Loading...
HomeMy WebLinkAboutWAT2025-00203 - WAT Application - 4/21/2026 Aulhentslgn ID:59D701D5-EF10-F111-A69A-0OOD3A4FF82A FATZO S O W 41314.6' Strcct MASON COUNTY Shelton.WA 98384 COMMUNITY SERVICES SI1el air;360.427-9670,EuL 400 Dclfalr:360.275�Id67,E1ct.400 aua3nyNamin¢cmmuwrmnW11.N1hcw+m,mOpll.dlh li n n:360182-5269,EXL 400 Application for Determination of Water Adequacy Instructions 1. Complete Part 1. No determination can be made until Part I 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 on Applicant; Yt4w A \kormeS I nC . Date: ' Mailing Address: ,�r�`� S± C-1- Y W Phone: J�p O.�i�4 , Parcel Number; 9( ?t41—a7 9toO1 Type of Water System Reason for Application j Public/Community Water System(2 or more .tom Building permit connections) O Division of land: O Individual water source(one connection), #of Parcels? SPL ❑ Well L3 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:&i V 0 w l k A' S c n Water Facility Inventory(WFI)Number: AT 7 t (write"none"for two-party) I am the manager of this water system.The water system has been approved for 1_servlces. There are presently connectlon(s)In use. This will be the 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)connection(s)without exceeding the limits of the water system or ay Nmitssset b state and local regulation. System Manager Ki stbee y Delany Date Q2/23/26 Signature of Water y This form may be scanned and available for public view at . J.111 I Fomu1 Drinking Water Revised 4/42018 Group B Water Systems Satisfactory bacteriological test within last 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 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) 0 Method of disinfection 0 1 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 '(z{124 This form may be scanned and available for public view at www.masoncountywa.gov Page 2 of 2 26276 T%Yclvc Trees Ln NW $"'•c SI°ECTRA L�tborntorieti- Paudsbo,WA ILtiU�] oBJ70 ,,.Nhcre etc erlenci: •saorlers (360)779-5141 COLIFORM BACTERIA ANALYSIS Dale Sample Coltecled Time Sample Collrb b, Colleried IknOi or, Yam .JL: ±LO-D1'M Sow Type of Watersyslem(check only one box) 0 Group A J3 Group B ❑ Group A and Group 8 Syslems—Provide from Water Facilities Inventory(ldVFI); IDJI 3 v System Name:J�+W r"W,%Jay - Y$ Contact Person: Day Phone: Cell Phone: Email: U]l Phone: Sendremite to:lPdallenacw, coperrwuau) OFFICE.NICHOLSONDRILLING(c�Gfv1AIL.COM --COHILTON;NICHOt=DRiCLINGni3K CCoM SAMPLE INFORMATION Sample collected by(name): Specific focallon where sample coll�ect{ed: Special Instructions or comments, 5a&lele- V Type of Sample(checkonly ono box) 1.❑Routine Disttlbullon Sample(AlP) 2.❑ Repeat Sample(AlP) Chlorinated:Yes 0 No❑ (from dlunblttlon system afterunsal.(outine) Unsatisfactory routine lab number: Chlorine Residual;TalaL_._Free-__, 3,Ground Water Rule Source Sample Unseliafaciory routine collect date: S I Chlorinated:Yes No_ . ❑Triggorod(AIP) Chlorine Residual:TolaL. Free ❑Assessment(AIP) ~ 4.Surface or GINI Raw Source Water Sample(EnumaraUon) S ❑ E,toll ❑Fecal Fifwod Yos^no_ _ 5. 2I Sample Coeeoled far Inrormarlon Onyx, LAB USE ONLY . DRINKING WATER RESULTS LAB•USE ONLY ❑Unsatisfactory Total Coliform Present And Sallsfaclpry ❑EcoNpresent ❑L.co absenI 3acterlal Density Results:Total Collform pnllogml,Ecoli m 11 Fecal Colifmm 0patl. cfvf100m1. teplacement Sample Required; 0 INTO ❑Sample loo old ❑ Sample Volume 0 Damaged Container ❑ )%errlule Re4 , \2s2© Lab Reforenco Nambar iecetpl Tamp C': / MeihedCode: �q , M9223 OT•CQuN71sfA92�Zp aloRop011 ih Ii nxaca� ,., se aot+u+ana Z aaa9 aosenei MrA aPAMadawo to laroadrd Iedpr.Sq w,.to naa.rilauarA,ox4obary�a0 brero ma,afrr:r o:s.Yan wads lmiMhMr MHa-I�LidlSy jl� rpfl Lob.eenrple f< daoaq Warepnlpunpar, n p� 1bop,eMraubdgra0g4p®i6xkdaerom'c �a )lO• raer :elcryNr upalrhel td be µ7bpwyl laiill,r<iAedpgcoy,ar mlamoOn.ardtrr89M,aln;gyy eDlrramRr)falsfdk:Gro0911�