HomeMy WebLinkAboutWAT2025-00208 - WAT Application - 10/27/2025 WAT . 2025-00208 __ l
MASON COUNTY 415N.6'1'Street
Shelton.WA 98584
ritn. 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 of Applicant: Mary Schuler Date: 10/27/2025
Mailing Address: 3113 W Little Egypt Rd Shelton Phone: 253-549-6678
Parcel Number: 32105-75-90050
Type of Water System Reason for Application
Public/Community Water System (2 or more tVi Building permit BLD2025-01168
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
II 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: Highland Park
Water Facility Inventory(WFI) Number: 32620 R (write"none for two-party)
0 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.
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: Inactive to Active Connection
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
I
Signature of Water System Manager _ \A_;L: 1 .j t I P?4n/ Date 09/30/2025
This form may be scanned and available for public view at www.masoncountvwaAtOv
1t Forrns\Drinking Water kevi,ed u5101.1202a Page 1 of 2
Group B Water Systems
❑ Satisfactory bacteriological test within Iasi 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 it 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)
0 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)
X 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:
NrYv St)44- Date 10/27/2025
Environ. Health:
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2of2
Thurston County Environmental Health
116* 412 Lilly Rd NE Olympia,WA 98506
��, 360 867-2631
THURSTV T'
N COUNTY
. •. •y, COLIFORM BACTERIA ANALYSIS
Date S - lected Time
Sample County
Cor ;al 7 , ply \ACLSt)Y�
7, :(. 'k!i
Day Year
Type of Water System(check only one box) (:Private Household
0 Group A 0 Group B 0 Other
Group A and Group B Systems-Provide from Water Facilities Inventory(WFI):
IDS
System Name:
Contact Person k,k(�j t j�i �'tl.(fit r ,,r
4
Day Phone:( ) Cell Phone:(2s 3)s4 -
E-mail: L1c;> c%IS gtvickl Eve.Phone:( ) (efs7-1,8
Send resuib to(Print full name,address and*code or email address)
A- ?1tfll( e91I1CtiI�
SAMPLE INFORMATION
Sample collected by(name): f -�A
� J Special instructions or comments:
Specific location or address where sample oolected:
(r. t • 4 - OR-
Type of Sample(must check only one box of#1 through#4 Gated below)
1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
Chlorinated:Yes _-No ) ❑Dlsttlbution System
Chlorine Residual.Total Free Chlorinated:Yes No
3.Raw Water Source Sample Chlorine Residual:Total_Free
0 E.cob-GWR(AlP)
❑Fecal-surface Gwr.sixings(emotion) Unsatisfactory routine lab nutter:
Filtered:Yes ,No ——
❑Assessment Moniloring(AJP) UnsaYdac kwy routine collect date:
❑Other / l
S
4.0 Sample Collected for Information Only �/
Im native Construction/Repairs l� Oft
LAB USE ONLY DRINKING WATER RESULTS USE ONLY
❑Unsatisfactory Total Cobbrn Present and I No detected
❑E. present 0 Eooi Sent
Replacement Sample Required:
❑Sample too old(>30 ham) ❑TNTC ❑
Baderiel Density Result:Total Coi(rxm /100ml. E.aou /100m1.
Fecal(oidonn I100mi Enterocood /100 ml.
•
Method Code�SM 92238 ❑SM 9222D Date and Time rRe�d+ 'I
❑SM 92158 ❑Enterolert� '%- 'T 3-L7 v(►4""-
Date and Time An ^
Analyzed. 1 t Dele Reported -15 k•/f
Sande Number tool renter a.M 4710 q. ,Z tab Use Orly. t(sv
0 8 0 SLt etl j ctiltt
09i1r")1( 0!" ti`h.rt 4^2.2