HomeMy WebLinkAboutWAT Application - 8/7/2024 WAT
415 N.6*Street
MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES Shelton:360427-9670,Ext 400
Belfnir.360-2754467,En 400
wd3 vb., rmma.m<ro i ram EMn:360-482-5269,EA 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 on Applicant: Jason Campbell Date: 8/7/2024
Mailing Address: 406 108th St S Tacoma WA 98444 Phone: 253-841-3600 Ext 211
Parcel Number: 22110-32-00010
Type of Water System Reason for Application I '
❑ Public/Community Water System (2 or more ❑ Building permit�l�=_4- Qqu`f
connections) ❑ Division of land:
[A Individual water source(one connection), #of Parcels? SPL
13 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.
(wrile`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 lime). 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.masonma.us.
I\EH Fame\pnnkin8 Water Reviews 4/42018
Individual Water Well
IX Water well report(attached to application). Depth 168 ft.
CR Well capacity Test(attached to application) 15 apm 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 performed
by a licensed contractor.
❑ Satisfactory bacteriological test(attach to application).Sample into to lab
Water Resource Inventory Area (WRIA)
Development within which WRIA htto Hais.co.mason.wa.us/planning 14X 15_16_22_
Water use or limitation recorded................................... N/A X Yes_
Well Drilled ...8/10/20.00.............................................. Date
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,Tide 6,Chapter 6.68.040-Detemlination 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
mason(s).
Reviewer's Signatures:
Environ. Health: Date
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
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COLIFORM BACTERIA ANALYSIS FORM
Data Smite Colteaed Tirre Sample County
Collecietl
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Type of Water System(dErk only one boa) �" �V,f, �¢��
❑Group A ❑Group B �inn. er
Group A and Damp B Systenm-Proetds Ron Water Feasible;lmonlory(WFI):
System Name:gc"t+ Lvell 78f M"Pir, 0webt
Cameo parson: V n Ve I I
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SAMPLE INFORMATION
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Specific location adore sample mucucted: Speael instructions M moments:
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Type of San*(salad only qne We of sample from types f through 5 below)
f.,*R.Udm Distribution Sample(AIP) 2.❑ Repeet Sample(AIP)
Chlorinated'.Yee_No� Iham deAibudrn sywmann urear.mum.)
- Unssufedory routine lab rumba[
Chlorine Residual:Total_Free_
3.Gmund Water Rule Source Smepte
Unsetistedory mulbw netted dNe:
S
Chlonneted:Yee No
❑Triggemd(ANP) Chlorne Residual:Tool_FM_
❑Assessment (ArP)
4. Suntans or GM Raw Sours Water SSMPte(Enmmbm) _ I
❑E.mfl ❑Fecal nwse na no_
5.❑$a*ctlkaa M Intonation c er
L USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑UnsBsfeetery Total Califon present and tlafeetery
❑E.od0preeent ❑E.00liabeenl
Bacbdal Density Results:ToW Cdgmm Hgdnl. E.sN IfgDol.
Fast Cd 0rrn MDDml. HPC It ml.
. Rphismsnt Sample Required: ❑TNTC ❑Sam*Mold
❑ Semple volume ❑Damaged Container ❑
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