HomeMy WebLinkAboutWAT2025-00025 - WAT Application - 3/10/2025 WAT?LZ5-- 600z5
MASONCOUNTY ton 415N.6• 8584
Sbeltoa,WA .400
Shelton:360-427A6 ,Ext.400
Public Health & Human Services Eelfav:360-275-046767,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/ Parcel
JIdentification
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Name on Applicant: rA Qn111rrLg�rtG Data:
Mailing Address: ;� C tut Phone: 3W WA 55W
Parcel Number. 3ig09) -32'0M,_b
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
ff you have more than one residence connected of water system below if applicable-no
to this we//, check the PublkXommunity,Water signature required)
System box. �20-LSD
Part 2: Water Connection Information
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: AC X kx,!�5
Water Facility Inventory(WFI)Number: ✓IAyIE (wife'none"for two-parry)
I am the manager of this water system.The water system has been approved for _services.There
1 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 change the use of an existing
i connection on this system(i.e.: recreational to full time). Please indicate on the following line the nature of
i this change:
This water system is able and willing to provide water to this(these)connection(s)without exceeding the
i limits of the water system or any limits set by Mc
and local regulation.
Print Name of Water System Manager / fG Phone ILd -04CQ
Signature of Water System Manager. Dale JZJ%
This form may be scanned and available for public view at unww.masoncountywa.uov
JTtl Fosmsl Dunking Waw aAxxl OWM024 Png Ior2
1
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
'/ Individual Water Well
u1.Water well report(attached to application). Depth tA,n`N'w'^^ .
Well capacity Test(attached to application) �S � Z— gpm 7 god.
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 resource regulations.
Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.66.040-Determination of
Adequacy for Building permits are satisfied. Additional Growth Management requirements may apply. Chapter
36.70A RCW.
❑ Unsatisfactory Determination:
Applicants voter supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health:�rl, ✓ Date (01�
This form may be scanned and available for public view at www.masoncoun�a.9ov
Page 2 of2
MOERKE & SONS PUMP ('DRU-LING, INC
1162 NW State Avenue, Chehalis, WA 98532 (350) 748-3805
PUMP TEST
AMBER KNOTTS 9/17/2024
P.O BOX 282
TENINO, WA 98589
WELL SITE ADDRESS: 430 SE BREWER RD, SHELTON 99584
Pump Make& Model: Pump Set At:
Sounder Make&Model;
Measured In: GALLONS
Make&Model:
MIN S GALLONS METER LEVELTO
PER MINUTE READING WATER NOTES
0 0 1232t3 75' —
1 15 123228 76'
2 14 123242 76'
3 16 123258 76'
4 15 123273 76'
5 14 123287 76'
6 15 123302 76'
7 16 123318 76'
g 14 123332 76
g 16 123348 76'
10 15 123363 76'
15 15.2 t23439 76'
20 15.8 123518 76'
25 15.6 123596 76'
30 15.6 123674 76'
35 15.6 123752 76'
40 15.8 123831 76'
45 15.6 123909 76'
50 16.2 123990 76'
55 15.2 124066 76'
SIGNATURE:
SONS PUMP AND DRILLING
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