HomeMy WebLinkAboutWAT-REPLACEMENT - WAT Application - 7/25/2019 / y WAT - I
- MASON COUNTY
COMMUNITY SERVICES
&Ming,Manning,Environmental Health,Community Health
415 N 60'Street,Bldg 8, Shelton WA 98584,
Shelton: (360)427-9670 ext 400 4` Belfair(3600)0,455-44667 xt'� 4- Elma: (360)481 cLogi CI v,FE
Application for Determination of Water Adequacy MAY 0 9 Z019
instructions 815 W- Alm eb
1. Complete Part 1. No determination can be to the type until
art wail fullyter ec plleted.ized.
2. Complete only the portion of Part 2 apply g
ion uti 7
3. Submit completed application,with any required attachments for review.
4. An approved building site plan must accompany this application.
Part 1: Applicant/ Parcel f"�4 L
'�Identification I, /�
Name on Applicant: r+., ' -diz- rf, fF don c,S Date: �/
to
/ �-,a,N u y A. Lora.Lora.Phone: Cz .�) s/y- 7 72
Mailing Address: 6 N� i-^'�"-- pp_
Parcel Number: 22-336 soot.2.0E3
Type of Water System Reason for Application
0 Public/Community Water System (2 or more auilding permit
Division of land:
connections)
•
Individual water source(one connection), #of Parcels? SPL
l!PWell 0 Boundary line adjustment
0 Spring/surface water ❑ ,other(explain)
❑ Other(explain) Qi/Replacement or Remodel (please indicate name
If you have more than one residence connected of water system below if applicable-nosi nature required)
to this well, check the Public/Community Water g
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)
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.
use of
❑ I am the manager of this system.This� to full time).on will
tPlease to rade or change indicate on the foellowing line the nature
an existing
connection on this system (i.e.: recreational
•
• 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 W"W o nhigti .wa us.
t.
Revised trzsrzots
WI• T Forms\Drinking Water "`
Printed from Mason County DMS
Individual Water Well
❑ Water well report(attached to application). Depth ft.
❑ Well capacity Test(attached to application) qpm qpd'
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://dis.co.mason.wa.us/olanninq 1415 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
❑ 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)
VSatisfactory 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,Chapter require68.0440 Deteerrminna ments may apply.Chapter
Adequacy for Building Permits are satisfied. Additional Growth Management
36.70A RCW.
0 Unsatisfactory Determination:
Applicant's water supply does not appear adequate to meet the needs of its intended use for the following
reason(s).
Reviewer's Signatures:
Environ. Health: ��
Date —7 l 06
2of2
CSD Director Date
Printed From iviason r UMS
Printed from Mason County DMS
.. . _. .
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N T R.1 c 1786 SE Mile Hill Drive
Port Orchard,W 98366
LABORATORIES .centriclAyticaLcom
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A•srErrItA 1,4,....i.,..r.1 (360)443-7845
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
........ 2Ctg Collected
U :0°-"D pod I V\ACOA
: 2,, Day YON
Type of Water System(ceck only one Ws)
0 Group A DGB iner
' Group A and Group B Systems-Provide front Water Fecif ties Inventory(Aft):
:: Srstem Name: \ 6 b.1-01U ti 61 -1,21 6 C 164\11.1VA 12- •
Contact Person: k(e__ Acrl ct c vs av)
DaY Phc"7.-6 3 7)•lk' Lfg Cmil Phone PclY1-F---
Enlaid a t010.ki-ClAti lig.20 Eve.
6iwrne
ns_rEat.r nt/1748Vd.Villie,-EID.Y1(1 .._.......
__13b 1901 2 2.1 I
61,11, 14a.1,1,c0Y )A ciS; c-T__
- ..'.• . smitaltiedwroN .. - ...:M.,,. .
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Sam*CattilldbY Otti*JU.Lit AAC(C.1,10'n'"
Specific looake where map. Special inetustions or conerwrts:
Spi
NC 17.0409u-Fa ciali-tyk t24.
Type of Sample(check only ono box)..- ---''''' • , •
' 1pfioutine Distribution Sample 2.Repeat Sample(star unset.roubne)
Chlorinated:Yes 0 No 0 0 Distribubm System -.
Chlorine Residue Total Free_ Unsatisfactory rube lab number.
3.Source Ground Water Rule Sample _-
IS I I I Unsatisfactory routine collect date:
. -J-J-
'.'. 0 Triggered Chlorinated:Y680 NOD
•!. 1 CI Assessment Chlorine Residua:Total Free
4. EnunwatiOn Soma Water Salvia 1 S I 1 1
CI E.(xi OFecal-Swaim GM*OW Famed YagO 4°IZI
,i; 5.42teampia Winded Ice Inform/don Orgy.
LAB USE ONLY DRINKING WATER RESULtt. LAB ONLY
(3 Unsatisfactory Total COGiOnll Present and I Satisfactory
0 E.cot present 0 E.coli absent
A M,, , A From aso D S
i.
Replacement Sample Required:
0 Sample too old(530 hours) 0 TNTC On7nt
Bacterial Density Results:Total Coll= 1100ml. E.cofi--_)100inly.
Fecal Coiforrn 1100m1. HPC It mi.
Lab ID Number Date end Time Received:
RYal 11-0\ MAY 2 9 2018 Iltt
Method Code: Date and Tncated; ..
SM 9223 B MAY Z zOlti 110
Date Analyzed: Date Recent
MAY 3 0 2018 MAY 3 0 '2018 • .
ow lab-Sirnpleat Lab Use Only.
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