HomeMy WebLinkAboutWAT Application - 6/17/2024 • � -
MASON COUNTY WAT
COMMUNITY DEVELOPMENT
vrmHasistame Ce ,9undlw Manning
415 N 6' Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 eat 400 O Belfair:(360)2754467 ext 400 O 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: Date:
Mailing Address: Phone:
Parcel Number. 6htLb h IA qt15A4 421 Z5 — 5m I
Type of Water System Reason for Application
Public/Community Water System(2 or more ❑ Building permit —ADLL 7,62.'-r. 00010
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 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 rV GL Z —arvzq
Name of Water System:
Water Facility Inventory(WFI)Number.
(write'none'for two-party)
I am the manager of this water system.The water system has been ap ved for A services.
There are presently connection(s) in use.This will be the connection.
❑ 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 y e 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
1'1EH Forms\D Oing Worn Re,1125=9
(
)
Individual Water Well
Water well report(attached to application). Depth I ft. y�
Well capacity Test(attached to application) 7 gpm ;"OpV O qpd.
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 0 the water well report does not have a capacity lest,
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 him//aiscomason.wa.us/olanning 1 15�1f�22J=
Water use or limitation recorded................................... N/A Yeses
WellDrilled ............................................................... Dale ®7'
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 6.68.040-Det$�nination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements m WR g Chapter
36.70A RCW. YIvP
❑ Unsatisfactory Determination: I
YO
Applicants water supply does not appear adequate to meet the needs of its intended y�se for the follgWing
reason(s).
Reviewees Signatures: qp
�Tl /7��" MFNTgI
Environ. Health: -r-r� Date
CSD Director: Date 2 of 2
I
Thurston County Environmental Health ?
412 LIlly Rd NE♦Olympia,WA 98506 J
360 867-2631
iNGR810N COUNTY
COLIFORM BACTERIA ANALYSIS
Dab Sample Cdlxbe Time Semple CantyCollecled
.
�p �� 2N L)(N ��
Mime 0.Y Y. �: ON )CC.J�,.) ! .
Type of WM,System lcheckanty am bail ❑ P. mmmob _ , 1.
❑Group A ❑Gap B olhe IU D It
Gmup A and Gmup B Systems-Pmvbe from Water racilhites lnvubry(WFO:
System Name:
r
Camaf Peram: 'j 1 4L
Dav Phme:( ) Cell Phara: bC
E-mail: 01, (1D Evs.Ph":( ) i.
Smd..bb:lPrM Imme, mtl ' roam imNasl I .
IA cs I
SAMPLE INFORMATION
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Sample mnecM by(nane): I jt N� • 'tee
r � m ie L f'asarnplekm,l l teE: Spapal nnametlong or�nmenb* - -
f It , } '�
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Type of Sample(muacMckmlyons lea, 41bmugh#411stedbeba)
1.0 Roudne MaIrI utlm Sample put Semple(eMrumfl.mudral
Chbrinvel Yes_No_ ❑Disalbulm,Spmm-�I( (Jk I e
Chbdne Resitlual:Total_Frte_ Chbdnebd:Yea_No X �
3.Raw Water Soume Sample Chlom.Resaud:Total_Fina_
❑E.cob-GWR WP)
❑Fecal-s ..W.wlntm lmnaeml Uns�ati(dw�to �ry. lab nnumber.dbe
R1Wec:Ym_No_ &-i i {- -
❑Assessment Mmibmg(A4) UnJ�rymutinecdWi ale ---
[3OMer !V r��e��!
S —/—'
4.[]Sample rdlemed tar Infer cm Only
Inmsigagve_ Cmelmc /Repairs_ Oba_
LAB USE ONLY DRINKING WATER RESULTS SE ONLY
❑UnuBahcbrytotal Coliform Pmmm and SaUsfe bry . .
❑E.mb present ❑E.catiabsemt NO CoIi(orm tlebcb.M
Replacement Sample Required:
O Sample hw oW(401rours) ❑rNTc O
Bacmdal Density Rewb..Total Conform HDOml. EmW HOOmI. i
Fecal Colifwm /100m1 EmemowcL ml.
Wtvd Cade: SM92238 EISM92220 p/a ad Thmm}Reahed: !
p SM 9215B. ❑Entsrderem 'O ,�,l�_ ///. '64
Dee eM Toe A?:. l tl' I � �^^°r""k^ 71
SanpNNumW 100N nunEmpreM�`e1 Ile We Omy:
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