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Home My WebLink AboutWAT2024-00003 - WAT Application - 1/9/2024 WAT 2 2 -00� 415 N.66 Street MASON COUNTY too WA 98584 COMMUNITY SERVICES REQ� 6ia,Et.40 -0467,Ext.400 Pu",PWnmq Env.nol n",K w--INealN Elmer 360482-5269,Ext 400 JAN 09 2024 Application for Determination of WatereAtdequacy Instructions 1WN 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. 1 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: jn— �/ M pr- S Date: T— ' n , Mailing Address: 25� CQYVrL9� �-iv Phone: .3bD"r{90— Z33y '. Parcel Number 37-0 2—) --IS— 00l 2.0 Type of Water System Reason for Application ❑ Public/Community Water System (2 or more ■ 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 connected of water system below if applicable—no to this"it, 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: Water Facility Inventory(WFI) Number: (write"none"for two-party) ❑ 1 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. ❑ 1 am the manager of this system.This connection will be to upgrade or charge 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 antl willing to provide water to this (these)connection(s)without exceeding the limits of the water system or any limits set by state and focal regulation. Signature of Water System Manager Date This form may be scanned and available for public view at yrww.cp.mason.wa.us. Individual Water Well • Water well report(attached to application). Depth /r(( . ft. Well capacity Test(attached to application) 1/ apm -7L40C-)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 welt capacity test,which provides stabilization of draw-down and recovery data, must be performed by a licensed contractor. 1111111, Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http,]/ais.co,mason.wa.us/i)lanninQ 14_16_16_22_ Water use or limitation recorded................................... N/A_X—Yes_ Well Drilled ............................................................... Date-- :- 2/ — 2D 2,3 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) tisfactory Determination: This determination does not address adequacy of the distribution system,guarantee an adequate supply of water indefinitely in the future, orguarantee 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. D Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended use for the following reason(s). �n�.,_,I,,�,',V^V' R�elviewer's Signatures: Environ. Health: �e �,YI Date 2,B2� This form may be scanned and available for public view at Pege 1 eR WATER WELL REPORT S DEPARTMENT OF N«io[oflntmt No. W1e52923 ECOLOGY Uniam Ewlogy Well lD Tag Na. 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Om 11211tl MetlmM _a lkmpe:rmewfwwm 51 •P Wna[Femvwlnalysis:xde± ❑Yn GNo gpn OMe 112123 ComPlMed DMe iiR1(13 WELL MNSFRUMON CERTIFICATION: 1 mnswckd of Wa a«epl respmsibiliry fareanslnwum ofNis well,utl its wmpl:ma unM1 aII WUM1ingm xdl cons ioo Mar,hokM iols mN mtl ee mf«`om mpoovi abmw me hue b my bme kmwlM,o aM bMkf 9 Dnller❑TrM«x❑PE-Print Name ROJBmYIW{bGn I)nIIMa ComWy Arcadia Omin9 Inc. SilPmmc /" %C/ Addrea PO Bm 170 Liana No.2a53 City.Saw,Zip SIMwn.WA 90584 i If TRAQiEE:$p«u«'a Lva Na Co:aacmr's $ponwi s SipmLne Reel FA m No.ARCADOIO991(1 DMe 11121123 ECY O50.1-20(Rev 09/ta) Iffy Nn diNsd« minanaite awranm<plememlltA W rRwm Pmgeom«3d0.40)EF)2.. Perams wlW Marbrg bM can call]Is/ar W«Mngron Feluy S'ervlre. Pertom with aspeweh O.abillry can=116]]d33.041. Thurston County Environmental Health 412 Lilly Rd NE•Olympia,WA 98506 360 867-2631 T COLIFORM BACTERIA ANALYSIS Dale Sample Collected Time Semple County 1 271 2,r n�p(m, 94ASOPA Men Da• You: Ow Type of Water System(check only one box) PMate Households/nyG ❑Group A ❑GrmpB ❑OMm .I _ Group A and Group B Systems-Pmvide from Wafer Fadlitlea lmentory(WFI): ID# - - - - System Name: Contact pension Mp Day Phone:( ) .. . Z Ce11 Phonxx 60 E-ma11 0 -.Phono: ) Sud medb b:(Pdntfu ,.,atdmm and dpmtla a anW etldees) �� / � I �?.Fz/ 8 SAMPLE INFORMATION Sample collected by hare): Fyf,S I I Specific location or address where a ple collected: Spe I lCd�ct/ mmnts. I ,So s� C� � �, J JA W, �N Type of Sample(nest check only one box of#1 through#4listed teener) 1.❑Routine Distribution Semple 2.Repeal Semple(after umat routlm) Chlorinated:Yes_No_ ❑Diumbutsm System Chlorine Residual:Totsl_Free_ Chbdnated:Yes_No 3.Rea Water Soume Sample Chorine Residual:Total_Free_ ❑Feca Unsaesfadory routim lib comber Fll.d:Ym Nc_ _ __ ❑Assessment M0nibrir4(AJP) Unsatisfactory routine Word date: ❑OMer S 4.0 Sample Collated for Information Only Imudgalin Conchction _ Other LV _ LAB USE ON DR INKING WAlRepainTER RESULTS LAB USE ONLY ❑Unsatisfactory Total Whom PresentatM tia(aclory ❑E.coll present ❑E.caVabsent Calilom tlebcled Replacement Semple Required: ❑Samplet000MQ30houn) ❑TNTC ❑ Bacterial Density Results:Total ColifomL-----—J100ml. E.mll /100red Fecal Colifem /10Dm1 EnOerooxd /1o0ml. Method Cade. l Nl 9223E ❑SM92220 DO.WTlme ❑SM U158 ❑EnletokrtD l-252 02,65 Date and Time Malynk Dab Repabd 7k ammaxememtoox maemgmman'sml _ ten lhewty: p®42_ .