HomeMy WebLinkAboutWAT Application - 8/12/2024 MASON COUNTY WAT.�,Xf�nGyW Q
COMMUNITY DEVELOPMENT /vI
Pvmtt Hulsulxe Center,BuildiM PlanN%
415 N Sth Street,Bldg 8,Sheton WA 98584,
Shelton:(360)427-9670 ext 400 O Belfeir: (360)275-4467 eat 400 O Elms:(360)4825269 ext 400
FAX(360)427-7787
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 I
�� 11. ardJe✓Date: q
Name on Applicent:Jgncf # 1'Aar�� � V 14, 9,
Mailing Address: QO4ow IOis Aklo Uj Phone:
Parcel Number I1W&0-$b- 40009
Type of Water System Reason for Application r.�
❑ Public/Community Water System(2 or mom Buildingpermft-M2a4-66ge �'
connections) I Division of land:
Individual water source(one connection), #of Parcelsv SPL
'1j.Well ❑ Boundary line adjustment
❑ Spring/surface water 4 Other(explain) (4asY4 y okaA flfr A;>
❑ Other(explain)
❑ Replacement or Remodel(please indicate name
If you have more than one residence connected of water system below rt applicable-no
to this well, check the PublioCommunity,Water signature required)
System box.
t.,-rn-p C&4ib 6�QY iry rw tel � 6Vun�ir^• '+� Pw+J � �ea�.�rtp�
Part 2: Water Connection Information Dau;g yaa,u, Lvs�`o P°�iob"�!
Complete the section appropriate for the type of water connection being evaluated:Public Water 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 www.co.mason.wa,us.
19HH F. Dorking W.I. Rn,,ed 1/252018
Individual Water Well to g�`�"
(Uu(Ji
❑ Water well report(attached to application). Depth It,
lot
❑ Well capacity Test(attached to application) gpm gpd.
DV
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 aY
well report cannot be located by the applicant or if the water well report does not have a capaclty 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 htto'//Qis.m.mason.wa.us/planning 14015L]16=22=
Water use or limitation recorded................................... N/AQYes_=
i
Well Drilled .................... ......P`.`SJ Data
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: / PVT Date
CSD Director: Date ^ L ' 2of2
Thurston County Environmental Health
412 Lilly Rd NE •Olympia,WA 98506
360 867-2631
TMT
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SAMPLE INFORMATION
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LAB USE ONLY DRINKING WATER RESULTS SE OILY
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Thurston County Environmental Health
412 Lilly Rd. NE 06 Olympia, WA 98506
360 867-2631
T NITRATE TEST PANEL
a . Report of Analysis
Date Collected: (MKMD/YY) 1 f System Group Type:(dmle ono) A B Other:
Water System ID Number. _ _ _ _ _ _ System Name:
l.ab A-Sam le A: OtiO —
Sample l.ocedon: Lao Stab' s Va^p 5;� Source Numher(s): (lira soucm itblmdM mcomposited__, _.
-,L-
4apple plumose,tdwk o ' east t=ived:(MM/DDIYY) k9
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RC—Routine/Compliancelwtisnesmonitanngiequimmem) Date Analyzed,(MMIDD/YY)
❑
C—Cont-rmation(mnfimmtimofrhemlwl-,A) Date Reported: (MWDD/YY)
❑ I—Investigativet ,ea am satisfy rnoniosing neanna las) Sar.-.pler Comments:
❑ O—Other lapecify -does not satisfy monitoring oa,uiwm<ms)
leCormaranort lcheckapintsmawbox) Sample M: (ebarkme) Pm-trearmennUntreated(Raw)
S -Single Source Post-treatment(Finished)
B- Blended(lis ammcs in'sa .Numbenr)'F ld) ❑ Unknown or other
❑ C- Composite(litt sources in•Spume Mumber(s)'fidd) Sample Collected by:(.) rlsy �lt Ce�bl!-✓
❑ D- Distribution sample Phone Number 71j�'i— Zbq— '7 '37i
Send Report to(mailing or e-mail address): Bill in: (diem name)
M O ckL v' t4d •�+n^'
EPA REGULATED AND STATE REGULATED OR REQUIRED
DOH ANALYSE DATA RESULTS UNITS MRL SDRL 7t000ER I MCL EXCEEDS METHOD/
A QUALH7ER MCL' ANALYST
(X Hyea)
0020 Nitrate-N mgn- 0.5 0.5 5.0 10.0 SM45M NOW
THIIIE NITRATE LEVEL IN YOUR WATER SYSTEM IS:
�In Compliance" '10 mg/L is the maximum contaminant level allowed.
Out of Compliance
MOTES:
`Confirmation:Include the original lab numben sample numbe,aM mllee ian dine ofosigivl sample in either lab or sampler comments seaim.
DATA QUALIMER: A cymbal m letter to denote additional informalim abom the result.
mg/L: milligramsperlimrorpmupermillion.
MRL IMatisoll Reporting Limit): The lowest quamifiable traf.a..analyse.
SDRL(Stare Deteetbn Repord"Liatith The minimum reponeble dmttrion of an analyse as esmdished by the*,vion ,ta.
TRIGGER: DOH drinking water rtsponse level. Systems with rmrywnds ddected at mncentmums in excess of this level may be requimd in leke additional samples or
monitor mort frequently.
EXCEEDSgICL(nandarm eonsudrann knell: Marked if the mnuminantaerne,ex¢Ns the MCL mticr elopers 24 2eoaM2 Nl WAC Deane mnmm IM
depmmenrs drinking water regional over in You .to daemine follow-upamloU.
Lab Commend:
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