HomeMy WebLinkAboutWAT2024-00298 - WAT Application - 8/7/2024 WAT -
415 N.6^Strut
MASON COUNTY Shelmq WA98584
COMMUNITY SERVICES Shelton:360-2754467,E=c400
hdt.:360-275-0467,Ext.400
�,Jd, Proms En M� xw'n e,,,,n„�,o.xdn Elms:360-082-5269,Ext.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 utilized.
3. Submit completed application,with any required attachments for review.
4. An a2proved building site PIan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name on Applicant: Jason Campbell Dale: 8/7/2024
Mailing Address: 406108th St S Tacoma 98444 Phone: 253-941-3600 Ext 211
Parcel Number: 12221-75-00100
Type of Water System Reason for�A1ppplliicva�tiion
❑ Public/Community Water System (2 or more ® Building permit f-wvgoo —OV na rub
connections) ❑ Division of land:
tie 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 PublicICommunify Wafer signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated: ""• ' J
Public Water System �P-m
Name of Water System:
Water Facility Inventory(WFI)Number: to n,,,VL P
(write-none"for two-party)
It I 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)connections)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.
Revised 4/4M 18
1:\Efr Fomu\Dnnking Water
Individual Water Well
Water well report(attached to application). Depth 81 ft.
Well capacity Test(attached to application) 20 gpm / `� pd.
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 drew-down and recovery data, must be performed
by a licensed contractor.
A///���
Satisfactory bacteriological test(attach to application). Sample at lab
Water Resource Inventory Area (WRIA)
Development within which WRIA http*//Qis.co-mason.wa.us/121annina 14_15_V'/i6_22_
Water use or limitation recorded................................... N/A ✓ Yes_
Well Drilled ............................................................... Date 7/7/2011
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 3: Mason County Community Services Evaluation (staff use only)
F
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
its
Adequacy for Building Perm are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures: a I uct Mtl
Environ. Health: `�� �l Date It 1
This form may be scanned and available for public view at www.co.mason.wa.us. P.,2 oft
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COLIFORM BACTERIA ANALYSIS FORM
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Type of Waw Sys*n(clwa&mo one boa)
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SAMPLE INFORMATION I
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5. Ne CWmedM tefamNen Ony:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
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Bacterial Densty Raub:TOW G^fifalm /10Gnl. E-00 10 W.
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