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HomeMy WebLinkAboutWAT2025-00178 - WAT Application - 10/9/2025 WAT 2O25-00178 1 415 N.6th Street ; MASON COUNTY Shelton,WA 98584 Shelton:360-427-9670,Ext.400 K COMMUNITY SERVICES Belfair:360-275-4467,Ext.400 �,;`/ Building.Planning,Environmental Health,Community Health Elm:360-482-5269,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: TODD & DIANE HUBBLE Date: 6/18/2025 Mailing Address: 51 DUNOON PL SHELTON WA 98584 Phone: 1-253-380-3737 Parcel Number: 42122-75-90072 Type of Water System Reason for Application Public/Community Water System (2 or more `IA 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) ❑ 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. EH APPROVED Part 2: Water Connection Information Rhonda Thompson 10/09/2025 Complete the section appropriate for the type of water connection being evaluated: Public Water System Name of Water System: Singh Water Water Facility Inventory (WFI) Number: 06204 P (write"none" for two-party) VI am the manager of this water system. The water system has been approved for 6 services. There are presently 4 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 limits set by state and local regulation. Print Name of Water System Manager Brandy Milroy Phone 360-877-5249 Signature of Water System Manager 4 ,.4,,fi. y .-I Date 06/18/2025 This form may be scanned and available for public view at www.co.mason.wa.us. J:\EH Forms\Drinking Water Re\ised•4'27'2021 SPECTRA Laboratories -Kitsap ...Where a forums matron I COLIFORM BACTERIA ANALYSIS FORM Date Sample Collected Time Sample County Collected �d Day 2 S l/.: Mason Year Type of W..>r System(check• ly a ne box) Group A rJ Group B 0 Other__ Group A nd Groupf��BB System -Provide from Water Facilities Inventory(WFI): Ott System Name: h Contact Person:Brand troy Day Plane:(360)877-5249 Cell Phone:(360)490-2459 Email:brandym@mason-pud1.org Eve.Phone:(360)490-2459 Send resdis b:rent full name,address end alp code or email above for electronic copy of results) bran dymvmason-Pud 1.org SAMPLE INFORMATION Sample collected by(name): Specific location where sample collected: Special instructions or comments: 80 E eobtai— flccov real 1 Type of Sample(check only one box) 1.❑Routine Distribution Sample(VP) 2.❑Repeat Sample(AlP) (hem distribution system a'ter unsat.routine) Chlorinated Yes ❑ No❑ Unsatisfactory routine lab number. tl Chlorine Residual:Totals,Free_ ———— 3.Ground Water Rule Source Sample — - - S Unsatisfactory routine collect date: Chlorinated:Yes No__ ❑Triggered (A/P) Chlorine Residual:Total_—Free ❑Assessment(A/P) • 4.Surface or GWI Raw Source Water Sample(Enumeration) Si I ❑ E.coil 0 Fecal Faeroe'Oa_No_. 5. Samprd Carideo for Information Only: 1 1 AB USE ONLY DRINKING WATER RESULTS LAB USE ONLY ❑Unsatisfactory Total Coliform Present and Satisfactory ❑E.coli present 0 E.coiabsent Bacterial Density Results:Total Coliform mpnl100m1.E.coli mpn1100m1. Fecal Coliform cfu/100m1. Replacement Sample Required: 0 TNTC 0 Sample too old ❑ Sample Volume ❑Damaged Container 0. Date/Time Received: Lab Reverence Numbe: Receipt Temp C': Method •• ; 0T•COUNT/SM92220 T1e noos1 is krvd whit MIts use d e+Denon or mery b Date Reported /7 elnnil4.dtrwed M7 me,roDle07 co adorn Doe Ow by he reobnonl isrosratOed II you Iwo mend Oil ripsot `� onto biro rota/dr..der Mncoro by of 3$0.U3.7e45 end dsey din,bOno Noo•obs. 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