HomeMy WebLinkAboutWAT2025-00147 - WAT Application - 7/15/2025 WAT 202s - oo Iq1
Street�i 6`h
• , ;�� MASON COUNTY
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415 N.Shelton,WA 98584
t s & Shelton:360-427-9670,Ext.400
Public Health Human Services 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: gciGj. 120 y 711►t.d Date: 7 -/S^" 2.S'
Mailing Address: 76,3 S!1 OLD M C4 D i 4 ao Phone: 360 LI 90 6 7O L!
Parcel Number: 3 .2 022.L/G C/0..1'12
Type of Water System Reason for Application
el Public/Community Water System (2 or more IN Building permit
connections) 0 Division of land:
O Individual water source (one connection), #of Parcels? SPL
O Well 0 Boundary line adjustment
O Spring/surface water 0 Other(explain)
O 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.
See two party well
Part 2: Water Connection Information WEL2025-00019
Complete the section appropriate for the type of water connection being evaluated:
�7
Public Water System
R Name of Water System: c- g- e 7lt 141v
Water Facility Inventory (WFI) Number: (write"none"for two-party)
O 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.
O 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 .36C; '90 6 7&f
Signature of Water System Manager Date
This form may be scanned and available for public view at www.masoncountywa.qov
J:\EH Forms\Drinking Water Revised 05/O8/2024 Paec 1 of 2
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Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
,--
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 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)
i) 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.
D 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: I
Environ. Health: C \IbliN°5 Date 8/8/25
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
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DEC-08-2005 THU 11:35 Aft FAX NO. P. 03
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Mark N . Nelson
Ik1Was Caapauy Arcadia D r i l ling Inc .
, • Addrmt 170 SE Welker Park Road
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1992 Zip Shelton WA 98584
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t.( p/✓^^ -ef 0Ic�L LABORATORIES 0 258 11202713
4 (, uG mum 1a1a poet et E,Tacoma.WA 9A V (�d7„ r I'' COUFORM BACTERIA ANALYSIS FORMCollected i DData Sample Collected i Tlme Sample County 23,1F:11
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Marsh Gay YON Cilli2
Type of Water System(check only one box) BV _.----------
0 Group A 0 Group B Ttr _ __ 1
Group A and Group B Systems-Provide tram Water FealtiesInventory(WFI) I ;,)
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System Name: C
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Contact PersonPJ( �LI
Day Phone:(() y j ' 3 J Cell Phone.( )
Email. Eve.Phone:
Send result to.( t toil name. ess and pp cede)
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SAMPLE INFORMATION
I Sample collected by(name)' pogo,-
Speta5c location where sample collected: Special instructions or comments:
i 1(k 3 SE Ck4 PrCOdta R{ I(
iv Otcn i
Type of Sample(select arty one type d.m tram types I thmugh 5 below)
I 0 Routine Distribudcn Sample(A/P) l 2.❑ Repeat Sample(A/P)
Ch onnaled Yes-_-- No__. than tilt a.=,ar^system a'tu•anat.ranncl
Unsatisfactory routtne lab number
C.hionne Residual:Total_Free_
3.Ground Water Rule Source Sample
Unsatisfactory routine collect date:
Isi — _ __ _
Chlorinated Yes No
0 Triggered iAR) Chlorine Residual Total Free_
0 Assessment (A/P)
• 4. Surface or GWI Raw Source Water Sample(Enumeration)
0 E croti 0 Fecal rare vim_ v.... ._ S i ( I )
5.v Sample Cdreexd for ktformstion Onty:
!b :USE ONLY DRt.N_K!rG ATER RESULTS LAB USE ONLY
❑Unsatisfactory Total Cobform Present and !)latIsfadory
❑E.cok present 0 E.coif absent
Bacterial Density Results Total Coliform /100ml. E.cob _/100mi
Fecal CokkHm /100mi HPC I1 ml,
. Replacement Sample Required: ❑TNTC ❑Sample too old
0 Sample Volume 0 Damaged Container 0
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pRrarce Nmber as 4 � CP'o-
Receipt Temp": Code S-^ cf 7 .a 3 13 ,
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