HomeMy WebLinkAboutWAT2024-00114 - WAT Application - 3/1/2024 WAT - 9)lt4
MASON COUNTY
COMMUNITY DEVELOPMENT
FermisA Istance Center,gulldin{,Planning
415 N 61°Street, Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 L Better: (360)275-4467 ext 400 4 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: Michelle Vote Date: 3/1/2024
Mailing Address: 8514 18th Ave NW Seattle WA Phone: 206-930-9466
Parcel Number. 22009-50-00026
Type of Water System Reason for 1A`pplliric,��ation 7
[IPublic/Community Water System (2 or more El Building permit B(,l]aZ1V17—00oZ79
connections) O Division of land:
O Individual water source(one connection), #of Parcels? SPL
0 Well Existing ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ 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)
❑ 1 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.
❑ 1 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 3/1/2024
Thisform may be scanned and available for public view at www.co.mason.wa.us.
J:TH Forms\Drinking Wow RevisM tMa018
Individual Water Well
i f Water well report(attached to application). Depth
Well capacity Test(attached to application) 1 gpm ;7 LtOc� 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 htto7/ois co masonma.us/planning 14 15p 160220
Water use or limitation recorded...................... _....... N/A —Yes F-1
Well Drilled ............................................................... Date J
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ 1 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 6.66.040-Determination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applicanfa 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 2°1`2
Pleas.4I111,sign and return to the Department of Eeol
Water Well Report Current
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AL MANAGEMENT
LABORATORIES rr+c�
= 1516 both M E.Taoorh,WA 94a94
lqw COLIFORM BACTERIA ANALYSIS FORM
Dab Sample Cdlectd Time Sample County
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SAMPLE INFORMATION
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Specifilantionwhereaempk�� Spedal mstuctlhns«mmmen%:
Type WSample(seledonly one typeof Marne from types 1 through 5 bebw)
1. Nine Diebibudon Sample(AIP) 2.❑ Repem Sample(AIP)
Cblonmed:Yes_Nq — (hole dsHbfion system.aw unsa muam)
Unsafafectory mlils lab number.
Chlonne Residual:Total_Free_
3.Groun
�d Water Rule Source Sample UnsaMcbry,munne culled date:
- I I _J—J—
Chlemwtd:Yha_No_
❑Tr%ered(AP) Chlodna Remmel:Total_Free_
W11)
ent (WP)
r GWl Haw Source Water Sample(Enumwelion) I _
❑Fecal riw.a Ya_xo_
Cdleond b Imormetlon only:
E ONLY DRINKING WATER RESULTS LAB USE ONLY
dnry Total Cott.Present and �Satlshctory
alipresent ❑E.coliabsent
.y Result:Total CalSorm 110Pd. E.cu6 110Pd.
Fecal Colifaml I100m1. HPC 11 m1.
Replaement Sample Requhad: ❑TNTC ❑Sample Iota off
❑ SampleVdume ❑Damaged Container ❑
P•nheC ""Zia
Human
I4cdq Tempc•: w cos.:
r089
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