HomeMy WebLinkAboutWAT2024-00337 - WAT Application - 9/24/2024 WAT 2024415
MASON COUNTY Shc N.
ass
COMMUNITY SERVICES Shelwe:360-427-9670,Ext.400
Belfair.360-2754467,Ext.400
alYdro MnM.rm:mm.mJx.hhrmn.nnywwn Elmer 360482-5269,Ext.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 Irdentifcation
Name on Applicant: I Xoa,511 tl�[I Date:
Mailing Address: »'0 0-1,1u kr A. I✓ Phone: 9I6 '3�S 7.69C
Parcel Number: q0o it 0!51r`/ CK 02
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more Building permit did,1Da,4• DIU,q
connections) ❑ Division of land:
Q� Individual water source (one connection), #of Parcels? SPL
jr 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 PublirlCommunity 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)
❑ I 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 Ume). 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.
P EH Forme\Drinking Water Rw 4/4/2018
Individual Water Well
Water well report(attached to application). Depth 13 o ft.
Well capacity Test(attached to application) k pm. I`j O''_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
'If
,.by a licensed contractor.
$, Satisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http,/Iqis.co.moson.wa.us./planninci 14_15_16_22_
Water use or limitation recorded................................... N/A_Yes_
Well Drilled ............................................................... 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 33: Mason County Community Services Evaluation (staff use only)
YSatisfactory 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 W DOE 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).
Revle er'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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2635 Padomont Lane SW
Olympia,WA 98502
360.967,1010
VANGUARID Report of Laboratory Analysis
LABORATORY
C.1koad by:
American Pump and Drilling Marro Drinking Water
360-754-7867 LabomtorylD:VU0410-5
Sampling Addreaa: Daft Sampled:VIOA413:Be
148'E Pickering Rmd Date RemNed:V=416:23
Sheltm,WA 98584 Dale Reported:4/152024
Semple ID: Andy Grotto Homo Inc
Analysis Result SDRL MCL Units DF Date Analyzed
Total Coliform @ E.colt by SM 9223B(IDEXX) Barth ID:V240410.5 AmlyaC VI
Coliform,Total Negative 1 I MPN/100mL 1 4/102417:00
E.coli Neeative 1 I MPW100ol 1 4/102417M
Nitrate by EPA Method 30.2 Batch 1D:VUO4I0-5 Malyn:RS
Nitnd,(as N) 2.545 0,50 10.00 mg/L 1 41IM41720
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2635 P d...t Lo SW,Suite A,Olympia WA 985021 Ofice:360.967.70101 testing@vangimrd[aW.Wry..I
www.vanguurdlaboremry.com