HomeMy WebLinkAboutwat2024-00046 - WAT Application - 2/3/2025 WAT 2bz4 - im-4 o
MASON COUNTY 4t5N@Strmt
Shel[9670,E 400
584
Shelton:360-275'4eID,En 400
Public Health & Human Services Helfav:360-276-0467,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/ P rcel Identification �1
Name on Applicant: Data: i 01''�1 r' y��
Mailing Address: E. (� Phone: UL70. 4,5 ( • qfJ (p
Parcel Number: 5
Type of Water System Reason for Application
Public/Community Water System (2 or more ❑ Building permit Z>ld 262A - 01443
connections) ❑ Division of land:
❑ Individual water source (one connection), If of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
❑ Replacement or Remodel(please indicate name
m you have more than one residence connected of water system below if applicable—no
to this well, check the PubAn Community Water signature required) -
System box.
Part 2: Water Connection Information U2,5 O O(�_
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System:
Water Facility Inventory(WFI) Number: no n E (write"none"for two-party)
pl I am the manager of this water system. The water system has been approved for 2- services.There
are presently=connection(s)in use.This will be the 2 connection.
❑ 1 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 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 limits�y�q�t by state and Iccal regulation. r)
Print Name of Water System Manager l'eSR-4 h Phone
Signature of Water System Manager SA-A Y451TMA Date !d
This form may be scanned and available for public vlew at www.masoncoumywa.eov
1:\EH Forms\Drivldng water Reviud 05Po8202! Page 1 of 2
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
NIVaterwell report(attached to application). Depth 0 ft.
, — b Well capacity Test(attached to application) lJ gpm / y Qapd.
(The well duller 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
y 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 distdtwtion 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,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 follovnng
reason(s).
Reviewer's Signatures: _i
Environ. Health: Date n ,/Z /
This form may be scanned and available for public view at www.masonmuntywa.gov
Pass 2 of]
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Thurston County Environmental Health
412 Lilly Rd NE 6 Olympia,WA 98506
360867-2631
'[1at]Il41DN fOUNiY
COLIFORNIBACTERIAANALYSIS
Dew Sample Cokcrsd Tare S"W County
t IaI I �r ,a Vim
Vpp ry v
Type ofWeter3ysbm(chakamy mebua) pmak Ho mew
❑Gm.WA ❑Gnwp0 ❑OMe,
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ID# —
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limed Pmmn: E ®OA
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SAMPLE INFORMATION
$ample mliec by(caret:
smoL boa50000,o saM Morro Wlleckd: $peEla111161NE5+1'I60rCg11meMa:
Type of Sample(mmtdWkoNy one bozo!Rl rh 9hkd listed bebm)
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DlHd bu tnon Semple 2.Rpet Somple(ear u raL mu m)
Chbnnaled Ye. No_ ❑OlWbuton Sydemalone.Reed :Tod_Fre _ Chbnnaled:Ye_No_
d.RaWWSoumeSek Chbdne Re .I:Toed—Fee_
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4.0 Sample Coiix for bfomrs9gn Only
Ineaakpeliye— Culishunionl Repairs_ OSar_
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Urea9ekckry Told Calibm prerentald oeeti Mrryy
❑E.mNPment ❑Emp ebfienl
R.o.orn em Sempk Required:
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