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HomeMy WebLinkAboutWAT2024-00318 - WAT Application - 2/22/2024 WAT zo2� nn�18 415 N.6m Sheer MASON COUNTY Shelton,WA 985" Shelton:3 6 0 42 7- ,Ext.400 COMMUNITY SERVICES Helfav:360-275J467467,ExL 400 a,iamu n.onms[„wocn�+,ix®imcoi,,.,�w8 n El=:360482-5269,ER 400 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 u tilized. 3. Submit completed application,with any required attachments for review. 4. An approved building site plan must accompany this a2plication. Part 1: Applicant/ Parcel Identification Name on Applicant: row._ �+..T/_L5 &!LJ Date: it ii I.y Mailing Address: III fgVrA K ILO {Jlk.tw Phone: 340- Z92 -0100 Parcel Number: 2Z2-Ll -l1-90000 Type of Water System Reason for Application ❑ PPublic/CommunityWater System (2 or more Cp Building pemtit-gLD20a4-01050 connections) ❑ Division of land: Individual water source(one connection), #of Parcels? SPL 6 Well ❑ Boundary line adjustment ❑ Springisudace 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 Wafer 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. ❑ 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 by state and local regulation. Signature of Water System Manager Date This form may be scanned and available for public view at vrvrw 4.o mason wa us. 1:TH Fame\Dr k.8 W.ta Revised 4/M2018 Individual Water Well Water well report(attached to application). Depth_2-6 ft. If Well capacity Test(attached to application) S;_0 pm tOOoPd 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). Water Resource Inventory Area (WRIA) Development within which WRIA htln'//qis co mason wa us/olanning 14_15_16_22_ Water use or limitation recorded................. ... ............ NIA-Yes__ WellDrilled ............................................................... Date 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 dlstdbution 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. Addibonal Growth Management requirements may apply. Chapter 36.70A RCVJ. Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). Reviewer's Signatures: Environ. Health: Date `Z This form may be scanned and available for public view at wyYL•co.mason.wa.us. 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A I n d.• P=ar.du.. .\a z.Rnoam'.Progrvm al J(0-IO]d41I Yrrwnl xltlr heunrlq lou Can nrll l)/wit" mRlaa mrrr. Prnwu xNhugeerh Jl}abillD Can Cdl F'1A3M34I34Nl. \ \ 13 � El ? l j ) 26 ) � .2 & ] | \ « E3t5 : cl � , ± : | | c 2 | | | ■ <{ ! ƒ j k / cr Lewis County EnY1rol3mental Health Laboratory 360 NW North Street,Chehalis, WA 95532 (360)740-3237 (gWD CD3Rir1[ Nitrate Report of Analysis Of��15me:)T. LSO am 8ystemUnmp7ype: (airdeana) A B t31bs Dale Collected: (kDelDnm) �- - SZ 3 System Name ( Y - A,, WatcrS IDNumber: ._ -- LabNombnr/S Is Numbs': 0911.)I rx4FY SU So•a^a Nnmlaa(s)' nir.a 'f Salt le Address' �'v-I'll, F j;- � 6 ,r% Fa(v I A- f •'"7 15me S 1 Pmou 'r^^^'': ®eatmm box) of;h i J Date Remived: !tea!! - - ''-I - ga _ RC -Rootim/Comphanne(snrNin mmi:orma rt9uhcmeou7 F� ��X-Co�fmalion(w:famad'n ruullis (- JY I-Inv«6gative fdan nd aadsryam:tadne rt9ulmmn.) Date Anal zed_(I�IYY) O-Othu( aif)' Joey ud adnfy moniraeg reyuncmenls) Date R tied' OWMAIM'y) _ I — / ._— CO �mul Tyce (c1r<kme7 m amamfUntreated(Raw) �nmoost fs-k nmunine dal post-Tralmot(Finished) ©- S-Singh:Source ❑ Unknown or Od e Lj B-Blloded Gist smuu numbers io"SwuceNwWs'f kl) lei r C-C:omposim(tut rauree number in"Swr Nivnbui'fieb) Sample Onlleelod by:heaba) . -- D_Diatr[bntion Sample j Phone Number: C o carrier Cnmmectts: SeW Reoort to: ) 1,1 e 4L, A � _. c:� S !i 1 pre 11 u ? ( ti�eti ire �ti /1 ` " ANALYTICAL RESULTS 9ECEEDS AN,u.YET DATA MCL? DOD ANALYTR QUALIFIER RFSLT.TS SDRL TRIGGER MCL UNITS' (R if Yes) METHOD IID7'IAIR 4 Hach oo2c Nitrate-N (� !� os 5.0 10.0 MWL 10206 1.()Nuiw *Cooarotatiao: Include the otigiml ub number,aauspla mother,aad co0ec1on date of ougival s"Ple nt rnvnrent aec0m DATA QUALIF@A:A symhnl a letxx m dcndc eddidmid irtfarmerinn about Ne rtsult- E%CEEDS MCL(Maximum Contaminant Level): Marked if the wnbadawd wuuunt exeecda the MCL enav r,,apens 1A6 y90 and 246-291 WAC. Pleesc,'dart the department's drinking wrier regional'here te your arts nu deee:mhw follow-uP actions. mg/L: mllbgmma Detection R or Pare P unitanmem. SDRL(StelaDemcOon Repurling Limit: The mirdmumel. sysbkrid tioaofan aeite&Yle azld.t d:ed by the dap be tired TRIGGER: The depedment's'driNdng wdu rtsponxc level SYatwm wiNeduaminanta deteetW deoncaumtiona in excess o:this larch may raq Io take mditiortnl samylcsainunitor more fro4ueotly. Plraec coflart the depadmcd's drinking waam«giannl nffrce in your area for further infarmedun. INTERPRETING NITRATE SAMPLE RESULTS FOR NON-PUBLIC WATER SYSTEMS Lasman0.SmgfL(<0.5m9/L): Wrierd'esndenlnnl'significant enwuuu of nitresM 0.5-3.0 WL: Water in Nis category should bo monitored regularly to determiceff"Rale Wncenhsbii"are increasing. We mmmmend yearly testing. 3.1.9.9 nag/L: Thae water should be monitored of{enxf yearly. Surface lend are should be evaluated to detvmim if them are oitrete sources that can be m er W inuniud or 6minated in order to Prevent fudhdaminalion. Great"than 10.0 mg/L(>10 nng/I•): Son¢people,particularly infants and pregmnt w'nwn,am considered to he al risk if they drink Nis wider. Additional info mdion from Ne Wuhtngtan State Depvrlmenl of Health is indud«. More information is available at the following Washington State Degadnwm of 14ea101 websites'. hll .sue!! doh. /Portals/IMO n —Tie baf331-214.odf hMa:/lw doh. eo /Dort 1s/INacuvwntdoubd331-549 aN