HomeMy WebLinkAboutWAT2024-00152 - WAT Application - 3/13/2024 WAT 2lYL1l -�IG/Z.
MASON COUNTY
COMMUNITY DEVELOPMENT
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`e It Ass Ist an re cem e,.B I,I dins,P I a n n.ng
415 N 6`1 Street, Bldg 8, Shelton WA 98584,
Shelton (360;427-9670 ext 400 •i Belfair (360)275-4467 ext 400 L Flea. (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: LEE RANDY WESTON Date: C 3- 13 - 2D24
Mailing Address: 30101 HWY 101 LILLIWAUP WhPhone: s,5tDa -'71a 53`7'4
Parcel Number 32320 24 00021
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more ❑ Building permi 9,6A --1
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels SPL
❑ Well ❑ Boundary line adjustment
❑ glsu ace wale 't0 ❑ Other(explain)
❑ Other (expl EXISTING Qnoe�
Irl A4 ❑ Replacement or Remodel (please indicate name
If you have m re ence 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 connectional 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
This form may be scanned and available for public view at www.co.mason.wa.us.
fr P:H runny.DnnkinF Ajt7l Recant I/2r2019
Individual Water Well
drirlaLy tb��eow N4 9, 04 {df
Water well report(attached to application). Depth ft. j$b M I1Jrd
ICl Well capacity Test(attached to application) C ( gpm ?, 90 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.
J Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htV./luis.co.mason.wa-us/planning 140 1 50 1 61XI 220
Water use or limitation recorded._......_........................ N/A]:�L Yes
Well Drilled ......._......................_......... ................. Date N�G
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 W DOE water resource r,e,gyulations.
Recommended approval indicates requirements of Sanitary Code, Title 6, Chapter 6.68.040-Det@C{ninji of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. lhyter
3670A RCW. s,^�
G'
I Unsatisfactory Determination: 4,
Applicant's water supply does not appear adequate to meet the needs of its intended use^'F@7 he foil s+y
reason(s). �Oc, Q� _
Reviewer's Signatures:
Environ. Health: Date
CSD Director: Date z"r'
Thurston County Environmental Health
412 Lilly Rd NE
Olympia, WA 98506
�>z 360-867-2631
ne�as�n�courcr
"` COLIFORM BACTERIA ANALYSIS
Dale Sample Copies' Time Sample County
olll
'z� ❑u, h'�vl Soi'v
Awar _'1: 3Lpe mx
; Typa oPFialer System(check only one bore) -Wi ousehold I
❑Group A ❑GroupB ❑Other t
Group A and Group 8 Systems-Provide from Wet Facilltim IIgntory(WEI}.
ma — AII{{ LL 6 7014
System Name: RECEIVED_ _
Gonad Person; L E,L ""
DayPhone_(=y,L) 7/ Z hone-( SGt 20 di3>
Emeil.� .p �pU��'cH Eve Rhone:( )
Send mm1%:adPdo,roll name_address and zip code or beata < <K
dast.�Ioa,"y lot
t6oeha us p t a C)� SSS
SAMPLE INFORMATION
Somplo collected by(,am,).
Specifm lecalipn or atldressrvhere sample collected' Speclallnslrudionsmcomme be
3o1b1 �.1t51�wrty to r
Lttl`w�u.la cd,c, 95�5
Type of Semple(mustnheck only one bax oLY1 Through iW I¢letl below)
1 [�[Routtnelostribution Sample 2.patent Sample(after dreat.routine)
Chlorinated:Yes-,No )4 ❑Distribution System
Chorine Rtostmol Totol Eree Chlorinated Yes No
3,Raw Water Source Sample Chlorine Residual;Total_Free
❑E.coP-GWR(AIR)
❑Freal-cm,ev a.,ipn,,,rnv.rcianonl Jdaterfactery routine lab number
trued Ye, NO_
❑Assessment Yon count fkP) Urea0,13dOry merge courier date
[-]Other I r
d.❑Sample Collected for Information Only
Investigative,-- Connotation l Repairs_ Other
Lee USE ONLY DRINKING WATER RESULTS Lee USE ONLY
❑IJnsatlefeetoryTcla Coliform PoSentand Satisfactory
❑Ecollpresent ❑Scan absent o Cfmmdete-to I
Replacement Sample Required:
❑Sample too old(,30 hours) ❑TNTC ❑
Bacterial Density Results:Torol Colifem I10mrl Eco11 1locrhl
moaf Coliform 1100m1 Entemcii i_ 10DA
Method Cotle. SM 9223E ❑SM 9222D Gale eo:Time aecei�ed. Earl
$M 5215B ❑Enterolerl0 -Los 1 A
Date and Time Arevzod 5`1 - [ate Rapehed.
sr,Vrrrin ic -m! Lab Use Ony
0 8 �.nOgwiamrr J
ro I)eW4@W't 79O or-.
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