HomeMy WebLinkAboutWAT2025-00239 - WAT Application - 12/19/2025 WAT 20
415 N.6'"Street
Shelton,WA 98584
#A Shelton:360-427-9670,Ext.400
4 t1t�L�4e Y Public Health & Human Services Belfair:360-275-4467,Ext.400
Application for Determination of Water Adequacy
Instructions `1 t?,l 266 --061O
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 Id ntification
•
Name on Applicant: J)i V')a..1 Date: ;��I-22-4-25
Mailing Address: 66 I../ '�-2 nil iI'la{..t.�.`. 'hit A"!.{, Q�4n -11:P1
1-3LsO .. `Y IC)1
Parcel Number: �,'V7�;(�17/!/� ( O�}:1 9'P)564-1-Type of Water System J 1 _ 3 C} Reason for
Application
❑ Public/Community Water System(2 or more O Building permit ?I,C ice,/-01-j'4'7,)
connections) 0 Division of land:
El Individual water source(one connection), #of Parcels? SP.L
❑ Well El Boundary line adjustment
❑ Spring/surface water ❑ Other(explain)
❑ Other(explain)
O 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.
_Part 2:_Water Connection Information.-.. .:
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: V(3 j n cL, UJaJ e 01-145-41"—,
Water Facility Inventory(WFI)Number: flont:... (write"none"for two-party)
El I am the manager of this water system.The water system has beeq approved for • services.There
are presently .1 connection(s)in use.This will be the cA 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)connections)without exceeding the
limits of the water system or any limits set by state and local regulation. O16.- r f ldL) _643 =!•
1 (
Print Name of Water System Manager rl5 t Il�: Ina)
Phone ,a.Ft- t
)(Signature ofWater System Manager/I:I 4 Date ` �▪ .�' 2.5
This form may be scanned and available for public view at www.masoncountywa.gov
I:\EFI ronns\Drinking Water Revised 05/08/2024 Page I of 2
r '
Group B Water Systems
O Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
79
RI Water well report(attached to application). Depth ft.
►:; Well capacity Test(attached to application) 12 gpm >400 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.
RI Satisfactory bacteriological test within last year(attach to application).
individual Spring/Surface Water
❑ WDOE permit(attach to application)
D 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) .
® 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:
Environ. Health:
° Date 12/19/25
This-form-may-be-seanned-and-available-for-public-view-at-www;masoncountvwainov
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MOERKE&SONS PUMP &DRILLING, INC
1162 NW State Avenue, Chehalis, WA 98532 (360)748-3805
PUMP TEST
DAN HESS -HESS LAND & HOMES 1 iL ' `
18623 ELDERBERRY ST SW a I' . —.--...,;
ROCHESTER,WA 98579 ' l
Lit
WELL SITE ADDRESS: 150 SE SISTER MEADOWS LW,SHELTON WA
Pump Make&Model: ° HP Pump Set At: Sy
Sounder Make&Model:
Make&Model: Measured In;GALLONS -::..
MINUTES GALLONS METER LEVEL TO
PER MINUTE READING WATER NOTES'
0 215816 31'
1 14
4 21830j2'
14 215844 33'
3 13 215857 35'
4 12 215869 36'
5 12 215881 36'
6 12 215893 36'
7 12 215905 36'
8 12 215917 36'
9 12 215929 36'
10 12 215941 36'
15 12 216001 36'
20 12 216081 36'
25 12 216121 36'
30 12 216181 36'
35 t� A �.12 2 216241 36'
40 12 216301 36'
45 12 216361 361
50 12 216421 36'
C 55 12 216481 36'
i 60 12 216541 36'
90 12 248001 36'
t 120 12 217261 36
RECOVERY
0 36'
1 34'
3 31'
it
SIGNATUR
, NS PUMP AND DRILLING
33
7[i9
I35
l.
I:
3;
3 f 1
I' . i 1 h'f`._ ... '1 ,€t�,.ti. ___., _n ! Vic a< <1: ....
1 Vanguard LaGOfator`y
• 2635 Parkt Lane SW,Suite ° ° , $' ' E
mon A 1q y ; if r'�
*, . Olympia WA 98502 i
' 4 i 360-967-7010 O i
Off03l!F04 COLIFORM BACTERIA ANALYSIS FORM ;
Date Semple(Netted r Um Semple County ay
m,
s �w�
cted
1 1 r
few. 6Y rest
Typo of Water System(check only case km)
O GrospA O Grotty S atitur......L.....DM
Gimp A aril Gm a Systems-Prcrrlde from W tar t s Inventory(INFO',
tDe ,
System Naas. 1>
ContactPerso: IdN'
Day Plicate[( ut Ha%T)"3 UO5 Gel€shone:( )
Ernst Eye,Prone:( )
San4 resale to;(Peke kit ran,edemas anrt*code orm ai)
llt,a. rt, Wt. �.
, .
SAMPLE INFORMATION
Sample cdlecded by(n )= I
t til Spacrm locationwhere sample caollected. Special.instructions or comments
1 ,if... le b W f.44 i
t , vte t cis a
'1*of Sample(fit oay One type oisa axis from typal lleough G lamer)
1.O Rawl₹roe Distribution Sample(AM) Y 2.O Repeat Sxrtple(NP)S' Chlorinated:Yea No team di5 1ufete eyeless OW nasal ass t
Unsatisfactory mutts tab;UMW:
Residual:Total Free
1 3.Ground Water Hole Soma Sample
t Unsatisfactorytr lecz dad a e:
! 1 1 1
f ablated,Yes Nu °
OTriggered(NP) ChbairtsRes M:To Free,__.__
ElAssoment{A/P) _
4. Surface or GW Raw Source Water Sample(Enumeration) 1 S-I_ I I
,¢ O£cot! C3 Fecal mew Yes_rte '
i 5.Xi SaripleCaacia tar Intaarsatlan Only:
USE ONLY DRINKING WATER RESULTS LAS USE ONLY
O tresaasfactory Total Coefonst Present end' kt Satisfactory . +
O Eccipfesertt O Ea*absent
i s Bacterial'Density;R outlet Total Colkat tlGOrnt Eon..___.._,_.J1
I. Fecal email 1100mi, HPC it ml.
S
. teepleconentSample Regt>iredr 0 Twrc O sat*tonold
O Saes$Vatatre Li Qamaged co thine: O
', ' Lab Refirarto Weber
:( .7 t—1-.Iwo .
I: if rer 13 ut ico4t:Sh49223B
Cam to DOH Lab Use
i
3
} a I , DOH tti pt 7 t1-33
i.-33',.„313:.: c-+En'<"k .?.��..°�i. C t `.y . ,»c>
is