HomeMy WebLinkAboutWAT2025-00155 - WAT Application - 9/10/2025 •
WAT 2O25-00155
MASON COUNTY
COMMUNITY DEVELOPMENT
vMn,t atascane Cmin,6und�nt.W.1nmr•t
415 N 6'"Street,Bldg 8,Shelton WA 98584,
elton.(360)427-9670 ext 400 +} Befair:(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:i1I,c ij �=4Jt, e �jbfidr ,DData: 7f//1o/45.-'
•
Mailing Address: j4/ C�sf/ E r ,tv�/ Y1�C4 e: _ 17.17 740 '-93-7/
Parcel Number: pi 9;y QV ya
Type of Water System Reason for Application
rif Public/Community Water System(2 or more tat Building permit
connections) 0 Division of land:
0 individual water source(one connection), #of Parcels? SPL
0 Well 0 Boundary line adjustment
0 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)
ystem box.
•
Part 2: Water Connection Information EH APPROVED
Rhonda Thompson 10;021202&
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: /7/t ,e//✓c /-9jgsc,,e9c'E
Water Facility Inventory(WFI)Number: , 77rA/
(write'none'for two-party)
•
A I am the manager of this water system.The water system has been approved for_& services.
There are presently 27 _connection(s)in use.This will be the 5 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 ' set by to nd local regulation
Signature of Water System Manager %TV/.
Date /D-D/'.?.�'..
Tp k-s"�'�
n'1�,�" /C
This form may be scanned and available for public view at y,r+itCv.co;rnason,wa.us.
MillIIIIMINIIIIIIIMINg
I ‘ '
`,5,i i 5 J •-•.
*-OLIFORM BACTERIA ANALYSIS FOR • ,
• ;; . • ,
) it)
1 ;
; ; •;-•••-•-• ">4 t
, . -
/ .....2 A,
,
, ‘
. - - -/7 ari%,., ,/,/, ..4...,f
} ' /-:,/, ? ir/1'\, , 2- "
7-i
t
, !/ '11 ;; . -../1, ,,
/- ) ; , i I"
Ief
. • . ' .
`--)
'''') " 4
f 2- /(-7/)‘ _3 f•i
----
L'''s ''- SAMPLE INF ATION
-,-.:.cz-i.c,tw nsle)../.'
__ ...,.
onet;'..t
7 :,...-r.,:g-tg.)n*heit samule cutted 3ve-a!ir10.4.6°.'s Li Wr
_— —_
-.. ,. .
i<Routme Orstributve,S.Tnple;MP) '1 D Repeat Sample I t .
tvrse ,stmaiStrtCtniSySti'altr u.1,1:1*,miko
0 NOM 'l.
...'"..SattSfar,9q touDne a moil,-
in:Ante ResieLac,'Ica____ I-;ec ..
.;roand Water Rule Source Samole — -- -- ---
U4saleboloiy-1441.1MF.C/IF.;C'.C Srt
t I
C
chk,,,,,,ted yek___ NIG
-::TAqved t AP; 1/41tIorxiu Rest.iial Total_ Het _
-•Assessmee:OR) ,
-----
iurface or GVII Raw Source Water Sample(enumeratoc, I S 1 I '
l I ,
E cc.:1 Da ilr.o..1 Ye,_ r.. _
D coPectel ft,.Infoneation Orly.
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
_.
' sateiactory rolg ilakint,Rceserit ared
D E colt resent 0 E cot abst
_ WI SatIstactcl
I
I Density Results lotal Caber; rupre1311st Er.ol_ __rip,"fi 3r-C,
-,Catyrn ..,___... cfulICOml 'PC
[
rtufttni.
placement Sample Requifet. 0 TNT C C Sample Ix olc '*
Sat*vokrne 11,1Danaged(-mane( 0
• ,, ..
—--- \-\-„:--* 1.... -I-Lai-C;;Am.v.,.t-antk• .,,
,rt;4,-.,c,,f,..:• .•' ‘,,,,•,; ; , ,„
'7 --4,-. , —4.c.- ',, <,. *c6Als •,,,, — -
: thihcdc= 42D.T.,-.-1,f4-,..SI/3.'22.
Tvir.„. \;\\
. , .:* .^ilea4rnec At!--.‘;wog 0 to. ,
Apt 1 3 I, 1 ottuat wow%6 at.10..Aditk 14A WO
I?.4e, , inc..phao rc.4 ts WU.kumstima.r Va. „
1
..r::::;IL .11e0PI.A0,14,40$my t db,;,40,ihrt4o4V Ma*n
..owoet)ttstimiar 71,01104,shof Re bc-44 ,.
*,..*tb ant PcortnsitNt 1074011 Is StigatlaNs
WATER FACILITIES INVENTORY (WFI) Quarter: 0
Updated: 09/29/2025
�� ��Department� FORM
; P Health Printed: 10/2/2025
ONE FORM PER SYSTEM WFI Printed For: On-Demand
D,DistOf o(Ertcxronnrenlni I h aidt
01/ur oF0rtuku,y Water Submission Reason: Contact Update
RETURN TO: Central Services-WFI, PO Box 47822, Olympia, WA, 98504-7822 or email wfi@doh.wa.gov
1. SYSTEM ID NO. 2. SYSTEM NAME
3. COUNTY 4. GROUP ( 5. TYPE
06775 N PICKERING PASSAGE#2
MASON I B
6.PRIMARY CONTACT NAME&MAILING ADDRESS 7.OWNER NAME&MAILING ADDRESS
JIM DICKSON [MANAGER] PICKERING PASSAGE WATER CO-OWNER
PO BOX 492 ASSOCIATION
GRAPEVIEW,WA 98546 JIM DICKSON
PO BOX 492
GRAPEVIEW,WA 98546
STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE
ATTN ATTN
ADDRESS 200 E CREST LANE ADDRESS 200 E CREST LN
CITY GRAPEVIEW STATE WA ZIP 98546 CITY GRAPEVIEW STATE WA ZIP 98546
9.24 HOUR PRIMARY CONTACT INFORMATION 10.OWNER CONTACT INFORMATION
Primary Contact Daytime Phone: (360)628-3157 Owner Daytime Phone: (360)628-3157
Primary Contact Mobile/Cell Phone: Owner Mobile/Cell Phone:
Primary Contact Evening Phone: Owner Evening Phone:
Fax: IE-mail: pxxxxxxxxxxxxxxxxxxxxxm@gmail.com Fax: IE-mail: pxxxxxxxxxxxxxxxxxxxxxm@gmail.cor
11.SATELLITE MANAGEMENT AGENCY-SMA(check only one)
for Not applicable(Skip to#12)
i❑i Owned and Managed SMA NAME: SMA Number:
❑ Managed Only
❑ Owned Only
12.WATER SYSTEM CHARACTERISTICS(mark all that apply)
Agricultural
❑ Hospital/Clinic X Residential
❑ Commercial/Business ❑
Industrial ❑School
❑ Day Care ❑ Licensed Residential Facility ❑Temporary Farm Worker
❑ Food Service/Food Permit ❑ Lodging ❑ Other(church,fire station,etc.):
❑ 1,000 or more person event for 2 or more days per year X Recreational/RV Park
13.WATER SYSTEM OWNERSHIP(mark only one) 14. STORAGE CAPACITY(gallons)
Association E County ❑Investor 0 Special District
City/Town ❑Federal 1st Private Q State
15 16 17 18 19 20 21 22 23 24
SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION
ci, 73
D C
A Z
m rn D
LIST UTILITY'S NAME FOR SOURCE r 2 co m i D m
AND WELL TAG ID NUMBER. Z Z A c1 .n D m O n-1 — 0
rn D to n 'z v m A rx C <T
oc Example: WELL#1 XYZ456 * r, xi - rn D T m o a n O — O D 73 -4 D— m{pozi A 0 -4
r-Orm z z D m D D A 3 xi z A o 0 z� 3rD m C
o
IF SOURCE IS PURCHASED OR INTERTIE r- r to O O * * r. O D y O ZrOZ >
z INTERTIED, SYSTEM * T m 33 -n m D D r -I z O m m z > > > _z S m O Z r at 3Z
3 ID m m m m m -+ -I m x m z z 73 0
LIST SELLER'S NAME r r r z r r m m x m z D n m z O O O c m mm "i Z 0 m T.
0
Cr Example: SEATTLE NUMBER r C C O C C x z -< A --{ r -C o m z z z .. A -1 z L"rn z x v m
S01 WELL#1 NO TAG X X Y X 126 37 SE NW 18 21N 01W