HomeMy WebLinkAboutWAT2025-00155 - WAT Application - 9/10/2025 (2) r
WAT 2025:00155
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COMMUNITY DEVELOPMENT
f r:n,,t A,ststan<r cetc,Irt,B1rtIdInIt.Otannnt ?".s
415 N 6th Street,Bldg 8,Shelton WA 98584,
Shelton (360)427-9670 ext 400 rr Belfair
FAX(60)275 67 ext 400 4. Elma.(360)482 5269 ext 4C0
_ Application for Determination of Water Adequacy s;``
1. Complete Part 1. No determination can be made until Part 1 is fully completed, a
Complete only the portion of Part 2 applying to the type of water connection utilized,
Submit completed application,with any required attachments for review. I
• An approved building site plan must acxompany this application.
Part 1: Applicant/Parcel Identification a /j y .. / ,
Name on Applicant. 4y _J�plitif'� ,p "l�f Date: / i b_C_�---
'` Mailing Address: 5y/ ,c, rifir SAC- �`s e 17 gee-7.:7 7/
Parcel Number: `2//R 4/ow fa
ype of Water System Reason for Application
ri Public/Community Water System(2 or more Building permit
connections) 0 Division of land:
i I,. :rividuai water source(one connection), #of Parcels? SPL
0 Well 0 Boundary line adjustment
0 Spring/surface water 0 Other(explain)
■ Other(explain) 0 Replacement or Remodel(please indicate name f
'`sir 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 kno ,i .t,,,n; , : ,:_:r:
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: x
Water Facility Inventory(WFI)Number 2 75 j%
(write"none"for two-party) i`
g I am the manager of this water system.The water system has been approve)for 6 services.
• There are presently y connection(s)in use.This wilt be the S"' 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 wat: to this(these)connection(s)without exceeding •
the limits of the water system or any set byig nd local regulation.
Signature of Water System Manager i %/- Alti.,,//.�i% Date /P'Q,l".2.5"--
•
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This • •,;may be scne,a►.>td available for public view at i,1 it 4
ORM BACTERIA ANALYSIS FpP,M
5 '
7/L� '� ';4
640 Vi SAIPLE INF MAT1tN1
r,i,e-co-;:.Eea fiy in t.
k r 5.3=npie,cherl zn1,nr,c
�p `"I meat Samp�lA�,
KRou:rne Drslf7t-on Sa�trt e, ;I�m a X:,,ss .(agcr :r;rof
;0 var f!• attstrIoty te,lene Lab nuatbec
- flee
,ro:nd Wale•Rote Source Sam*
at*inetary rooms cwe o
Tor r�ei ;h1., i71tpttitNtief,181.7 ::a�
iurtace or G V1 13 Sbyr, Water Sample(Eratnerawl) I 6
F c r} ❑FeCa -- —— —_
`AgE LILY DRINKING WATER RESULTS Lik6 USE ONLY
Ur.SaiaCtQry
Tott Cdg rn P,tserst and
0 E ci>k absent
ccoF Fri r_....W
-___-____�. _...___�...._... niiflCrst Etchmprl;fOpn1
ytenal Dtnsity'Results'Tots,Catbmt n '
CtUiNkli
pent Sample Required: 0 INTC G Sart a ttn c1Id
ELI Sacrfile Volume ❑Dammed Ccn1&ner D
Ti.
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AUG I 3 za vm.Mw� *r.aa�tb a+v ri6i!
I.V ... sue, d+'+KY Sstitrowy PIiNX•Atte
WATER FACILITIES INVENTORY (WFI) Quarter: 0Updated: 09/29/2025
FORM
z�' Washington State Department of Printed: 10/2/2025
�i Health ONE FORM PER SYSTEM WFI Printed For: On-Demand
okihiiar ut c,rvtronmenlal irr°r(' Submission Reason: Contact Update
olywe al Orfrriong Wilier
RETURN TO: Central Services-WFI, PO Box 47822, Olympia, WA, 98504-7822 or email wfi@do4.h.wa.gov s. TYPE
3. COUNTY
1. SYSTEM ID NO. 2. SYSTEM NAME MASON B
06775 N PICKERING PASSAGE#2
6.PRIMARY CONTACT NAME&MAILING ADDRESS
7.OWNER NAME&MAILING ADDRESS
PICKERING PASSAGE WATER CO-OWNER
JIM DICKSON [MANAGER] ASSOCIATION
PO BOX 492 GRAPEVIEW,WA 98546 JIM DICKSONPO BOX 492
GRAPEVIEW,WA 98546
STREET ADDRESS IF DIFFERENT FROM ABOVE STREET ADDRESS IF DIFFERENT FROM ABOVE ,.
ATTN
ATTN ADDRESS 200 E CREST LN
ADDRESS 200 E CREST LANE
GRAPEVIEW STATE WA ZIP 98546 CITY
GRAPEVIEW STATE WA ZIP 98546
CITY
10.OWNER CONTACT INFORMATION
9.24 HOUR PRIMARY CONTACT INFORMATION Owner Daytime Phone: (360)628-3157
Primary Contact Daytime Phone: (360)628-3157 Owner Mobile/Cell Phone:
Primary Contact Mobile/Cell Phone: Owner Evening Phone:
Primary Contact Evening Phone: E-mail pxxxxxxxxxxxxxxxxxxxxxm@gmail.com
Fax E-mail: pxxxxxxxxxxxxxxxxxxxxxm@gm
ail.com Fax:
11.SATELLITE MANAGEMENT AGENCY-SMA(check only one)
x Not applicable(Skip to#12) SMA Number:
0 Owned and Managed SMA NAME:
0 Managed Only
Owned Only
12.WATER SYSTEM CHARACTERISTICS(mark all that apply)❑ Hospital/Clinic XResidential
Agricultural El Industrial School
Commercial/Business El Licensed Residential Facility ❑Temporary Farm Worker
El Day Care 0 Lodging 0 Other(church,fire station.etc.):
0 Food Service/Food Permit
Recreational/RV Park
0 1.000 or more person event for 2 or more days per year 14. STORAGE CAPACITY(gallons)
3.WATER SYSTEM OWNERSHIP(mark only one) Special District
County Investor
Assoaatio State
Federal Private
�City I Town 22 23 24
15 16
17 18 19 20 21
SOURCE NAME INTERTIE SOURCE CATEGORY USE TREATMENT DEPTH SOURCE LOCATION
xi m 0
A z -i y m
LIST UTILITY'S NAME FOR SOURCE r z y z p x y m
C _ -4 n n
AND WELL TAG ID NUMBER. = Z n ^ m _- -{
0 D 'y' (n T Z m cAi r T C 0 GOT m{ a Z
0 Example: WELL#1 XYZ456 m m o A m m 0 �+ m m A r A --4 12 55 m-< rn z O
E r(t�1t 3 D
F- rr- in O z D m D 3 to 5 z A o O O z'i r 0 z Z D
D IF SOURCE IS PURCHASED OR INTERTIE P. y z z r
INTERTIED, SYSTEM -n m y D i O m m z + = moo O -) m Z
LIST SELLER'S NAME r r r Z rm- rm- m m X m z zv 0 m z 0 0 0 c m mill 'i z O m O
® NUMBER r 0 0 0 0 0 73 M mt 7J -I r { 0 m Z Z Z A -i Z m O Z ZI 55 m
Example: SEATTLE 126 37 SE NW 18 21N 00
SO1 WELL#1 NO TAG
x x Y X
1W
Page: 1
DOH 331-011 (Rev.06/03) DOH Copy