HomeMy WebLinkAboutWAT2024-00282 - WAT Application - 5/2/2024 WAT 2�2�"ooa,3�
MASON COUNTY
COMMUNITY DEVELOPMENT
PermR BUIsUnce Center,Bulldin ,Plannlry
415 N&Street,Bldg 8,Shelton WA 98584,
Shelton:(360)427-9670 ext 400 O Beffalr.(360)2754467 ext 400 46 Elms:(360)482-52N 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: N � + ^J.T�� 'S Date: �7�2�UaLt,
Mailing Address: cJ(.i�, t}o�os�acd D7 Phone: 360-t-tt-3 -475Ci
Parcel Number: 1 2'Z 1,72_'-15Q033
Type of Water System Reason for Application 000-15
❑ Public/Community Water System (2 or more Jq Building permit eLt) o,aA
connections) ❑ Division of land:
p /y Individual w r 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 PubliclCommunity 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
This form may be scanned and available for public view at www.co.masonwa.us.
Revised 1/25/2018
J:\EH Premd\Drinking W mrr
Water well report(attached to application). Depth ZC' 7 ft.
Well capacity Test(attached to application) gpm—2—LIL Ogpd.
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 rapacity 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 htto'/lais flgis.w.mason.wa.us/planning wa us/planning 14015=]160 22[]
Water use or limitation recorded................................... N/A O Yes—_
Well Drilled ............................................................... Date `-I �-
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 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-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 as intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: ��� Date
CSD Director:
Date 2 of2
I
h
WATER WELL REPORT "MEND Or Nmkcoflmeol No. WE55543
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❑. Driller❑T inn O PE-Prim Nome ROBERT LAYMON Deli" conopen,ADVANCED DRILLING LLC
L.fi_- _ Adtwv 11530 SCHOOL LAND RD SW
License No.2566 L-ly 4mm Zi ROCHESTER WA 9B679 -
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Vanguard Laboratory
S AV 2635 Parkmonr Lane SW
Olympia,WA 98502
360.967.7010
V.kMgUARD Report of Laboratory Analysis
LABORATORY
Collected by:
Ackley Pump Marta Drinldug Walnut
360-956-1052 Laboratory to: V240703-8
Sampling Address: Doh Sampled: 7/324 15:20
51 E Homestead Dr Dah Received: 7/324 16:25
Allen,WA 98526 Date Repassed: 7/5nOM
Sample ID: 51 E Homestead or
Analysis Result SDRL MCL Units DF Date Analyzed
Total California&E.soli by SM 9223B TDEXX) Batch m:V2407034 Analyst:VI
Coliform,Total Negative 1 1 MPN/100m6 1 7/3/2417:34
E.coli Negative 1 I MPN/100 nd. 1 7132417:34
Nitrate by EPA Method 353.2 Batch ID:V240703-8 Analyst:RK
Nitrate(as N) ND 0,50 10.0(I mg/L 1 7/32417:10
No.
MPN:MostP ble Number
pan:pens per million
nd'.nondnecl Reviewed by Donnas Newman,Laboratory Director.07/052024
Na:nor applu able
SDho, Side Det«lion Reposing Limit Approved by Teri Johnson,Operations Manager on 07/052024
DF'.Dilution Four 1IMMol 10
MCL:Maximum Contamiiant levid sbilwaidEff
P.,l of]
Samplasweromml,,,inse,pmblecoudhioa The msult(s)in this report relit,only tothe portion ofthe emplos)tested Advishesoc,crelboodonscosunit
with the Quality Admmce program of Vanguard Iabwdory.Please must the labordary ifyou should huve any 9neatonsabout the resuas.
2635 Parkmom Ln SW,Suite A,Olympia WA 985021 Office:360.967.70101 testing@vanguudlaboratory.com
www.vanguardlabormory.com