HomeMy WebLinkAboutWAT2024-00289 - WAT Application - 7/30/2024 MASON COUNTY
COMMUNITY DEVELOPMENT
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415 N 6' Street,Bldg 8,Shelton WA 98584.
Shelton:(360)427-9670 ext 400 4 Belfair:(360)275-4467 ext 400 4 Elma:(360)482-5269 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.
L3. 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: BARBARA HARVEY Date: 1/30/ 102�
Mailing Address: 2673 NW Nordeen Way Bend, OtPhone: 207-233-WO
Parcel Number: 32424-22-00040
Type of Water System Reason for Application
ElPublic/Community Water System (2 or more 0 Building permit 13bWo94-ov/,�y�
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connections) ❑ Division of land:
❑ 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 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: gidden GvE
Water Facility Inventory(WFI)Number: 32.(-133A
(write"none"for two-party)
VI am the manager of this water system.The water system has been approv for services.
There i presently��connection(s)in use. This will be the connection. 7k S pmplck
R dy Ca i! �D 17p Wm175 SY�+r�-
❑ 1 am the manager of 7 hrs s em. I his connection wi�e 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 lind set b/y state and local regulation.
Signature of Water System Manager L` Date 7AF/,.?�/
This form may be scanned and available for public view at www.co.mason.wa.us.
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Individual Water Well
❑ Water well report(attached to application). Depth ft,
❑ Well capacity Test(attached to application) opm apd
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).
Water Resource Inventory Area (WRIA)
Development within which WRIA hftl2�//gis.co.mason.wa.us/plannin!I 14015E1 1fi022I=
Water use or limitation recorded................................... N/AQ Yes_=
Well Drilled ............................................................... Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ Method of disinfection
❑ I 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
CSD Director: Date 2 orz
Thurston County Environinental Health
20DO Lakeridge Dr.SW ♦Olympia,WA 98502
360867-2631
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COLIFORMBACTERIAANALYSIS
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Type of Water System(dedcOnly one boa) ❑ Pthate Household
❑GmupA in Group 8 ❑Omer
Grotto A aynd Systems
Croup B Syste -Provide from Water FadRtes Imenory(WFI):
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System Name:
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Day Pemm:( ) Cel
Email: : .Eva.Ptme:( )
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SAMPLE INFORMATION
Sample ooltectetl by
Speak location or address where sample oapected: Special insbucdonsor cmme :
Type W Semple(must check only one box of#1 Nrough 9 Instant Now)
1. patine Distdbution Stamps 2.Repeat Sample lager urmri whine)
Chbnna&d:Yes_No� ❑DerbiWAon System
Chlorine ResWwl:Total_Free_ Chlorinated:Yes_W_
3.IIaw Waar Source Sample Chlorine Residual:Tolel_Fme_
❑E.m9-GWR(AR)
❑Fell-sane=,cxi.a„raalreor+swl ILmahWory routine lab number:
Flue J.Ya W_
❑Assessment Moniong(AR) Unsatisfaclayralna cdteddate:
OOmar � r__
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l❑s rnple ooWcod for fniommlon Only
Investigative_ Canslmcoonl Repairs_ Omar_
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Umatisfacory Total Coliform Presentand rT Saaateelay
❑E we present ❑Ecop ebwml y��pp C'oylonn�� ,
Replacement Sample Required:
❑samgeoodd(>301aours) ❑TNTC ❑
Beckrkl Density Results:Total Cd'rfam 1100m1. Em9 n00M.
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