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Home My WebLink AboutWAT2024-00348 - WAI Health Waiver - 11/18/2024 �-��_ MASON COUNTY WAT COMMUNITY SERVICES Buld,q,PWnIn4EmirmmeMel lbltlu CnmmunMNwM 415 N 6e Street, Bldg 8,Shelton WA 98584, Shelton: (360)427-9670 ext 400 4 Belfain(360)275-4467 ext 400 O Elms:(360)482-5269 ext 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 she plan must accompany this application. Part 1: Applicant/ Parcel Identification Name on Applicant: Mark Buntins Date: 10/18/24 Mailing Address: Phone: Parcel Number: 32224-75-90110 Type of Water System Reason for Application 05 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 well, check the Pub iclCommunity 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:_Iddings 1 Water Facility Inventory(WFI)Number. AE295J (write"none"for two-party) I am the manager of this water system. The water system has been approved for 8 services. There are presently 2 connection(s)in use. This will be the 3 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(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 limits set to t to and local regulation. Signature of Water System Manager Date_10-18-24 This form may be scanned and available for public view at www.co.mason.wa.us. IIEn F.k Dei ,WN Rrvi.d1/2M018 Group B Water Systems Satisfactory bacteriological test within last year(attach to application). Individual Water Well ❑ Water well report(attached to application). Depth ft. ❑ Well capacity Test(attached to application) opm opd. 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 3t:: Mason County Community Services Evaluation (staff use only) yy 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 resourceu}ations. Recommended approval indicates requirements of Sanitary Code,Title 6,Chapter 6.68.040-Deter Adequacy for Building Permits are satisfied. Additional Growth Management requirements may apply. 36.70A RCW. fl Unsatisfactory Determination: 61gSO, N Applicants water supply does not appear adequate to meet the needs of its intended use for��i®,(ppowing Z9 ioz10 O reason(s). F 1 NyN A, �N,IjF Reviewer's Signatures: Mq( Environ. Health: ft� Date This form may be scanned and available for public view at www.masoncoun�a.uoy Page 2 of 2 .276 T.],. rocs Ln NW Sm.0 SPECTRA LebUTBIUFICS - Kitsap .14 ,WA .. ...vM•r e.nrmn 99370 w n9.s141 COLIFORM BACTERIA ANALYSIS FORM Dula Semple Comdeb Time Semple Cmnry L cdleamd I l ... � rye Of Wdd Sysmm(dmdc myyme bm) ,,yy fiy r't ❑Gm A ❑GmWB 1J'Oder '( U '8 y AeMGMWB$yemnm-Pimitle6am WRWFWitln Imabry(WF* #1 — — _ — - - NwName: i 4�ya< mud poem: J ay Phone: Cd Phma Out Ey0.Phma: M nmlatx Wexai...Wr N 1`mmnnalxm.ftr .nk aW el muml SAMPLE INFORMATION duple-laded by(nmrm)'. pedhabmtiad ands sam*colYledatl• :' 'Specal areWddmmcanmenm: So vo -k, r ypaof Smn lla(check odyons bm) .❑Rauene Didrlbullon Sample(AP) 2.L]Repad Sample(AP) Chbmekd:YN ❑ NOD Ix9m d'amnueonsysWn luuaet.mien.) Unsepetatmy rodna lab number. Chrome Rssidmt Tales Fme_ .Dmund WaMRWSouma6mPl- ——— ——— — Umalsmc wy mulns rtlact&m: Chbdnded:Y%_No_ �Tnggdad (MP) Chrome Redd at Tdel_Fee_ ❑Aaemrent(AP) .Su Nce or DWl Ram Soma Waapr SmnPm(Enumemlm) 1 e ❑ E.cok ❑Faal (Zf Bmge C9siee M aaamapan oar LAB USE ONLY ORRRONO WATER RESULTS LAB USE ONLY 7 Un..ft%-ery Tout Catilom Presedand 7 ❑Ecolpresent ❑FooNsa eOt ladarlal Density Reaub:Tdd Cddxm mpN00A E.mf�n)lWml. Fecal ColAmn_.__du+lOpml. NPC__CUIK Wacemed Sample Required: ❑TNTC DSamplo wald ❑ Sampe Vomnm ❑Damaged Cmbaimr 0_ a L / 019 aolmmmoNunp -10) + 607mnpe& ammodc smm3a cou6r0 am&= �.om.r.e.aaa...n... ..r.r.wi..�iriaemnn r wxu-nwx pwr..msea...a.x WATER FACILITIES INVENTORY (WFI) Quarter D 9 A Nb 5Y p m aeYq FORM Updated: 10/1 W024 025 14bHealth ONE FORM PER SYSTEM twin r: On-Demand �m l°daw.x w..mrw Hmm WFI Printed For: OrFDemantl Submission Reason: Pop/Connect Update RETURN TO: Central Services-WFI, PO Box 47822, Olympia, WA, 98504-7822 or email wfi@doh.wa.gov 1. SYSTEM ID NO. 2. SYSTEM NAME 3. COUNTY 4. GROUP S. TYPE AF295J IOOINGS1 MASON B 6.PRIMARY CONTACT NAME B MAILING ADDRESS 7.OWNER NAME B MAILING ADDRESS EMILY J.DAVIS[MANAGER] ITS YOUR HOME, LLC OWNER CONTACT 340 NE DAVIS FARM RD EARL J.IDDINGS BELFAIR,WA 98528-9670 PO BOX 2755 BELFAIR,WA 98588 STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE ATTN ATTN ADDRESS ADDRESS CITY STATE ZIP CITY STATE ZIP 9.24 HOUR PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION Prmary Contact Daytime Phone: (360)W14375 Owner Daytime Ph One. (206)391-7502 Primary Contact Mobile/Cell Phone: (360)801-4375 Owner Mobile/Cell Phone: (206)391-7502 Primary Contact Evening Phone: hxxt-..-xxxx Owner Evening Phone: Fax: E-mail' M1xxxxxxxxxxxxr@gmaiLcom Fax' E-mail exxxxxxxxxxs@gmail.com 1.SATELLITE MANAGEMENT AGENCY-SMA(check only one) Fj Not applicable(Skip to#12) Owned and Managed SMA NAME: CUES Water SMA Number,162 X Managed Only Owned Only 12.WATER SYSTEM CHARACTERISTICS(mark all that apply) Agricultural (]HospitallClinic jifResidential Commercial/Business Intestinal Cl School Day Co. Licensed Resldenfial Faulity ❑Temporary Farm Worker Food ServioelFood Permit Lodging Other(chuM,fire station,eti � 1,000 or more person event for 2 or more days per year Recreational RV Park 3.WATER SYSTEM OWNERSHIP(mark only one) 4. STORAGE CAPACITY(gallons) [3Associali0m E]Coumty Investor Special District city/Team p Federal Private state 15 16 17 1s 19 20 21 22 23 M SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION 'a LIST UTILRY'S NAME FOR SOURCE m 4 g v D AND WELL TAG ID NUMBER = G m in o a = D mg m� q 2 °c Exa.,W WELL#1 niA56 ar w a j n v m r c <yw m: i i IF SOURCE IS PURCHASED OR INTERTIE re F F N ai z F i O s bpi m z v o_ O Z wINTERT u c F c LE:T SELLERI3DNAME SYSTEM IDEM m m m p rn m y m ? m ? A O g ? my =O 'i m r° yy2 2 he p m z > O he m 0 0 0 = m m mz O m z Ll Example: SEATTLE NUMBER F O G , rO rO P A < m . < o z z z 5 P yz z A -ti no 501 Well#1 AAX105 X X V X 1 473 1 14 SW Nev 24 22N 03W r WATER FACILITIES INVENTORY (WFI) FORM - Continued 1. SYSTEM ID NO. ]. SYSTEM NAME 3. COUNTY 4. GROUP S. TVPE AE295J IDDINGSI MASON B DOH USE OH USE ONL ACTIVE ACTIVE CALCULATED TIED ED APPROVED SERVICE ACTTIVIE CONNECTIONS CONNECTIONS CONNECTIONS 25. SINGLE FAMILY RESIDENCES(Him many of Me following do you haw?) 4 8 A. Full Time Single Family Residentas(Occupied 180 dawor more per year) 4 B. Pad Time Single Family Residences o3onJIled less than 180 days per year) 0 n. MULTI-FAMILY RESIDENTIAL BUILDINGS(How many of the following do you have?) A. Apartment Buildings,mndi duplexes,bona ou dome 0 B. Full Time Residential UnIN In the Apartments,Condos,Duplexes,Dome Mat are occupied more than 180 Martin r 0 C. Pad Time Residential Units In Me Attendants,Condos,Duplexes,Dams that are occupied less Man 180 dayalwar 0 37. NONRESIDENTIAL CONNECTIONS(How many W the fallowing do You new?) A,Recreational Services and/or Transient Accommodations(Campsiles,RV safes,holellmolellovemighl units) 0 0 0 B. Institutional,CommerciallBusiness,School,Day Care,Industrial Services,etc. 0 0 0 38. TOTALSERVICE CONNECTIONS 4 8 29. FULL-TIME RESIDENTIAL POPULATION A. Haw many residents are served by this system 180 or more days per yeah 8 30. PART-TIME RESIDENTIAL POPULATION JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC A. How many part4ime residents are present each month? B. How many days per month are they preea i 31. TEMPORARY&TRANSIENT USERS JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC A. How many total visitors,attendees.travelers,campers,patients or customers have access to the water system each month? B. How many days per month Is water accessible to the public? 33. REGULAR NONRESIDENTIAL USERS JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC A. Ifyou have schools,daycares,or businesses connected to your water system,how many students,daycare children andsor emplowes are pmsent each month that are NOT already Includen in the resMendal population? B. Him many days Par month are they present? 33. ROUTINE COLIFORM SCHEDULE JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC L. NITRATE SCHEDULE QUARTERLY ANNUALLY ONCE EVERY 3 YEARS (One BampN per source by time Period) Sol 35. Reason for Submitting WFI: ❑Update-Change ❑ UpdaM-NOChum, ❑Modest. ❑Re-Activate ❑ Name Change ❑New System []Other W. I county that the Information stated on this WFI form is correct to the best of my knowledge. SIGNATURE: DATE: PRINT NAME: TITLE: