HomeMy WebLinkAboutWAT2025-00135 - WAT Application - 6/25/2025pink
•
jWATOS - OO/
s
A, MASON COUNTY s �;w�Street
%
Public Health & Human Services Bel
faiShelton:360-275-%70,Eac aoo
Bclfair:360-ns-aaa7,Eat aoo
Application for Determination of Water Adequacy
Instru• ions
1. ( . plete Part 1. No determination can be made until Part 1 is fully completed.
2. 0.• pieta only the portion of Part 2 applying to the type of water connection utilized.
3. 'ubmit completed application with any required attachments for review.
4. 4n approved building site plan must accompany this application.
Part 1: Applicant/Parcel Identification id 45)/1.1 r4 6 -2 S, z 5
Name of Applicant !'flsCkacei IPDPbb;e Date:
Mailing Address: l n i5 R ST e s r hone: 3(,o 37 7 2q 70
Parcel Nu ber. z2Zb2c /o/oo6/// ���. ''
Ty of Water System Reason for Application
' Public./ munity Water System (2 or more Building permit B Li)a Oc AD7'
connecti ) 0 Division of land:
0 Individua ter source(one connection), #of Parcels? SPL
Well 0 Boundary line adjustment
Spring/surface water 0 Other(explain)
❑ Other(explain)
❑ Replacement or Remodel(please indicate name
If you h more than one residence connected of water system below if applicable—no
to this we , check the Public./Community Water signature required)
System APPROVED
Part 2: W r Connection Information JUL 1
Complete thepection appropriate for the type of water connection being evaluated: 4 20 E
MASON COUNTY EhV1ROh'MEh'TAL HEALTH
Public Water System RET
Name of Water System: L,L._) t L La -P-e
Water Facility Inventory(WFI)Numb F (write'none'for two-party)
I am the manag r of this water system. The water system has been approved for services. There
are presently connection(s)in use. This will be the DC> 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 'f the water system or any limits
set by state and local regulation.
Print Nam of Water System Manager a+-1- MI III e_ Phone o� ' 3 o�'
Signature Water System Manager i1'v�J Date 1!0
p� Miele,� form may be scanned and available for public view at www.masonaount>Mra„golr
RFI D _a 111 a,a l�IY�� ..
Spectra Labs - Kitsap, LLC (Poulsbo)
• J SPECTRA Laboratories - Kitsap 26276 Twelve Trees Ln NW Ste. C
Where experience matters Poulsbo,WA 98370
Phone: (360) 779-5141
www.spectra-lab.com
Spectra Labs- Kitsap, LLC (Poulsbo) received samples for Wagon Wheel Estates on Thursday, May 29,
2025 at 11:40 am. Unless otherwise noted, all samples were received in good condition and were tested in
accordance with the laboratory's quality control procedures. A summary of the samples received are
outlined below.
Sample No. Description Location Sampled
252022-01 Wagon Wheel 171 NE Wagon Wheel Rd 05/28/2025 14:30
This report package contains laboratory sample results and any attachments listed below. If you have any
questions please call (360) 779-5141 or email us at www.spectra-lab.com.
Attachments
01)
This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other
than by the intended recipient is unauthorized. If you have received this report in error,please notify the sender immediately at
360-443-7845 and destroy this report promptly.
These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced
except in full,without prior express written approval by Spectra Laboratories.
06/02/2025 Page 1 of 1
I .
26276 Twelve
Trees l.n NW 11
Ste.0 11 SPECTRA Laboratories -Kitsap
Poulsbo,WA
J
98370 ...fin experience/bolter.
(360)779-514I COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
l2c5 1 2�` 5 Collected
cont Day Yu 2 — arm 1r14 AS�tiL
Type of Water System(check only one box)
[Group A ❑Group B ❑Other _
Group A and Group B Systems-Provide from Water Facilities Inventory(WA):
ID# Z C D ::_ +-
System Name. 49"A ltlilCEL
Contact Person: bw ft Mr(/(1
Day Phone: Z-S' . 3 JD -276.'7 Cell Phone: Sp,,
Erm n, ti : t1; 4;1 t G MA I,r Eve.Phone:
Send results to:Print tel nam ad6.es and rip code a tm.11 above for eiectronic copy of results)
SAMPLE INFORMATION
Sample collected by(name) ^l�
✓.\4 #/ w1r(t'rl
Specific location where sample collected: Special instructions or comments
t �1�c,-� w��s:� R� Leaf Sidi .;6
f f1
Type of Sample(check only one box)
1.'Routine Distribution Sample(A/P) 2 ❑ Repeat Sample(A/P)
Chlorinated Yes ❑ No Er (from distribution system after unsat routine)
Unsatisfactory routine lab number
Chlorine Residual.Total_Free •
3.Ground Water Rule Source Sample
Unsatisfactory routine collect date
S ( I
Chlorinated:Yes No
❑Trggered(A/P) Chlonne Residual Total Free
❑Assessment(A/P)
4 Surface or GWI Raw Source Water Sample(Enumeration)
❑ E coli ❑Fecal F. Y.
No S 1
Fabled
5-(P Sample Collected for information Only
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Coliform Present and Satisfactory
❑E cok present ❑E.cob absent
Bacterial Density Results Total Coliform mpni100m1 E cob mpn/100m1.
Fecal Coliform cfu/100m1 HPC cfu/1mi.
Replacement Sample Required: ❑TNTC 0 Sample too old
❑ Sample Volume 0 Damaged Container 0
g�to Time R eed lab Reference Number
7l Z� �1.v,),_ /l'f0 ZS7--0LZ'O I
Receipt Temp C' Method Code:
I 1 . ' •2238,.T-COUNT/SM92220
!• T1r lean b..�a sarr b.r uw d ew wncrl o angrrr b
Date In- Dp Q�f(:7O "^( ewee*.es.wd Mr ow.copraoamre a.Ow, byte
r 1 g �rric A ly ..1 ^wr.e r.O•e n wt uu.e r ru Mn wrwe vanpan
tiro Pam.Wel M for/m.rarr/r)60.779b14 1 or
dn.q.f.We Prw1,41
DOH Lab-Sample
Tb.n results rfMt ofr b elt rlPb b.bd.Ir to.b1gb(f)es
010. O L�U I - r77.4bt.iefDv.ory 7f.""1"..baba.r.t=
fa w Pm.pees ww.n sve.rtn sp.u.t�u+.rr
Dote pantyes)131elPMrneof,•'
I