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HomeMy WebLinkAboutWAT Application - 9/3/2024 WAT toff ate. 415 N.6th Street MASON COUNTY Shelton,WA 98584 47137 COMMUNITY SERVICES Shelton:360-427-9670,Ext.400 Bclfair:360-275-4467,Ext.400 Building,Planning,Environmental Health,Community Health Elma:360-482-5269,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 Identification C� Name on Applicant:Q j\ JllteS b�2u�� W1 Date: Mailing Address: Zul £cs j y r-1 0, , Phone: I - � Ni�I �- 7`4 ' O r`4 Parcel Number: Lo)jOl& !� " OWIU 'T�}�{" Type of Water System Reason for Application 0 Public/Community Water System (2 or more uilding permit 'Didd 2,�).2�- 0 !Au I connections) ❑ Division of land: Individual water source (one connection), #of Parcels? SPL y ❑ Well 0 Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) El Other(explain) Replacement or Remodel (please indicate name If you have more than one residence connected of water system below if applicable—no to this well, check the Public/Community Water signature req red)LL l System box. Or' ' I n� f l m b�6Tr0YQc� 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) 0 I 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. 0 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 state 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:\EH Forms\Drinking Water Revised 4/4/2018 Individual Water Well ❑ Water well report(attached to application). Depth ft. ❑ Well capacity Test(attached to application) gpm 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 http://qis.co.mason.wa.us/planninq 14_ 15_ 16_22 Water use or limitation recorded N/A Yes Well Drilled Date Individual Spring/Surface Water ❑ WDOE permit (attach to application) ❑ Method of disinfection Ai I have reason to believe that this water source can provide at Least 860 gallons per day; and/or ides water at a rate of 2 gallons per minute bas the following observations. O t?' r — b ) ©� Author of Stat nt Date S —� Rela ip to Applicant t' • • 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 6.68.040-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 following reason(s). �i p�� R viewer's Signatures:• n�,,� Environ. Health: `�)L`�' ' hf� +C����' ''�,i Date This form may be scanned and available for public view at www.co.mason.wa.us. Page 2 of 2 Thurston County Environmental Health r 2000 Lakeridge Dr.SW •Olympia,WA 98502 —, 360 867-2631 THURSTON COUNTY - COLIFORM BACTERIA ANALYSIS Time Sample County Date Sample Collected Collected q /30 ' ay AMIN4 on pm Mourn Der Yearccyy Household Type of Water System(check only one box) W,Private ❑Group A ❑Group B d Otherl 4 Group A and Group B Systems—Provide from Water Facilities Inventory(WFI): ID# -- System Name: Contact Person: .. .. y'"9 Cell Phone:( ) Day Phone:(�j� ) �7 o . � „ ) a Send results to:(Print full name,address and zip code or email address) ---- SAMPLE INFORMATION Sample collected by(name): i Mrhet •A 111 Specific location or address sample collected: 0Special instructions or comments: ,vetozaas Type of Sample(must check only one box of#1 through#4 listed below) 1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine) No 0 Distribution System Chlorinated:Yes Chlorinated:Yes No Chlorine Residual:Total_FreB— Chlorine Residual:Total_Free__ 3.Raw Water Source Sample ❑E.coil—GWR(AP) ❑Fecal—sudaoe,GWi springs IngmeraIenl Unsatisfactory routine lab number: Filtered:Yes__ No— ___— ❑Assessment Monitoring(A1P) Unsatisfactory routine collect date: ❑Other 1 1 S1 - 4,k'.Sample Collected for Information Only Other Investigative Construction 1 Repairs DRINKING WATER RESULTS LAB USE ONLY LAB USE ONLY `i'l Satisfactory ❑Unsatisfactory Total Colitorm Present and 'o Cotrfonn detected ❑E.coli present 0 E.coli absent Replacement Sample Required: ❑Sample too old(>30 hours) 0 TNTC 0------- 1100m1. E.coli_�1100mI. Bacterial Density Results:Total Colifonn__ 1100 ml. 1100ml Enterococa�— Fecal Colifonn_ _— pie and Time Received: Method Code:t w 9223B ❑SM9222D U lap ISM 9215B ❑ Enterolert® 1 2 Date Reported 16- ,.14 Date and Time Analyzed:save Number(DON number dus five&g Lab Use Only:rts) / 31; ' • opN Fam Y331.31g(mvsed 01na)