HomeMy WebLinkAboutWAT Application - 5/1/2025 WA -kid 1 a 1I
MASON COUNTY 415N.6"Street
Shelton,WA 98584
`:;..4:-;;-- , Public Health & Human Services Shelton:360 427-9670,Ext.400
',. Belfair:360-275-4467,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 "'
Name on Applicant: 6�! I u()Yl l611 Date: ( — 1 — 2O25
Mailing Address: I70 E?t(S lug (Aj 1 • Phone:
Parcel Number: ' Z 1 as - so - co 33 (,v 8 JQ � SBt-1-
Type of Water Systemii
Reason for Application q
Public/Community Water System (2 or more 0 Building permit {��d !�[12lj (�Q�j2
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
0 Well 0 Boundary line adjustment '
❑ Spring/surface water Other(explain) t TLfC1 ( )
❑ Other(explain) '
❑ eplacement 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: L_.J iCE Lu ' _.c _
Water Facility Inventory (WFI) Number: (write "none" for two-party)
❑ 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.
Print Name of Water System Manager Phone ...
Signature of Water System Manager Date
This form may be scanned and available for public view at www.masoncountywa.gov
J:\E'I Forms\Drinking Water Revised 05/08/2024 Page 1 of 2
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
O 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.
O Satisfactory bacteriological test within last year(attach to application).
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)
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).
Reviewer's Signatures:
Environ. Health: _61Date
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
Maples Excavating
911 SE Arcadia Rd 3604638474
Shelton, WA 98584
PROPERTY INFORMATION
Location:170 E PAISLEY WAY
Shelton
Tax ID: 321225000332
Mali To KELI DUNLAP
170 E PAISLEY WAY Use:
SHELTON,WA
98584 GENERAL SYSTEM TYPE:Conventional (Non-Pressurized)
l
ON ID: 321225000332
County Area: Oakland Bay MRA
Peal ON-SITE WASTEWATER TREATMENT SYSTEM INSPECTION REPORT ' Fold
Here
Here
Inspected:05/06/2025 - Inspection Type:ROUTINE - Correction Status:No corrections needed
Company: Work Performed By: Submitted 05/06/2025 by:
Maples Excavating Shane Maples Shane Maples
COMMENTS& GENERAL INSPECTION NOTES
No Deficiencies Noted
Flow tested the drainfield for 25 minutes. Drainfield accepted all water,testing good at this time.No observed problems.
GENERAL SITE& SYSTEM CONDITIONS
The General Site and System Conditions were: Fully Inspected
Components accessible for service: YES
All required service performed(if no-specify omitted inspection items in notes): YES
Surfacing effluent from any component(including mound seepage): NO
Components appear to be watertight-no visual leaks: YES
Improper encroachment(structures/impervious surfaces) NO
All riser lids securely fastened upon departure: N/A
Electrical repairs needed. If YES describe in comments: N/A
Inspected components appear to be in good physical condition: YES
Root intrusion on any components. If YES describe in comments: NO
Settling problems observed. If YES describe in comments: NO
The house/structure was vacant or used infrequently,assessment of the drainfield was not possible. _ NO
ONSITE SEWAGE SYSTEM INSPECTION DETAIL
•istribution:D-Box
This component was: Fully Inspected
D-Box in good condition: YES
D-Box outlets set to allow e.ual effluent distribution: YES
ANK:Septic Tank-2 Compartment
This component was: Fully Inspected
Effluent level within operational limits(if NO explain in comments): YES
All required baffles in place(N/A=No baffles required): YES
Compartment 1 Scum accumulation(Inches,if other specify):
Compartment 1 Sludge accumulation(Inches,if other specify):
Compartment 2 Scum accumulation(Inches,if other specify):
Compartment 2 Sludge accumulation(Inches,if other specify):
Pum•in•recommended: NO
grainfield(disposal):Gravity
This component was: Fully Inspected
Component appears to be functioning as intended: YES
Ponding present?If YES explain in comments: NO
Drainfield was vacuumed,flushed or hydro-jetted?(If YES,explain in comments) NO
This report indicates certain characteristics of the scone sewage system at the time of visit.In no way is this report a guarantee of operation or future performance.
ReportlD: 1400726 View inspection reports online at www.onlinerme.com Page 1 of 1