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Home My WebLink AboutWAT2024-00039 - WAT Application - 1/22/2024 W A 1 MASON COUNTY COMMUNITY SERVICES BuiNnq Flaming Emimmm4l HWM,Canmuniry NMM 415 N 60 Street, Bldg 8,Shelton WA 98584, Shelton: (360)427-9670 ext 400 4 Belfair:(360)275-4467 ext 400 J Elms: (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: r1S Date: \a A 2024 Mailing Address: F{r•ra k A Phone: �5(11r) Parcel Number: -2 70 '3t7?1 1 q CDO 41Z -Z ari . "71 1 , 5 fie% I Type of Water System Reason for Application PQ Public/Community Water System (2 or more 0- Building permit 3LMOM-00090 connections) ❑ Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well ❑ 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 welt, check the Puhlidcommunity Water signature required) --,v"lXV System box. Part 2: Water Connection Information1 Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: 1 Water Facility Inventory(WFI) Number: /Jt7^-Q, (write"none"for two-party) ❑ 1 am the manager of thi water system. The water system has been ap rZd 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 an(( M limits4set�nd local regulation. Signature of Water System Manager "" ✓ Date ",`t„Z— Z Y This form may be scanned and available for public view at www.co.mason.wa.us. 1:\EH Forms\Drinking Weser R,vmd 12512018 Individual Water Well Water well report(attached to application). Depth ft. Well capacity Test(attached to application) opm !;&0() pd. 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). ff Water Resource Inventory Area (WRIA) Development within which WRIA htto://gis.co.mason.wa.us/olanniNlAfr� Ye�t�22= Water use or limitation recorded.................... . �Y�— � Well Drilled .......................... ........ _....._._......... Date ��Z3Mr15 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 666.040-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 mason(s). �,.Q�� CReviewer's Signatures: Environ. Health: l u l u '• Date CSD Director: Date '°�' Veug..rd L,borarn,. 2635 Parkmbnt Lanc SW Olympia,WA 98502 360.967,7010 VANGUAR]D Report of Laboratory Analysis LABORATORY conNlm to: Ann......Pungand DnIfina 5fevia @.Akin,wet" 360-754 7Sb7 L.bornmb it): V240227-9 Sampling Addrea.: 11.1,S.mpled: 2?2724 12'111, 5384 Sk Arcadia Rd Due seethed- 22724 I J.I1 Shelton.WA 98584 are Reported: 3t1/2024 SnrnpleID: Copps Analysis Re,nit SDRL MCL U DF Date Anal— d Tool Coliform A,E.col.by SM 9223H IIDEXX) Match 11)V240227-9 Ano,t vi CJli In,Total \ .,ntipp I I MPN/IW nil, I 22724 1701) Nano, MPN/I00 mi. 1 2/272317:00 4- A' Natcs' 1 MPN.Mac,PmWble Nunitic, > 'Panapernullion € ➢d;nbndeleel Itcvlewed by Roll Smalling,Chemist on 03/01/2024 n..nouppllrable SDRL:State Deteclion Roncri Lunn Approved by Tarr Johnson,Operations Manager on 03/01 Q024 DF Dilution Factor yv1�p nygogg17 CL:Mmmam Commmwnl Lnel m 70 C-Dn- Page l of l Ie received in accepable condition TAe niadgs)in dis report read only to the po"i nt Aftitin tans ho)l000d.All anal}xs xer,peU'otnwd. .."con �lh Nc Quality Assurance Pragrun of VangwN laWraron'.Please conact 2c leborewryif Sou sboWdlusx anY Qneat bolA. 10 ,-Is.- 2635 Pdrhmont Ln SW.Sultd A. Ohmpm WA 985021 Office:360.967.701011c5ong6banguardlabamtory.cons ww5v.vangtw'dlaboratory.com