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HomeMy WebLinkAboutWAT2025-00076 - WAT Application - 5/14/2025 ;ti. ;t WAT 0007() MASON COUNTY r.., . 4 COMMUNITY SERVICES ij Budding Planning,rnvironmental Ilcvhh,Community rlealth �•'•H: 415 N 6e' Street,Bldg 8,Shelton WA 98584, Shelton: (360)427-9670 ext 400 •:• Belfair: (360)275-4467 ext 400 Elma: (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 site plan must accompany this application. Part 1: Applicant/ Parcel Identification Name on Applicant: t)AN)p , 11�Aiti[��, Date: S I+ '4 25 Mailing Address: E'7 L c NIJ.1 �� 4 y Ro Phone: 3 k;O k: �.O .7 t 0 Parcel Number QdZa`.Ati=QrT�`v .�i4. A 1� a .?. 1 cc. Li Type of Water System Reason for Application II Public/Community Water System (2 or more lie Building permit • connections) 0 Division of land: ❑ Individual water source(one connection), #of Parcels? SPL ❑ Well 0 Boundary line adjustment ❑ Spring/surface water ❑ Other(explain) 0 Other(explain) 0 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 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; 0 L,y 0 i i=to a, Water Facility Inventory(WFI) Number. 0 S-61 '' 3 2> (write"none"for two-party) ❑ I am the manager of this water system. The water system has been approved for 6 services. There are presently . . connection(s)in use. This will be the 3 P_I) 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: FALL -r:Zrv•e.. 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 ow.. �, ,h�,r,,,� Date 6 j This form may be scanned and available for public view at www.co.mason,wa,us. I:'EH I-onus',Drinking Water Revised 1/25/2018 Individual Water Well ❑ Water well report(attached to application). Depth ft. O 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. '74/Satisfactory bacteriological test(attach to application). Water Resource Inventory Area (WRIA) Development within which WRIA http://gis.co.mason.wa.us/planning 14_ 15_16 22 Water use or limitation recorded N/A Yes Well Drilled Date Individual Spring/Surface Water ❑ WDOE permit(attach to application) LI 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) 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,Tife 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). Reviewer's Signatures: 7 r 2 of 2 Environ. Health: 141 Date S�" O CSD Director: Date ,,r 2627( Twelve I Trees Ln NW ll stec (� SPECTRA Laboratories - Kitsap Poul:ho.W A -- .--Where experience natters y779- (360)77 J- COLdIFORM BACTERIA ANALYSIS FORM 5141 Date Sample Collected Time Sample County DM{ Ml�.�t kV r N Collected i-A/ �V,a.C- Day Year 00 { Type of Water System(check only oneon box) 0 Group A roup B 0 Other ° Group A and Group B Systems-Provide from Water Facilities Inventory(WFI): ID# O 5 Z System Name: ... r1 G Lyv1i-rw -C. Contact Person: D A N P \A}\M AR. Day Phone: Cell Phone: fit:1 b.D.o 'l l 2,t;. i, — Email Akxi.,0,1c\v .( (.0 M411.), Eve.Phone: Send resu a:(Print w name.address and zip code orr email above fa Outrank copy of Mob)---- an.c.a V104 1:12i0t r & t- i0i3a1. C.o+tioN SAMPLE INFORMATION Sample collected by(name): A tV `� MA Specific location where sample collected: Special instructions or comments: Type of Sample(check only one box) 1.ri.Routine Distribution Sample(AIP) 2.0 Repeat Sample(AN) Chlorinated:Yes ❑ No V (from distribution system after unsat routine) Unsatisfactory routine lab number: Chlorine Residual.Total Free 3.Ground Water Rule Source Sample _ — — Unsatisfactory routine collect date. SI l l Chlorinated:Yes No ❑Triggered (AIP) Chlorine Residual:Total Free ❑Assessment(A/P) - 1 4 Surface or GWI Raw Source Water Sample(Enumeration) I S ❑ E.coil 0 Fecal Fxered Yes Nn 5.❑Sample Collected for Information Only: LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY 0 Unsatisfactory Total Coliform Present andafistactory 0 E.coli present ❑E.coli absent Bacterial Density Results:Total Coliform mpn1100mI.E.rAli mpn/t00ml. Fecal Coliform cful100m1. HPC cfu/lml. 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