HomeMy WebLinkAboutWAT2025-00249 - WAT Application - 12/16/2025 WAT 2025-00249
} 415 N.6't'Street
�. 1 MASON COUNTY Shelton,WA 98584
COMMUNITY SERVICES Shelton:360-427-9670,Ext.400
Belfair:360-275-4467,Ext.400
Building,Planning,Environmental Health,Community Health Elma: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
- )_ r
Name on Applicant: C�,ia f;l(4tr.. WI ix ri f Date: Z / D 1 ®� 5
Mailing Address: �of w sl R6u '0 Phone: 3 (,0 X 0 3 9 9 7
Parcel Number: tt t 7 21" 3 2. 600( 6
Type of Water System Reason for Application
' Public/Community Water System (2 or more -'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
0 Other(explain) 0 Other(explain)
❑ 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 See WEL2025-00109
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: V--)ki%.7(?(1 Ca O W - Sys
Water Facility Inventory(WFI) Number:•1hreidi e
(write"none"for two-party)
I am the manager of this water system.The water system has been approved for 2_ services.
' There are presently I connection(s) in use. This will be the 2- 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 ate a local regulation.
Signature of Water System Manager 4:ODate)2-I( 12-6
This form may be scanned and available for public view at www.co.mason.wa.us.
J:\EH Forms\Drinking Water Revised 4/4/2018
Individual Water Well
Water well report(attached to application). Depth 1O O ft.
Well capacity Test(attached to application) ,5 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.
LvSatisfactory bacteriological test(attach to application).
Water Resource Inventory Area (WRIA)
Development within which WRIA http://gis.co.mason.wa.us/planning 14_15 16_22_
Water use or limitation recorded N/A Yes
Well Drilled Date
Individual Spring/Surface Water
❑ WDOE permit(attach to application)
❑ 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)
IX 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:
�� 1 1/7/2026
Environ. Health: Date
This form may be scanned and available for public view at www.co.mason.wa.us.
Page 2 of 2
gavi4 Pwnpa, inc.
340 W Dada Farm lid
`8elfair,`Wa 98528
(360)801-6107
Project 4464 W SR 108 Shelton
Capacity Test TAG: BQC407
Date 10/19/2025
Pump %hp 10gpm
Well Depth 300'
Static Water Level 27.1'
Draw Down Recovery
Time Water Level GPM 0 39.9
0 min 27.1 13.5 1min 36.0
5 min 31.8 13.5 2 32.1
10 min 32.7 13.5 3 31.8
15 min 33.4 13.5 4 31.6
20 min 34 13.5 5 31.5
25 min 34.5 13.5 10 31.3
30 min 35.4 13.5 20 28.5
1 hr 37.3 13.5 30 27.4
2 hr 39.9 13.5 40 27.1
Capacity Notes:
' Vanguard Laboratory
.' 2635 Parkmont Lane SW
••••.-tie Olympia,WA 98502
t t` 360.967.7010
VANGUARD Report of Laboratory Analysis
LABORATORY
Collected by:
Davis Pump Inc Matrix Drinking Water
360-329-2699 Laboratory ID: V250808-13
Sampling Address: Date Sampled: 8/8/25 14:00
4464 WA State Rte 108 Date Received: 8/8/25 14:30
Shelton,WA 98584 Date Reported: 8/11/2025
Sample ID: 4464 WA State Rte 108
Analysis Result SDRL MCL Units DF Date Analyzed
Total Coliform&E.coil by SM 9223B(IDEXX) Batch ID:V250808-13 Analyst:IT
Coliform,Total Negative 1 I MPN/100 mL 1 8/8/25 16:29
E.coli Negative I 1 MPN/100 mL 1 8/8/25 16:29
Notes:
MPN:Most Probable Number
ppm:parts per million
nd:non-detect Reviewed by Dustin Newman,Laboratory Director on 08/11/2025
n/a:not applicable
SDRL:State Detection Reporting Limit Approved by Tori Johnson,Operations Manager on 08/11/2025
DF:Dilution Factor
17025:2017
MCL:Maximum Contaminant Level Iv ACCREDITED
� LT0ORATORY
Samples were received in acceptable condition.The result(s)in this report relate only to the portion of the sample(s)tested.All analyses were performed consistent
with the Quality Assurance program of Vanguard Laboratory.Please contact the laboratory if you should have any questions about the results.
2635 Parkmont Ln SW,Suite A,Olympia WA 98502 I Office:360.967.7010 I testing@vanguardlaboratory.com
www.vanguardlaboratory.com
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