HomeMy WebLinkAboutWAT2026-00051 - WAT Application - 3/19/2026 WAT 2026-QP051
61, MASON COUNTY Shel415 N.6th Street
ton WA 985R4
Public Health & Human Services Shelton:360 427-9670,Ext.400
Be'fair: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.
32,..
. 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: G—,�\ b f Yv)iN.C9X-. Date: 31)(i I Oa(s)
Mailing Address: 61(p-2. 1 (p R- �A- Sr V Phone: 9 23-- 2 3o L,2_u,i 9
Parcel Number. 1,J-cc 9,. V.. cl$ZS� 1
W 22.O1— 1 --°1 O'-k-I 2..
Type of Water System Reason for Application
�$t Public/Community Water System(2 or more tg Building permit itEV2026 00019
connections) B L D2025-01020
O Individual water source(one connection), O Division of land:
#of Parcels? SPL
❑ Well O Boundary line adjustment
❑ Spring/surface water
O 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 EH APPROVED
Rhonda Thompson 03/19/2026
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: 1. ' f•Ct (i-ve D,�i 6
Water Facility Inventory (WFI) Number: k Q 4.,i—I (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.
Cf. 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 fall time). Please indicate on the following line the nature of
this change: he'., (A)n4,-iXJ)oyy-\ y kA1r-- VY.z
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 r...r 1a Y 1 CZv e v� -(�,p. qt)„_1
Phone �1 l S`1
Signature of Water System Manager s -- �I 1 toh—t,
Date
This form may be scanned and available for public view at www.masoncountywa.gov
1:\EH Forms\Drinking Water
Revised 05/08/2024 Page I of 2
it, SPECTRA Laboratories -Kitsap
...Where experience matters
COLIFORM BACTERIA ANALYSIS FORM
Date Sample Collected Time Sample County
Collected
7 26
Jitml
Month Day Year V : " p PM )�4�"i f
Type of Water System(check only one box)
❑Group A CI.Group B ❑Other-_
Group A and Group B Systems—Provide from Water Facilities Inventory(WFI):
IDif A 0 S 8'L 1
System Name: 5.1Air\CA CO r P
Contact Person: -�—J (�0 S
Day Phone: '(,_O y 9 D oan Cell Phone: 3 t(I Li 90 0 Z I )
Email: +J q ao 56) k c fc Cot'h Eve.Phone: SH t
Send results to:(Print Unarm.address and rip code craned above for electronic copy of results)
T1 rolDs)S 150 1=- ✓ 1 , Sck R c
51r,e 11-ov, (,s 9 5-g -
SAMPLE INFORMATION
Sample collected by(name):
11065
Specific location where sample collected: Special instructions or comments
emit ,Fh5AP
I.-UtII Clot-l.5-(-VA p jcoo• JItLAT., L.0,'"I
Type of Sample(check only one box)
1.❑Routine Distribution Sample(A/P) 2.0 Repeat Sample(NP) --~
Chlorinated:Yes 0 No❑ (from distribution system after unsat.routine)
Unsatisfactory routine lab number:
Chlorine Residual:Total Free
3.Ground Water Rule Source Sample --—— --———
ISI I I Unsatisfactory routine collect date:
I
Chorinated:Yes No
❑Triggered (A/P)
Chlorine Residual:Total Free_
0 Assessment(A/P)
4.Surface or GWI Raw Source Water Sample(Enumeration)
S
0 E.coli 0 Fecal Filtered Yes _No
5.( Semple Collected for Information Only:
LAB USE ONLY DRINKING WATER RESULTS LAB USE ONLY
0 Unsatisfactory Total Coliform Present and )(Satisfactory
❑E.coli present ❑E.coffabsent
)(Satisfactory
Bacterial Density Results:Total Coliform mpnll00ml.E.coll mpn/100mi.
Fecal Coliform ctu/100ml.
Replacement Sample Required: 0 TNTC 0 Sample too old
D Sample Volume ❑Damaged Container 0
Date ime Recdved: Lab Reference Number
I1?IL_6 /S��/U 2 \ )\ - - \
Receipt Temp C': Method ";grikii OT-COUNrf SM9222D
tLhI
Date Reported Ns awl r limed salely bluing'elk Far=caompsiv
/ Q/ .we arukka.a.Mtuaam ye.hay
e.n oho hen by Oho
Q 1 r
in !smolt-Azaddol=Or!smolt-Azadeyw hearnvedeimpr1
sear,plow nay M rdv lmnabtdya13a 443.7e6 end
DOH L�—Sarngh fl **WV INHVAP ooph'
010
- S Theon bei.odr lee.Wers latMda n.a.petyr
b r D nicsind bolo Maxim.This spat Mal not Mnpedowlmewl
6h4 r4outpio ormsW ng:O0dby mod.Laboratories.
DOH Form 1331 315 Mecle.ruin
Spectra Labs - Kitsap, LLC (Poulsbo)
SPECTRA Laboratories -Kitsap 26276 Twelve Trees Ln NW Ste. C
...Where experience matters Poulsbo,WA 98370
Phone: (360)779-5141
www.spectra-lab.com
Spectra Labs - Kitsap,LLC(Poulsbo)received samples for Sund on Wednesday, January 7, 2026 at 3:40
pm.Unless otherwise noted, all samples were received in good condition and were tested in accordance
with the laboratory's quality control procedures. A summary of the samples received are outlined below.
Sample No. Description Location Sampled
258615-01 Sund Well House Tap 01/07/2026 8:00
This report package contains laboratory sample results and any attachments listed below. If you have any
questions please call (360)779-5141 or email us at www.spectra-lab.com.
Attachments
01)
This report is issued solely for the use of the person or company to whom it is addressed.Any use,copying or disclosure other
than by the intended recipient is unauthorized.If you have received this report in error,please notify the sender immediately at
360-443-7845 and destroy this report promptly.
These results relate only to the items tested and the sample(s)as received by the laboratory. This report shall not be reproduced
except in full,without prior express written approval by Spectra Laboratories.
01/12/2026
Page 1 of 1