HomeMy WebLinkAboutWAT2024-00315 - WAT Application - 9/24/2024 WAT oo� 1S-
MASON COUNTY 415 N.,W Sheet
Shelton,WA t 400
SM1eltm:3NM27-9670,Fxt.900
Public Health & Human Services aelfar:360-275-W7,Ent.400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. Nod etermination can be matle 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. Ana roved bi ildin site Ian must accompany this application.
Part 1: Applicant/Parcel Identification
Name of Applicant Kyle and Michelle Emtman Dale: 912 412 02 4
Mailing Address:
5970 NE Arrowhead Or Kenmore, WAPhone: 425-894-8155
Parcel Number: 221275002002
Type of Water System Reason for Application
M Public/Community Water System(2 or more W Building permit
connections) ❑ Division of land:
❑ Individual water source(one connection), #of Parcels?_ SPL
❑ Well ❑ Boundary line adjustment
❑ Spfing/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: Orchard Beach Community Group(Water System)
Water Facility Inventory(WF0 Number: 640310 (write"none'for two-party)
❑ I am the manager of this water system.The water system has been approved for 39 services.There
are presently 39 connection(s)in use.This will be the 39 connection.
exlsexl iln Conne ion
01 1 am the manager of this system.This connection Will be to upgrade old r2range the use of an existing
connection on thisRecreationsystem
(i e. re of to Full Structural IShopindicate 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.
Print Name of Water System Manager Melissa Cox on behalf of NWS Phone 360-876-0958
Signature of Water System Manager -/! e(rill ��(•.Y on behalf of NWS Date 09.25.24
This form may be scanned and available for public view at wyrar masoncountYwa.90V
1IEH Fams1 Drinking Water
Revised 051 W024 Pic l of2
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) pm 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 the
by a licensed contractor.
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Spring/Surface Water
FO OE permit(attach to application)hod of disinfectionve ;wate;rat
ieve that this water source can provide at least 800 gallons per day;and/or
ideate of 2 gallons per minute based on the following observations.
Author of Staternent Date
Relationship to Applicant
Part 3: Mason County Community Services Evaluation (staff use only)
atisfactory Determination:
This determination does notaddress adequacy ofthe 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 Cnde,Title 6, Chapter 6.68.040-Determination of
Adequacy for Building Pennits 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
reawn(s).
(� Revi War's signatures:
Environ. Health: � Date
This form may be scanned and available for public view at www.masoncountvwa eoy
Page 2 of
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301 E. Wallace KneeHntl Blvtl STEit224-332
Shelton, WA 98584
PROPERTY INFORMATION
Loeatlon:321 E ORCHARD BEACH DR
Grepevlew
Tex ID:22127WO2002
w+Te: kylie EmMen EQUITY TRUST COMPANY,CUB Use;
3306 E ROCKY POINT DR
BREMERTOR WA GENERAL SYSTEM TYPE:Cpnverltron]e0d98312 ON ID22127500202
County Area:Case Inlet
F,
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roe dq Sb N dad
wm InsPaRed:03/O1lL024 - Inspection TyPe.ROUTINE C Submitted 03ro !10 by:
WBM1 Porlormod BY
Company: Thaddeus Bamford Thatldeus Bamford
SE,bM septic Repaif,LLC
COMMENTS 8.GENERAL INSPECTION NOTES
No Deficiencies Noted race lot Marie.
It OO" mfmmfm well Ien both sites with moo,fake. OW adl bg for resaneterds. tank one enin field are on men.slCe of lot as you
GENERAL SITE S SYSTEM CONDITIONS Fug
TM Generd See and S dram Cordi°eru were: YES
ES
Cgrr,onBn6 emesvble IBr ed ff n NO
Nl required service pIrrfwmetl ono-a omitltli coon i.1. in ndMs YES
Sudadn esuent from an component Indudl mound °: NO
Cempdnenls aq,eerm be wrteN M-no vislullealu: ES Y
Impro ranaoedlmam awaureanm cue sudacea WA
ld r150r IIdS SBLure I86lerretl UpBn de armra: YEB
EIec41cN regatre needed. tf YEo d nd ood cc..cgntliBon:
I d mmimne ,pe ar NO
Rod Inwsion one am onenu. If YES...-in comments: NO
Seem ems obSS,,S, If YES deacebe in oom.rda of tlrelnaNd a nIX Ooaaibla. - WA _ -___..__.
Tlu houWewdam vrsa smarnor ueetl
ONSITE SEWAGE SYSTEM INSPECTION DETAIL
FJN Inrye4Yd
mis mm em was. vEs
o-Ba.m Doe mndmom ras
Peon oullete set to allows ualeMuenl disvibution'.
sanula.Yunr: LwlNanuleclurar Mold:contra. FJIY IndFaMd
ES
Thiet,m Hem wad'.
11 r. ,awl walnn 0 .0 lmlls 11 NO x Idio m mmmsn6: YES
NI re aired..,Iles In lace 11
NIA=No bslpea re aired
corn mnem 1 Sam aoumubtlon Incnes,M Hoer s e
Corn rtmam 1 Slud a aoamumnon Inches,a gMer
Co moon,. um eccu
Co nr mmluledo
Pum in o Incne rR oma�eN U
231
^recommended:w JN lnl>ab
ES
mid wm rent was NO
kinto earsmbe fundiomn as Intended: eC
Min nfl If YES lam in dommeMd: 711 YEe sa in ammenra —
preimlwd was vawumed nueM1etl or r 'esOtl
munMNu`+eaen[Nrrnwre>rtv evwrrYaYer^Nwewamanw.uYkrti,wmeawr.+a.wnenra,waaranRn^ew Pa9e', ort
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