HomeMy WebLinkAboutWAT2026-00005 - WAT Application - 1/20/2026 WAT 2026-00005
MASON COUNTY 415 ton `i Street
Shelton,W,W"A 98584
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: WALTERICK DAVID R&MARY J Date: 1/20/26
650 E JENSEN ROAD SHELTON,WA 98584 Phone: 360-801-1383
Mailing Address:
Parcel Number: 32132-23-90034
Type of Water System Reason for Application
❑ Public/Community Water System (2 or more El Building permit BLD2025-00297
connections) ❑ Division of land:
El Individual water source(one connection), #of Parcels? SPL
® Well ❑ Boundary line adjustment
O Spring/surface water ❑ Other(explain)
❑ 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
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System:
Water Facility Inventory(WFI) Number: (write"none"for two-party)
O 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:
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 Phone
Signature of Water System Manager Date
This form may be scanned and available for public view at www.masoncountywa.gov
J:\EH Forms\Drinking Water Revised 05/08/2024 Page I of 2
Group B Water Systems
❑ Satisfactory bacteriological test within last year (attach to application).
Individual Water Well
® Water well report (attached to application). Depth 57 ft.
❑ Well capacity Test (attached to application) gpm gpd.
N/A for The well driller often performs well capacity tests at the time the well is constructed. Results from
garage
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.
® Satisfactory bacteriological test within last year(attach to application).
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.
I 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:
�S Date 1/20/26
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of 2
Jun 13 07 05: 16p mart
360-782-5491 P.. 1
•
WATER WELL REPORT CURRENT NoticeIntent NO. (.)a 00,)c7; ----
..t,.„ O, .il&1'espy-EesIcs7.1' eon-..oer.3»c.pj-driver Well ID Tag No. 1� lr U'�
111
1:1 i'i c i Unique Ecology
C astractinn/Deeoneua�ioo("x"in circle) W Rat Permit No.
/ won,..: O �
O Decommission ORIGINAL INSTALLATION Notice Property Owner Name i'��: 'r%^• Co.t. F ` {._
of Intent Number Well Street Address c/ L a F E (' '
City . lie County 1';'i.:� eZ i l'.. ._..-
0
Pftot D MI 5O kitg iim-the 0 iessWell o C' ;�Dewaiv D n+b�e0 ❑Tai Well Location X1/4-1/41i1� /4 Sec, :Twn Ra• i w�
cirde
TYPE OF WORK: Drees number of (if roam than one) O Ddwu Loa M _ a.
7dNew wdl 0 RceosdMoced Medved:O Drs CI Teaod Lat/Long(sop
r Let Leg
0 D(obis xoury
of ta±eba drilled a- ' Still REQUIRED) Long� Long Min/See
DIMENSIONS:DisaMer � ,...
n�e„twep�! L��i r Tax Parcel No. -3 --�------
oolrsTTt •
pain - welded _i Dion Etx P ft m CONSTRUCTION OR DECOMMISSION O�U�
IesaJl.k D TLime Mulled lreaded " Diaat Rorn 2M.- .:.o
- Dlsm 4om 9 to FomtMiiac patcnte try color,aacr._nortrrt/Ui and Modem M/me Woo sal
Falsrad.rr Yes No men cane mitoridis mob MOM v' a +o lees es§easy for oaeb elms of
L. tnlbaoation (USE ADDITIONAL MISTS tP NECESSARY.)
Type otperfo+scer used �Q� RR _ • .
STO •
SIZE of perfs ,la.by.� kit and no,of yerfs_.Ban-_—R to A MIERI-r
Sams • a Yes No 0 r-Pao Location —r/x L l� r,e l 1 1 ` i f f
Diem Slottbe--- froth-----R in____—.11. • ' .t C 'r • r �'�_t^ t ek��`�7
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Dian StMslta _Son �� ' -- A r 4 1,,i -✓✓ f3
Gray.VFllerPale: 0 Yea No CI Sire ofglerNsaad________a - ,
Weedids pl m R to f
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• 9asficslntl� •+'p No T �� 1 R
MateHY use in sots , ,�
Old soy Me.0 m ts& s wane? , -
Type of wee? Depth of strata
Method of whoa aura off
Ty : eesNsae HP.
Ty y,a
WATaRL IL& aetwitkn stove roan seabird ftI'�
Stabs level /' R.bcbwtop ofwd D l ..e G
Artesian promos ---Iba per muse loctr Daft -- I
Antaian water 4 tsmalted by (em vatvo,c4-)
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WELL TEEM Dssrdonn k ssos ierd Es towered blow Mme lend
We a pump lest wade?0 Yes Dyer,by w$rom?
R&eroti tm air M.
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Yield: �Jmtn+im
with ft dra+vdowe efts:
tae.
vO.cheeses after foes. I
Rd.eewsedauo(fret tae.r ca te.,sae,.P..4,r.rwrzt 411 fti.,ae,r wi stantrartfrom won
top to rarer kvd) 71 ne Weer litre
Tien Weer Level Time Wafert.evel
arm emu
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Mtsii.nflew! a.p.m.Date ft� S
r of lamwai a drarril nriysn trade? CI Ya No Start Dabs Y= ti {! i ....D./-L C /
WELL CONSTRUCTION CIRTIFICATION: I constructed and/or accept responsibility for construction of this well,and its compliance with all
Washington well construction standands. MiqMilis used and the info tion rva tted above are true to myabest knowledge and belie. .
Q'Deject (Riot) 1 r� '.• •r:. ~^` 'I 'I ') Ditties Comps+y i.t,( 1.•.i t; i • {( >,•; i t • `''
pnilec D Engineert ,� .
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Diller or trainee Lice=No. 7 C:- _ -
comtacto'a - r
rTRAINEE. xa{i Parlor Na:.'Ia'r 1�'''r•>V )1 l�Li We e� ( ` ~J ,
ria.s'.tloeatet @l.rt0er.aviat r. Faeroes is as Rind Oppoaadty Fla
l 5h r De of Ecol PT warranty the Data andlor information on this Well Report.
. � � !o. . IVIason L.ounotr ) Kiln
Printed fro.?Mason County MIS 06/13/2007 into 17118 (JOB NO. 5734] ®001
_ Printed from Mason Oiu
Thurston County Environmental Health
.- 417.Lilly 11d NI:• Olym�ala,WA 9850f:
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t COLIFORM BACTERIA ANALYSIS
Datea Time Sample County
Date Sample Collected Collected f
s I t 12 I (7.61;16 �l.ra ,t(S6 N
Morn Day Yea: �?
Type of Water System(check only one box) ❑ Private Household
0 Group A
Group B ❑Other__.
Group A and Group 8 Systems—Provide from Water Facilities Inventory(WFI):
ID# _ — _...— ---- _----
System Name:
OA�wA�r�,c�ri
Contact Person: Cell Phone:(jyp)�D7.1 ,
DayPhone:t3�7) &'D/ — I3b' „ !
t ,f erroJG@,0,44. Eve.Phone:( )
E-mail; d�auftcZ•
Send results to(Print full name,address and zip code or emar address)
DA11t f r1At�IG....,_ . _ ___—_.
1 SAMPLE INFORMATION
Sample collected by(name):.^AV1(] u Lvatic,
Specific location or address where sample collected: Special instructions or comments:
KrTt-I
Type of Sample(must check only one box of#1 through#4 listed below)
1.❑Routine Distribution Sample 2.Repeat Sample(after unsat.routine)
I I Chlorinated:Yes_No__
O Distribution System
Chlorine Residual;Total_Free_
Chlorinated:Yes_No
3.Raw Water Source Sample Chlorine Residual:Total_Free_
❑E.cell—GWR(AR)
❑Fecal—Surface.DWI sponge(numeration) Unsatisfactory routine lab number:
IFiltered:Yes No . _— -
❑Assessment Monitoring(A/P) Unsatisfactory routine collect date:
\j81
❑Other
4.0 Sample Collected for Information Only
Investigative Construction i Repairs Other
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
, O Unsatisfactory Total Coliform Present and 'Satisfactory
j O E.coli present O E.coli absent
No Coliform detected
f Replacement Sample Required:
O Sample too old(>30 hours) O TNTC El
Bactenal Density Results:Total Coliform /100ml. E.cdi /100ml.
Fecal Coliform /100ml Enterococci /100 ml
I Method Code.K SM 92238 ❑SM 9222D Date and Tine Reserved:O'1'to
I ❑SM 92158 ❑Enlerolert® /•N.2(Q is
1 Date and Tune Analyze I'!'{• 7 f,. Date Reported 't. ' 14 1_1"`
sanpb h l o 'We.awe r e wa n, Lab Use Omy V.•-.
i1 0 8 4 0 I �'2y �S
.
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