HomeMy WebLinkAboutWAT Application - 7/31/2024 RECEIVED 1AOlJ a02� -oobC�
JUL 31 2024 WAT
615 W. Alder Street
415 MASON COUNTY lux,, AStreet
steel-9670 F 98584
J, �• Shelton:360A27-9670,Ext 400
Public Health & Human Services Belfair.360-27541467,Fxc 400
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No tletermination can be made until Part 1 is fulty 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: /74 c rice * L&ffXL Date:
Mailing Address: LtIr A< f,4.t/lt t. R 116 C Phone: 194111, -444I4-W411if
Parcel Number. 1.111gL J0y4h/�
Type of Water System Reason for Application
Mr Public/Community Water System(2 or more W Building permit
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 ocnnected of water system below if applicable—no
to this well, check the Public/Community Wafer signature required)
System box.
nd B/19/70
1trn i
Part 2: Water Connection Information fr"�/I Su
Complete the section appropriate for the type of water connection being evaluated: F
Public Water System
Name of Water System: a4 gY *�
Water Facility Inventory(WFI)Number. AD S7ft'i (write'none"for two-p rt)
y� am the man�ge�oi this water system.The water system has en a loved 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 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.
Aux% Phone
Print Name of Water System Manager
wr 0=Y10-0217
Signature of Water System Manager
Date -li-3 T4
This form may be scanned and available for public view at www masoncountywa.aov
Forms\printing Warer
aeviva 05/(WM4 Page I oft
Group B Water Systems
❑ Satisfactory bacteriological testwAhin last year(attach to application).
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) qpm 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 bactedological test within last year(attach to application).
Individual Spring/Surface Water
❑ WDOE penult(attach to application)
❑ Method of disinfection
❑ I have reason to believe that this water source can provide at least Boo 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: uarantee an adequate supply of
This determination does not address adequacy of the distribution system,g lyf
water indefinitely in the future,or guarantee compliance with all applicable WDOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Tde 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 Toro towing
rei
ry y G
Reviewer's Signatures: t i
Date /y
Environ. Health: � y
This form may be scanned and available for public view at www masoncou�a. `�qy
Pagel M3tyl
SPECTRA La3bGTBtOri�-Kitsap
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Spectra Labs -Kitsap,LLC (Poulsbo)
26276 Twelve Trees Ln NW Ste.C
SPECTRA Laboratories-Kitsap Poulsbo,WA 98370
...�r"`••""••�`"`•"�°"�•' Phone: (360)779-514RECEIVED
www.specria-lab.com
JUL 31 2024
615 W. Alder Street
Spectra Jabs- Kitsap,LLC(Poulsbo)received samples for TJ Goo;on Wednesday,July 24,2024 at 4:40
pm.Unless otherwise noted,all samples were received in good condition and were tested u accordance
with the laboratory's quality control procedures. A summary of the samples received are outtlined below.
Location Sams
Sample Sascriptioa 07242024 10:45
242345A1 Surd Welihouu
This report package contains laboratory sample results and any attachments listed below.if you have any
questions please call(360)779-5141 or email us at www.spectra-lab.com.
Attachmats
01)
This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other
than by the intended recipient is anauth9riud.If you have received this report in error,please notify the sender immedratdY at
360-443-7945 and destroy this report promptly.
These results relate only to the notes tested and the b 5aas received Lbomp (s) �hy the laboratory- This report shall not be reproduced
except in full,without prior express written approvalY P
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