HomeMy WebLinkAboutWAT2024-00219 - WAT Application - 10/20/2024 1
MASON COUNTY 415N.66 Sees
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Application for Determination of Water Adequacy
Instructions
1. Complete Part f. No detemrinatlon can be made until Part 3 is rulW completed
2. Complete only the portion of Part 2 applying to the type of water connector utilized.
3. Submit completed application with any required attachments for review.
4. An approved building site plan must accompany this a2plication.
Part t: Applicant/Parcel Identification
Nameof Applicant Dour R, VA . ���.. 9 Data: 1O�2O�eIy
Mailing Address: 1891Z�ourulPhone: g06—q31^ 1(04
Parcel Number: Se1yO651 DOO t�
P op,qut �71 t�.Miclvb�cr Ln,L+O'r'r/ rWAr "r(3555
Type of Water System Reason for Application
.( Public/Commundy,Water System(2 or more Building pemdt
connections)
❑ Individual water source(one connection), ❑ Divisbn of land
❑ Well u of Parcels?_ SPL
❑ Spring/surface water ❑ Boundary line adjustment
❑ Other(explain) ❑ Other(explain)
❑ Replacement or Remodel(please Indicate name
Ifyou have more than one residence connected of water system below if applicable—no
to this wet/,,check this PubtloCommuntry Water System bpx. signature required)
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated
Public Water System
Name of Water System "t"¢.t Kl NEAR l r,(grK &s0CA ON
Water Facility Inventory(WFI)Number W$ ID: �'�yy7� (write'none fortwo-parry)
I e pth�dmuns®r a dus water system me water system has been approved for cod services.Thera y�.,connaosum3)In use.TIDa will ue me ® B s connection.
❑ 1 am the manager of this system. This connection will be to upgrade or change the use of an existing
connection on Nis system(i.e.:recreational to full time).Please indicate on the following tine the nature of
this change:
This water system is able and willing to provide water to this(these)connecti0n(s)without exceeding the
limits of the water system or any limits set by state and local regulation.
Print Name of Water System Manager uc.e, oZ
Phone 8a�i7•,�i 74&
Signature of Water System Mans r Date Zo 31? eY1a4
This form may be scanned and available for public New at www.masorbcpurbtvwaIev /
J rElf Forms\0.inlo�Winer a..a.4 esssrma4
rq�r ore
Group B Water Systems
FO SIINCIory bacteriological test within last year(attach to application).
Individual Water Well
❑ Water well report(attached to application). Depth
❑ Well capacity Test(attached to application) apm opd.
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 drew-down and recovery data, must be performed
by a licensed contractor.
❑ Satisfactory bacteriological test within last year(attach to application).
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)
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 WDOE water resource regulations.
Recommended approval indicates requirements of Sanitary Code,Idle 6,Chapter 6.68.040-Determinaton 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 most the needs of ita intended use for the following
reason(s).
Re�vleew�errl§ Signatures:
Environ. Health: , Date
This form may be scanned and available for public view at www.masonmuntywa.gov
Page 2 af2
Rhonda Thompson
From: Dankberg Bruce <bmce@dankberg.com>
Sent: Tuesday,October 29,2024 8:27 PM
To: Kell Rowen; Ian Tracy
Cc: Amber Selby, Rhonda Thompson; Nicole Norris
Subject: Re: Backous Permit Water Adequacy Form
Attachments: DOH WFI Form -Oct-24 Update.pdf,Water Adequacy Form -Water Adequacy Form
2024- Executed.pcf
Caution: External Email Warning!This email has originated from outside of the Mason County
Network. Do not click links or open attachments unless you recognize the sender,are expecting the
email, and know the content is safe. If a link sends you to a website where you are asked to validate
using your Account and Password, DO NOT DO SO! Instead, report the incident.
Hi Everyone,
And now looping in Ian Tracyas I understand thatthis matter mayfall into Ian's department as well...
As a follow-up to my Last note, I sought clarification from the Washington Department of Health-
Drinking Water Admin Staff for the Southwest Region regarding the information listed in the'Group A
General Data'database that Ms.Thompson has been referencing suggesting the 3rd party contract agent
who is listed as the contact in that database needs to approve the Water Adequacy Form rather than our
board as managers of the system.
After speaking with the Admin specialist at DOH,they confirmed that we as the water system
owner/manager have the discretion to designate the Primary contact to be listed in that database and
how to amend the WFI -Water Facilities Inventory(WFI) Form to clarify. That has been done and
submitted to DOH (see attached)listing me as the primary contact and identifying our 3rd party contract
agent for water testing(1-120 Management Services- Kelly Brown)as Other contact for our water system
testing and reporting.
Accordingly, 1 would ask all approvals, questions, etc...regarding Water Adequacy forms-whether for
existing connections, or new connections of whatever form (ADU, new construction, etc...)be directed to
myself or any subsequent elected officer of the board for our water system.
Lastly, in the matter of the Backous' permit application. I would ask the attached Water Adequacy Form
with my signature as president of the Triton Head Association,water system ID no:89450(attached) be
confirmed and accepted in support of the Backous'application.
And let's please do this asap allowing the Backous' plans to progress....this issue has held them up for
more than 7 months-the poor people have suffered enough.
Bruce
i
WATER FACILITIES INVENTORY (WFI) Quarter: 4
wM^a^.smrurm.rlq
FORM Upicki 1ami2024
**Health ONE FORM PER SYSTEM Fueled; 10/282024
WFI PdrOed For: Or,Deman l
Submission Reason: No Change
RETURN TO: Central Services-WFI, PO Box 47822,Olympia,WA,98504-7822 or email wfi@doh.wa.gov
1. SYSTEMID NO. 2. SYSTEM NAME 1. COUNTY 4. GROUP S. TYPE
89450M TRITON HEAD ASSN MASON A Comm
S.PRIMARY CONTACT NAME B MAILING ADDRESS 7.OWNER NAME a MAILING ADDRESS
PRIMARY TRITON HEAD ASSOC[OMER MANAGER] TRITON HEAD ASSN
BRUCE DANKBERG-PRIES KEMMIE HASLETT TREASURER
291 N WEBSTER LANE RD BOX n8
LILLIWAUP,WASIII BRINNON,WA90320
OTHER-CWO KELLY R.BROWN[CWO-MANAGER)
H2O MANAGEMENT SERVICES
PO BOX 20H
SHELTON,WA 99584
STREET ADDRESS IF DIFFERENT FROM MOW STREET ADDRESS IF DIFFERENT FROM ABOVE
ATTN ATTN
ADDRESS ADDRESS
qry STATE ZIP CITY STATE ZIP
S.24 HOUR PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION
Primary Contact Daytime Phone. (360)427-06M Owner Daytime Phone (206)459-5643
Primary Contad MobilanCell Phone: (360)463-2923 Owner Mobile/Cell Phone:
Primary Contact Evening Phone: (206)054-575B Owner Evening Phone:
Fax: E-mail bxopXxxa@gmaiLoom Fax'. E-mail:
I1.SATELLITE MANAGEMENT AGENCY-SMA(check only one)
Not applicable(Skip to ell)
Owned and Managed SMA NAME: H2O Management Services Inc. SMA Number,140
Managed Only
pa ed Only
12.WATER SYSTEM CHARACTERISTICS(mark all that apply)
Agricultural pHospaeuainic XResidential
Commerlaal I Business Industrial School
Day Care Licensed Residential Facility Temporary Farm Worker
Food ServicelFood Permit El Lodging Other(church,Are station,etc.):
C31,000 or more person event for 2 or more days per year Ll Recreational l RV Park
3.WATER SYSTEM OWNERSHIP(mark only one A STORAGE CAPACITY(gallons)
pilAssociation 0Coenty Investor �Bpedal Dui
CitylTown Federal Private State 53,613
15 16 17 10 19 20 21 ZZ 23 24
SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION
F a v
LIST UTILITY'S NAME FOR SOURCE I pa z in D
AND WELLTAG ID NUMBER. r n Cc t to c IS �y n in
M
EumPle: WELL M1%YZ456 > isF F Are in p an n T re b i T rp r p � y1 an w i
i IF SOURCE IS PURCHASED OR INTERIM c x > In 3 D z E P 'I z y u ;� i Oz
re
INTERTIED, SYSTEM $ r r 9 +t P
3 LIST SELLER'S NAME ID Id m in i rn rn D D F i i Z m p 2D y y y ? = m09 y0 y m
A D an D O p r1I In i i m Example: SEATT E NUMBER F O O 41 is O A A K A H O 2 2 2 S A y :m A
S01 WELL OIAH6641 X X Y X 195 55 NWSW Ofi 24N 02W
DOH 331-011 (Rev.06103) DOH Copy Page: 1