HomeMy WebLinkAboutWAT2024-00401 - WAT Application - 12/20/2024 WAT�,02A_- -�
415 N.6°Sm
QPMASON COUNTY Smlt^WA 99584
COMMUNITY SERVICES Skim:36 -427-9670,Fort.400
B elfair.360-275a467,Et 400
w+a'wvw�msrn.. N.,�x�+nn con.,.mnx Elmo:360482-5269,ExL 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 appwved building site plan must accompany this a icatbn.
Part1: Applicant/Parcel Identification 1�I��h ���
A 1
Name on Applicant: l ft10 3 VA. �(lf'^ ann Date:
Mailing Address: `tol IL 11-0" tPLbtF4rr1 WA1 phone:
Parcel Number. 52MI -97'70c020
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more k� Building permit gLDa V4 - 61511
connections) ❑ Division of land:
;9: Individual water source(one connection), If of Parcels? SPI-
X Well ❑ Boundary line adjustment
❑ Sprirglsurface water ❑ Other(explain)
❑ Outer(explain) ❑ Replacement or Remodel(please indicate name
If you have more than are residence connected of water system below ti applicable-no
to this wall,check the Public/Community Water signature required)
System box.
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection bein 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 water system has approved for_services.
There are presently on(s)in use.This will be connection.
❑ 1 am the manager of thi em.This connection will be to upgrade or change the use of an existing
connection on this am (i.e.:recreational to full time). Please indicate on the following line the nature
of this cha
This w system is able and willing to provide water to this (these)connection(s)without exceeding
its 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 vies at www.co.mmm vra us.
aev WV,112018
J:�n F.\D�i,ware
Individual Water Well
1 N Water well report(attached to application). Depth L ' ft.
Well capadty Test(attached to application)—3m 7 0 O
Q• {d
The well driller often performs well capacity tests at the l}a the well is trucled. 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-do" 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 hho//Qjs.co.masgO.wa.us/plannincl 14_15_16_22_
Water urea or limitation recorded................................... MIA_Yes_
WellDrilled............................................................... 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 600 gallons per day;andlor
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 on
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,Tide 6,Chapter 6.66.040-Detemrination of
Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
Unsatisfactory Determination:
Applicants 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
This faro may be scanned and available for public view at wrrrr.ca.mawn.wams.
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Vanguard taboratory
2635 Parkmool lane SW
Olympia.WA98502
360.%7.7010
VANGUARID Report of Laboratory Analysis
LABORATORY
Colleeterl by:
Davis Pwmi Repay Matrix D.A g Water
daviagmgrepair(a}gmail.cem Laboratory to: V241121-6
SaWfin Address! Date SampW: 112124 1300
480 W sumsoo Rd Datc Recetved: I ICL24 1U5
SheRoo,WA 911M Date Reported: 11252024
Sample ID: 480 W Simpson Rd
Analysis Result SDRL MCL units DF Date Analyzed
Total Coliform&E.roll by SM 9223B HDEXX) Batch ID:V2411216 Amlysr.AV
Coliform,Total Negative I I MPbU100.1. I 11212419:44
E.roll Negafivc I I MPN/IODmL 1 11212419:44
Nitrate by Hach Method 10206 %wb ID V241121-6 Analyst AP
Nitrate(as N) ND USO 10.00 mg/L 1 1l2 M 16:40
Metal,by EPA 200.8 Batch 0 V241121-6 Aoaly t VJ
Arsenic(As) NO 1000 10.000 pg/1. 1 11/25/2024
Notes:
M1IPN:I.1M Robable Numbw
ppm: minim
�.u�tacttea Rcviuwed by Dustin Newmev,Iahoretory Dirscta ov 11252024
Na:mraMb abk
MRL:g Dcuati o R.,hag Laat Apluuved by Ton Johc o ,Operehora M gcr m 11/252024
DF Dilutim Faro I larL20rl
MCL Alaxnnmi Cbewarbwa level �iaaw aory
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wiW�QualiryA macpoBam ofvmgmdlebornaY vloac moan the la6aYnrY ifYm rhouN 6avc aeY4�^^°
2635 Paul wont Ln SW,Suite A,Olympia WA 985021 Office:36o967.70101 resting@vanguardlabomt«y.c=
w .vanguardlabotatary.com
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