..t..;._ _ .,yl . . i --.t.. . }...
SHRUBS OR TREES SHOULD NOT BE PLANTED CLOSE TO 1 •. , i- -..-," 0; , .4.
_ : "
THE SEPTIC TANK AS THEY WOULD INTERFERE WITH _ • .a..-;..„I !. •-_ ; ,� 0,; .#---i Y� — ; - 4-I-1 1 Y -
CLEANING OF THE TANK. THEY CAN BE PLANTED IN THE --- ;• -4-- -� 0� -� ; -x- ----tt'1--- --� 't. r •�•; -•-•--
DRAINFIELD AREA PROVIDING WILLOWS ARE NOT USED. :--"-j _I. -"` '- . 1 - - `"'"�1' '� -'i-% ''"__ -,.
THE YARD GRADE •IN THE DISPOSAL AREA SHOULD BE �_: ; d-_ :..�_ .✓...�\_.
SUCH THAT SURFACE WATER IS NOT POCKETED ON THE ;• ----�-t "'� , r • ` ; — ..0-----. ••• -
DRAINFIELD. ANY SETTLING OF THE GROUND OVER THE : r I-'-L- � 1 •'--1 ' ' -._..' �..�\,!']�_,__.._r.;
TRENCHES SHOULD 8E FILLED IN WITH SOIL. DO NOT EX- t r 1 '' ‘+' ''_� O! i 7!"(..).--
Qom_ _
CESSIVELY WATER THE LAWN IN THE DRAINFIELD AREA. : . • '.-: :— --�- ' '‘'' ::-•_,... _':-.! 1 .
• . . :Lr_• 4 .. , . �i.'.. .�‹
WATER EVAPORATION FROM THE DRAINFIELD IS ABOUT `-'--'--;-':' -'.` -- - ''' 1' '
EQUAL TO ONE HALF INCH OF RAIN PER DAY. _ : . 1 _ ' ` ':`r �_
I
FOOTING . DRAINAGE, DOWNSPOUTS AND WATER • - t. t.., -1.- ;_-._ ____ 411._... ._ __ 'y...:.\. :_ ._
SOFTENER RECHARGE WATER SHOULD NOT BE CON- . , ' . . N '. _ 'v. !�I .
NECTED TO THE SEPTIC SYSTEM OR DISCHARGED INTO THE :_I 1
DRAINFIELD AREA. .., _. 1 i- ;. , • : I `- \•. -, : .v1 ,
THE TYPES OF BACTERIA NEEDED IN A SEPTIC TANK ARE • • - .'`}i• ,�.
ALWAYS FOUND IN SEWAGE. THERE IS NO NEED TO ADD • •• • ' • • • • • - .7 - . : -' 1 T
YEAST OR OTHER STARTERS TO A SYSTEM. THE USE OF RE .. I. _ - . ._ . , _ •. , ..
JUVENATORS OR CHEMICALS TO CLEAN A SEPTIC TANK 1
HAVE NOT BEEN PROVEN TO BE BENEFICIAL AND MAY BE • . • _. 1 • •-• I • •• . • . • • - •• •C -
HARMFUL BY FLUSHING SOLIDS OUT OF THE TANK OR BY k _ _ I -
CHANGING THE CHARACTERISTICS OF THE SOIL. THE _-._ ; • • , I
NORMAL USE OF BOWL CLEANERS OR CLEANING COM- . t , -: --- • -
POUNDS WILL NOT KILL THE BACTERIAL ACTION OR SLOW r ' + SOUTH.
DOWN THE OPERATION OF THE SEPTIC TANK.
/0--267-gz___ 12.__
TH1.S-IS AN IMPQI�TANT DOCUMENT t.., 4AjE-- . APPROVED BY
• it ..ritelti.r"1 ii(iT''WITH'1Ei�v` )BJ THER .a Li r i IN I�. :f 1F . � CA)
. EJ4,4T,14 41,pws-,,,utity DMS DATE - CERTIFIED BY