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Home My WebLink AboutWAT2025-00020 - WAT Application - 1/25/2025 wAT�-00oap MASON COUNTY COMMUNITY DEVELOPMENT Ynm@Pslslan[e Cenhg BUIWIn&PlanNn( 415 N 60 Street, Bldg 8, Shelton WA 98584. Shelton:(360)427-9670 ext 400 P Belfair(360)275-4467 ext 400 4 Elma:(360)482-5269 e#400 FAX(360)427-7787 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 Identification Name on Applicant: Karl kA[g Date: Mailing Address: g2JJ NE (b1uob Woods CA. Phone: ,34ct4700-(,I�-v 0 Parcel Number: 321 iF-75_000M Type of Water System Reason for Application $--Rablic/community Water System(2 or more Building permit $ 4)cqw$-O'(3`j connections) ❑ Division of land: ❑ Individual water source(one connection), #of Parcels? SPI. ❑ Well ❑ Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) ❑ Other(explain) ❑ Replacement or Remodel(please indicate name If you have mom than one residence connected of water system below if applicable-no to this well, check the Pubho 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: Cel f"aH g-iAge t,UR}tr SUShEM Water Facility Inventory(WFI) Number: 03f]bb u (write"none"for two-party) Pt I am the manager of this water system.The water system has been approved for services. There are presently_5 connection(s) in use.This will be the�conne lion. ❑ 1 am the manager of this system.This connection will be to upgrade or change the use of an existing connection on this system(Le.: 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 lim�its�at by sta local regulation. Signature of Water System Manager Lrli.✓.r+t `1,JRars.- Date 1121T/2 o7- This form may be scanned and available for public view at www.co.mason.wa.us. I SEll Fmms\Doo m,Wa.cr Revisal 1n5QpIB Group B Water Systems c� Jp, Satisfactory bacteriological test within last year(attach to application). 200/�Z✓ Individual Water Well ❑ Water well report(attached to application). Depth ft. ❑ Well capacity Test(attached to application) apm 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 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) 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 resouroe4egulations. Recommended approval indicates requirements of Sanitary Code,Title 6, Chapter 6.68.040-D eon of Adequacy for Building Permits are satisfied. Additional Growth Management requirements ma er 36.70A RCW. O Unsatisfactory Determination: Applicant's water supply does not appear adequate to meet the needs of its intended us Qf�e fo0A./1T1�� O reason(s). Gv�,FNt' i17e_ Reviewer's Signatures: Z Environ. Health: Date t This form may be scanned and available for public view at www.masoncountywagov Page 2 of2 26916'fwelve ssm.c� " SPECTRA La P Pad ,WA 3 9�9151i1 CO-WORM BACTERIA ANALYSIS FORM MN$w119N CAeFNE Tlme SanFb_— Cawy 1191 z 5 }}//*((i1� � ewn Cy Yw 3L.��OW Typemwpkr Spkm ldieaanNaw Om�) , .a ❑G=pA $GmWS ❑owr GWAId GmW SSyekme-PmeNetrpmWekrFpNMMJm 'M SSFlr n \ Mo CpYppwem: PSTAJ Cd O WATte- f7 sTe ? RF�Fi`�o`�lS by phwex , 6 of ,— , fpwk'W Lvs.Pnar pwgn•YNpwee.n.r.eeewewe �r.w.rreaNwma 3 • - - IcfpNR w7 tY alff'I �y �Q.t11 Alt Lo vAYf Y_/.1a GH S SAMPLE INFORMATION saroNwklNe hy1�):AlorlH a tSFf 3 spKft G�•'f � 1Z7Nlw8wwacawiw+s: 1 TA A WA Q 658 P��`�iyFS��S Typeol swnplelNed�_adyoiwEm1 '. o it tM Satln meeleutlen 8en8kWP) i.❑NPertSempkpWl ��.` ChOk W:Ve30 No13 rypn lekb�eale.Mrwt�wNel � UmNNdxy ealkw YD nunElr: ChbRw RdAiel:TotW_Fne _ `_ 5.8nwMWpbr RNeewlu BnPN GreekN[brl�aSyw wleq SYw m a- cnbmYNp:r._Ne_ to 13rnSpea5 lAp1 cwNw R®NeLToW_Feee_ ¢ 3 ❑Aieevmenl(API U i8al+u erGWl qew Boas Webr SempN lEamemSm) �� ❑ Em ❑Few m•m ru_w_ 2T S.❑5..ikc<auee a bNmmeeoeM ' 2 LAS u5E ONLY DRINKING WATER RESULTS ,PNLY- eiA3Q ❑UKe1NMmnroNl CdAoim Pmcenl enS Sawn `\)` ❑EwFanenl ❑EcoeeMpnt eeebrNl Oxu8y 11au8c Tobl Coalam_mWloom.Eml`_mpNl6lmt Few Calibnn__dW50NN. HPC_�Sl'IRA RepkumeMBempN PpiiM: ❑TNIC ❑Se3rykmp ok ❑ 8empk VOMw ❑DwegeA or4Ner ❑ pwlllYlw valwtl. lee NlMwew Mwiw PA.W roC': \qz,\ NWwl Gle tlFGOLtIp StHNID �suvnv pfE919 palNe-e.wbe mw..ma�eper.vnn WATER FACILITIES INVENTORY (WFI) °iMReC D Updated: 02/012007 � 21612025 � Kbd.VW5bkD7m -f FORM I*Health Printed For: On-Diem ONE FORM PER SYSTEM WFI Pdnled For: On-Demand none. ck^ e+ mm e,ftv"v m . Submission Reason: Annual Update RETURN TO: Central Services-WFI, PO Box 47822, Olympia,WA,98504-7822 or email wfi@doh.wa.gov 'SYSTEM IO NO. Z. SYSTEM NAME 3. COUNTY e. GROUP S. TYPE OW66U CAPSTAN RIDGE MASON B A,MMARY CONTACT NAME S MAILING ADDRESS 7.OWNER NAME BUNG ADDRESS LARRY PARSONS(OWNER) CAPSTAN RIDGE COMMUNITY OWNER REP 1310 32ND AVE S LARRY PARSONS SEATTLE,WA 98144-3914 1310 32ND AVE S SEATTLE,WA 98144-3914 P1{EET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE iii ATTN ADDRESS ADDRESS DITY STATE ZIP GITY STATE ZIP "E4 HOUR PRMIARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION Primary Contact Daytime Phone: (206)325-2002 Owner Daytime Phone: (205)325-3002 'reni Contact Mobiliti Phone (360)372-2877 Omer Mohile/Cml Phone: (360)372-2877 remary Contact Evening Phone: (xxx}ga-xpa Owner Evening Phone: edo)-1 xx-pax Fax E-mail Lxxxxxr@msn.ocm Fax E-mail: Lxxxxxr@msn.com 1.SATELLITE MANAGEMENT AGENCY-SMA(check only ona) IK Not apptcable(Skip to ell) Owned and Managed SMA NAME: SMA Number ❑ Managed Only Owned Only 12.WATER SYSTEM CHARACTERISTICS(mark all lhat apply) 0 Agricultural Hospitavoinic Residential Commercial I Business ❑Industrial ❑School Day Care ❑Licensed Residential Facility ❑Temporary Farm Worker Food Service/Fuod Permit ❑Lodging ❑Other(church,Ne amtlon,ear: 1.000 or more person event for 2 or more days per year Recreational/RV Park 3, OWN liffix(dreark deftwM (aaltoM Association County Investor El Spacial District �Cityf Town Ei Federal Private QSlate 13 IS t] to 19 n 21 u 23 d4 SOURCE NAME 80URCECATEGORY USE TREATMENT DEPTH SOURCE LOCATION w p f y z n LIST UTILITY'S NAME FOR SOURCE c A ? D AND WELL TAG ID NUMBER 2 t c is O 0 n n A T a c Example: WELL 91 xYZ458 T T 9— P �e O m z M m re re 0 r S 5 Dw an 0 pd^dx1 O iIF SOURCE IS PURCHASED OR INTERTIE F T r w 0 T D D rP- O i m m z > Ob D x O ztsr- re 2 = z INTERTIED. SYSTEM m m m i 'm < m s m z z z 0 '1 y s m 9 00 w a LIST SELLERS NAME ID t7i M re > n re z O 5 O O m m m p�z s O Example: SEATTLE NUMBER r o O D rO G at p < p y < O m z A z S A yx M x A v m S01 WELL Mt NO TAG X X X 433 38 SE SE 15 23N 03W