HomeMy WebLinkAboutWAT Application - 3/29/2023 < , ,
WA
' r 7 , MASON COUNTY
COMMUNITY SERVICES
1,c;;. Building,Planning,Environmental Health,Community Health
415 N 6'h 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
Name on Applicant: i CL. � Q4,tor • KOt)k.al�� Date: 3//
2A17 ;
Mailing Address: 13o6 ,�t '7� l" 5-1 siek i-He Pone: (7(A)?U./ —2.66 7
Parcel Number: 221_33- 5 ( -cX .oe
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more ,P7 Building permit 2..1)23-QOL 1 2)
connections) ❑ Division of land:
Individual water source (one connection), #of Parcels? SPL
fl
,1%:1 Well 0 Boundary line adjustment
• 0 Spring/surface water 0 Other - : .in)
❑ Other(explain)
Re• acemet.t or Remodel (please indicate name
If you have more than one residence connected of ater .stem below if applicable- no
to this well, check the Public/Community Water sign. ure required)
System box.
Part 2: Water Connection Information
0 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 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 http://gis.co.mason.wa.us/planning 14D 15n 161 J 22=
Water use or limitation recorded...... . N/A EJ Yes I-1
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:
4 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: Date
CSD Director: Date '"'
Thurston County Environmental Health
2000 Lakeridge Dr.SW !Olympia,WA 98502
360 867-2631
THURSTON COUNTY
COLIFORM BACTERIA ANALYSIS
Date Sample Collected Time Sample County
Collected
e/ / -3 i 23 00 er., M A.(C nJ
Month Day Year
Type of Water System(check only one box) ❑ Private Household❑Group A ❑Group B (�'Other�```n lll
t 1 ly WA
i
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):�
ID#
System Name:
Contact Person: 1111 L4 t L K•0 I D (�
Day Phone:( j„,) 70 7 2_lob-7 Cell Phone:( )
E-mail yv1 Ne_ot >4h}1_(9 bo1[1r I, L0,41 Eve.Phone:( )
Send results to:(Print full name,addr and zip code or email address)
I'7 D c .lc: 7 Sfir ---
rh ti\ Ct3M
SAMPLE INFORMATION
Sample collected by(name):
a
th �.` �k\
Specific location or address where sample collected: Special instructions or comments:
qO c Vvvl s vt (A viz_ ✓. L, i ''l G:(( � ?fi
r ,��,j,vJ (A)A- ` (&s--i ' 20e,.;707•-2
Type o 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 0 Distribution System
Chlorine Residual:Total Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total Free
El E.colt-GWR(NP)
❑Fecal-Surface,GWI.springs(numera'tiorr) Unsatisfactory routine lab number:
Filtered:Yes No
❑Assessment Monitoring(A/P) Unsatisfactory routine collect date:
El Other I I
S
4.4Sample Collected for Information Only
Investigative Construction I Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and 4Satisfactory
❑E.coli present ❑E.coli absent Coliform detected
Replacement Sample Required:
❑Sample too old(>30 hours) ❑TNTC ❑
Bacterial Density Results:Total Coliform I100m1. E.coli /100m1.
Fecal Coliform /100m1 Enterococci 1100 ml.
Method Code:VSM 9223B ❑SM 9222D Date and Time Received:'_"
❑SM 92158 ❑Enteroler:0 1 21f' 2-3 �CI
Date and Time Analyzed: ••-4--- 2_22 Date Repoded j ,)-3 eta-
Sample Number(DOH number ties fire digits) Lab Use Only:
l Ks"c t, ‘n �r
DOH Faint331-319(revised 01/16) r e`.C; 3C - (-01%,;�