HomeMy WebLinkAboutWAT2024-00305 - WAT Application - 8/6/2024 WAT �D�- OQ3OS
MASON COUNTY 415 N.Wm Street
Shel WA 4
Shelton:3fi0-027-96-9fi70,Ext..40000
Public Health & Human Services Belfair:360-2754467,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 approved building site plan must accompany this application.
Part 1: Applicant/ Parcel Identification
Name of Applicant: Empire Home Construction LLC Date: 8/6/2024
Mailing Address: PO Box 241. Kelso, WA 98626 Phone: 360-751-8062
Parcel Number: 41905-22-00050
Type of Water System Reason for Application
❑ Public/Community Water System(2 or more R Building pernh 9LDaoa4-ow
connections) ❑ Division of land:
KI Individual water source(one connection), #of Parcels? SPL
N 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
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 approved for services.There
are presently umnection(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.
Print Name of Water System Manager Phone
Signature of Water System Manager Date
This font may be scanned and available for public view at www.masoncountywa.9oy
I:1EH Forma\prinking Water Revised Oh00024 Page 1 of2
Group B Water Systems
❑ Satisfacory bacteriological test within last yea�(.ttwh plication).
Individual Water Well
0 Water well report(attached to application). Depth 367 8 ft. / � �
9 Well capacity Test(attached to application) 9 7 gpm/415 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 lest,
a well capacity test,which provides stabilization of draw-down and recovery data, must be performed
by a licensed contractor.
121 Satisfactory bacteriological test within last year(attach to application).
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)
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 its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: Date l
This form may be scanned and available for public view at www.masoncountvwa.gov
Page]of3
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Vanguard Laboratory
2635 Palkmont Lane SW
Olympia,WA 98502
360.967.7010
VANGUARD Report of Laboratory Analysis
LABORATORY
Collected by:
Amcric.Pump and Drilling Matrix Drinking Watm
3604547867 Laboratory ID:V2406200.7
Sampling Addnsa: Dose Sampled:6202413:09
180 W Art d.Rd Daft Reesived:6202414:45
Shelton,WA 98584 Date Reported:6242024
Sample m: Empire Home Construction
Analysis Result SDRL MCL Units DF Dore Analyzed
Total Coliform&E.too by SM 9223B(IDM) Batch ID:V240520.7 Analyst VJ
Coliform,Total Negat I 1 MPN/100 mL 1 62024 17:00
E.coli Negative 1 I WN/100 mL I 62024 17:00
Nitrate by EPA Method 353.2 Batch ID:V240620.7 Analyst RK
Nitrate(.N) ND 0,50 IBM mg/L 1 6202417.00
Notes:
MPt4 Moll Probable NumMr
p,c:pampe vwWcn
no,nondctect Revicwcd by Robert Smelling.Chemist on 06242024
Ntnotapplirew,
j SDRL:Slice Dnccuan Reporting Limit Approval by Tod Johnson,Opcmtions Manager on 06242024
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witha Qm1ayAmnancepmp of Vangm lab wu Plea conbcl WelaM MdWushouldhavemy9ummsa Wthen U
2635 Padmwnt Ln SW,Suite A,Olympia WA 985021 Office:360.967.70101 wsting@vanguardlaboMory.com I
www,anguarellabom ary.wm