HomeMy WebLinkAboutWAT2024-00299 - WAT Application - 8/9/2024 ENVIRONMENTAL
HEALTH
WAT - nog
415 N.W Street
MASON COUNTY
Bhcltco,WA 98584
Public Health & Human Services Behon:360-275467o,Exr 40o
aclfair.360.275446].Et.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 �Z
Name of Applicant fa,�v�-� It1c beyr.�11y"..1f,r Date: t5IM /�
Mailing Address: W(j PinFxGIL 90 CC4*kR XA- Phone: �bp-292-OSOy
Parcel Number: (01q )0 ^q? -90Cu3
Type of Water System Reason for Application
❑ PublictCommunity Water System (2 or more Building permit
connections) ❑ Division of land:
Qr Individual water source(one connection), #of Parcels? SPL
I- t� 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 PubliclCommunity 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
connecton 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 forth may be scanned and available for public view at www.masoncountvwa9ov
I:U',H rove r pnullong Water Ro is 0S 20?4 P.E,e 1 nr2
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to app8cetion).
individual Water Well
Water well report(attached to application). Depth 01 Li
Well capacity Test(attached to application) �O gpm l 00gpd.
The well dnller 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 0 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.
0. Satisfactory bacteriological test within last year(attach to application).
1 �' 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 ne distribution system,guarantee an adequate supply of
"Illwater 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 forthe following
reason(s).
Reviewer's Signatures:
Environ. Health: ' Date
This form may be scanned and available for public view at www.masoncountywa.gov
ENVIRONMENTAL
HEALTH
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Vanguard Laboratory ENVIRONMENTAL
2635 Parkmont Lane SW, Suite A HEALTH
Olympia WA 98502
puiao6iD 360-967-7010
COLIFORM BACTERIA ANALYSIS FORM
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