HomeMy WebLinkAboutwat2025-00015 - WAT Application - 3/6/2025 ' o2 - t70o15
MASON COUNTY WAT
COMMUNITY DEVELOPMENT RECEIVED
Permit Kzlsbn¢Center,BUlldry,Plannln(
415 N 6-Street,Bldg 8, Shelton WA 98584, JAN 3 U 2025
Sheton:131 4 27-967 0 exl 400 O Belfair'. (360)275-4467 ext 400 O Elma:(360)482-5269 am 400
FAX(360)427-7787 015 W.Alder Street
Application for Determination of Water Adequacy
Instructions
1. Complete Part 1. No detemlination 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: Gregory + Tiffani Allen Date: 01/29/2025
Mailing Address: 233 E Williams PI Allyn, WA 98524 Phone: (360)188-4004
Parcel Number: 12229-24-00010
Type of Water System Reason for Application
❑ PublirdCommunity Water System (2 or more Building permit
connections) ❑ Division of land:
Xe Individual water source(one connection), #of Parcels? SPL
i ❑ Boundary line adjustment
Spring/surface water
❑ Other(explain) [3 Other(explain)
❑ Replacement or Remodel(please indicate name
ff you have mom than one residence connected of water system below if applicable—no
to this wolf, check the Public/Community Wafer 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.
❑ I 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 set by slate and local regulation.
Signature of Water System Manager Date
This form may be scanned and available for public view at www.co.mason.wa.us.
J TH Forms,Drinking Winer Revisal II25I201 X
Individual Water Well
X Water well report(attached to application). Depth 11 .
r,
X Well capacity Test(attached to application) it pm v 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(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA htto;//ais.co.mason.wa.us/plaMLM 140 15= 16=220
Water use or limitation recorded........_........................ WA=Yes_Q
Well Drilled ........ __...__. _._... __. 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 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)
IfSatisfactory Determination:
This determination does not address adequacy of the distribution system,guarantee an adequate supply of
water indefinitely in the future,or guarantee compliance wth 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.
r Unsatisfactory Determination:
Applicants water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
/VrReeviewees Signatures: I .1
Environ. Health: � Date -Z';�1'I
CSD Director: Date °r'
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WATER
MANAGEMENT 1515 axk 9,F
T eem..WA 9
LABORATORIES iNc. 1253)531-3121
NitratdNRrits
Report of Analysis
date Collected 02-24.2025 System Group Type (circle one) A 8 oMer
Nater System ID Number N/A System Name: Greg Allen-233 E Williams Place,Allyn
Ab Number Sample Number: 089/01040 County: Mason
Sample Location: Wellhead Source Number(s): (list all sources if blended or cumposited)
Sample Purpose. (check appropriate box) Date Received 02-24-2026
❑ RC-Routine/Compliance(satisfies monitoring requirements) Date Analyzed: 0224-2025
❑ C-Confirmation(confirmation of chemical resuk)' Date Reported 02.28.2025
❑ I -Investigative(does not satisfy monitoring requirements) Supervisor Initials:
® O-Other(specify-does not satisfy monitoring requirements)
Sample Composition (check appropriate box) Sample Type (check one) ® Pre-treatment,Untreated(Raw)
❑ S-Single Source ❑ Post-treatment(Finished)
❑ 8-Blended(list source numbers in"Source Number'flew) ❑ Unknown or Other
❑ C -Composite(list source numbers in'Sowoe Numw field) Sample Collected by:Vince Stacy
❑ D- Distribution Sample Phone Number:253-8475259
Tend Report 3 Bill to: Mountain View Pumps 8 Filtration, Inc Comments:
32519 Mountain Highway East
Eatonville WA 98328
ANALYTICAL RESULTS
DOH# ANALYTE DATA RESULTS SDRL TRIGGER MCL UNITS EXCEEDS METHODt
QUALIFIER MCL7 INITIALS
mate as N < .5 1 m L o
OTES:
Confirmation: Include the original lab number, sample number, and collection date of original sample in either comment section.
No exisiting value.
.NALYTE:The name of an analyte being tested for.
DATA QUALIFIER:A symbol or letter to denote additional information about the result.
PON#: Department assigned snalyte number.
XCEED MCL:(Maximum Contamination Leve): Marked if the contaminant amount exceeds the MCL under chapters 246-290
nd 246-291 WAG Please contact the department's drinking water regional office in your area to determine follow-up actions.
IETHODIINITIALS:Analytical method used./Initials of the analyst that performed the analysis.
1g/L: milligrams per liter or parts per million.
:ESULT:The laboratory reported result.
DRL: (State Detection Reporting Limit): The minimum reportable detection of an analyte as established by the Department
f Health
RIGGER:The department's drinking water response level. Systems with contaminants detected at concentrations in excess of
ns level may be required to take additional samples or monitor more frequently. Please contact the department's drinking water
:gional office in your area for further information.
AS COMMENTS: