HomeMy WebLinkAboutWAT2026-00063 - WAT Application - 3/25/2026 WAT Z0 - Qf _a� j
MASON COUNTY 415 N.6a Street
Shelton,WA 98584
Public MeaLthl & Human ServicesShelton:360-427-9670,Ext.400
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
� r r
Name on Applicant: Q Lam- d? !1, ,',j Date: -__ 5•_ �
Mailing Address: ••-^o Phone:
Parcel Number: _ ,C h '`G'Y LO1 Sb 4
Type of Water System Reason for Application
Public/Community Water System(2 or more Building permit io r�LC l
connections) ❑ Division of land:
❑ Individual water source (one connection), #of Parcels? SPL
❑ Well ❑ Boundary line adjustment
❑ Spring/surface water 0
❑ Other(explain) Other(explain)
0 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 two-party well
WEL2025-00027
Complete the section appropriate for the type of water connection being evaluated:
Public Water System
Name of Water System: U).e
Water Facility Inventory (WFI) Number: 1\O('1 E. (write"none"for two-party)
I am the manageç of this water system. The water system has bee approved for services.There
are presently connection(s) in use.This will be the rA connection.
❑ 1 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. ,f
Print Name of Water System Manager
Qt1CI Phone 25' 3�'"7961
Signature of Water System Manager �7C ��' Date
This form may be scanned and available for public view at www.masoncoun�wa.gov
J\EH.Forms\Drinking Water Revised 05/08/2024 Page 1 of2
Group B Water Systems
❑ Satisfactory bacteriological test within last year(attach to application).
Individual Water Well
® Water well report(attached to application). Depth 232 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.
l 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
o �
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.
O 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 4/15/26
This form may be scanned and available for public view at www.masoncountywa.gov
Page 2 of2
Water Well Report For An Existing Well
v6ur well must benproperiy tfigged prior,o'submitting'thisfoiiii.
FFEI,AA �SE�ar Asterisks('4)indicate required'tields.M trrstnfrtetod orfgfiial farm to,
ECO »C GY WA State t) plrnent of colooy PO t3tax,37600,Oiyrnpa.'dYA r3 5f3l-
t I ttrig faun tt an original Water Wett R Prrtwas never Hied cr is missing f�ronl L:ccto gy rccrards
?!;c I
ks"i razesric. Cft rtx�trfat Urairraa Fcntz y Wall ID Tay Nurrt r• . . O
�tPdlr��xp�f �'1 �.�t�r
nild9a6on ( l' r VVIA) Q uirt:_~ "§•1'r:ter Right:DYES(f yros,OItth a copy) D Ca g ;w
pT
enstcras r" !y Owner r rne. ...,,�o r r
ir
c�Sa'ti a tn.
iaf exa,s t d tv fl 3r rt 6r i Sli r. fry; o t_ O + a a
Construction Details
Linerifs#3tf i. Y&s DNo 'TlUlh n- 'Sde
a Oun no� U f��: `Ta3€P'areal Rumbe:
L r+r°fas�3mea��, `fa t=y g ll structe d._.
Q Do .lr k6,I "t„nc-11M(Township*Range,Section)
����03` �ara�s try,t�� .� fn.
s +,r h se f rfarjxsrsr r6 ,. ft € t mla l at h of your'dr 1 iii very frrr fatfta. t c
+„ �... a section "f ownship,Range,anti .V4 can be fawd on yet
v items
tx
fey � a r cc a Fri a P0(cO1 legal cc eptrt 't cr €Faro f yo ut't1;d
} T + . } tairil ss seet Orrvc OO f r r
t16 rt r, Skit Srze rt ~ to fl,
a s�r.TnsAr, DEWM ar MWI `M,
Gr.weUFPlter RAcrc ; Cif'art !4 1d.1-S!4 LL114
}lira umfla
L rxtaal rafa`ae ffG£61 .l? ~ ft tsOrr9tl malts: Lam? C/ t P° f
c Sra#ace Sear
#f kno m, w at depth t
� trsa15 r:s'eit il'kt ^. •-�.:`-.
Pump o D4lnkrr.ar3
i-atttvtiongteade
Water of (DecfrrraC Vagrccs recorded to 6 decirnal places)
far !�Rt 6 el 3 t: X34 s5,e3a6�e*� - d fte ..et'tfu<k(Ex ' 318 47.12345)
Z Can slickiip of e yr i f surfe
f� ear a !r ek Ir.of rn,a r, ` t
o ". t Carr irt3eit (Fxarrrrf0 116.12315)
v * r n r rse t .€mac square ar6 Pale measure:
>' WJ F.-ad has RYe 0taa Sui sJ we?Qy Oo
4°fell> ��cs� Additional Information(ff avaftabfe,pfcase at€ach)
tr,a, rs ra arrr.^ar water te et is w ed tseJ w•t t frL a aged an•lap e hmap
o 'd'a'is a pump tesf made?%tea fatfach copy iJ?,,n O t.r°6lcrracncrr Onrniced ura Pis ftttcto t�
r : ant i.u th #t_drar�7t m artrrr .t hrr. DCransui#antwo report
"4�erttticatiorl Td t motion rotted a bas P is hue to the best of my krw%vledge nd t3.effa€
DCorYath g F DDriro+er EJEnginer Poperty Ovrnor
t' rle. r) t'[ .tl r_ ;
Address of 9,Moi Carray eUnq tits farm:
Z a' aty list Z M t .
spa a jWit3 r u td' 5'6 SSA 'tea asul"
a= xsfa '9b;ass aza�+ is xa r ₹ _==-
s�rz��"�:a3r Y$: k�ea��$2io�xr�Laa X55 ai�fr;.�$5•L��P�a
Arcadia Drilling It c.
P.O.Box 1790
Shelton,WA.98584
Cu rner:Doug W llis Well Tag#:Unknown
Site Address 3070 E flar5tine l land Rd S,Shelton Depth.232'
Date of Test 3 124 Static 207.1
Pump Set Unknown
liME GPM 1.EV1=1. RECOVERY
Y
1 Min 8 208 TIME LEVEL
2 Mtn 5 2093 1 Miry 209
3 Min 12 209.7 2 fvtin 2t7,1
4-
4 Mn 12 202,2 3 Min 207.1
M 12 213.1
6 Min '12 213.8
7 Minn 12 213.9
8Mit 12 213.0
c 9Mm 12 213.9
10 Min 12 213.9
I 15Mm 12 213.6
20M€n 12 213.6
25M !H '12 213.6
30 man 12 213.6
* 35 Min 12 213.7
40M.fl 12 213.8
45 Min 12 213.9
50 Mi ,.n . 12 214
a Min 12 214
z 1 Hr 12 214
1 H 10 Mir° 12 214.1
0
Ts�tal Gallons Pum d:826
w-
0
E
Ln
L3.
Thurston County Environmental Health
412.Lilly Rd NE 6 Olympia,WA 98506
360.867-2631
Thtmsnrr
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COLIFORM BACTERIA.ANALYSIS 2
Data Sample Collected Time Sample County
Collected
_
'' � ra'uas onl
Type of Water System(check only one bed) El Private Household
C3 Group>A 0 Group6 )0'Other r W 0
Group'Aend Group 13 Systems-Provide from Water FacllIUas:inventory(WFI)
System Name:
Jr✓ 't T 1/1lATf (Titlitil /�1 U ew
Contact Person: Z O.U.& vJ n S i.
tJfhone(x_5 ) 3U 'T 'g . 'Cell eho4 J i
E•roail:: I1UCs. Ulfr'L 15C..�1L4(rLL EVePhOne:•(--�?,
Send rasulls 10:f nt lug nameraddfess end ip ode or:eman address) I U L=. '�jJii1 7"�V %l,'s C?. � Ft1t, _+u>.�•t _ _. } ` MAR 162026
SAMPLE INFORMATION ply
Sampleooiiectedby(name)syou - W )i•
�Spectl'ic location or address where sample collected.: Special instructions orcdmments:
• 3o7a. $ u7tfIMIIS11Na
Typo of:Sample(must check only and box of#1 though#4 listed below)
1.0 RoullneDistribution.Sample 2.Repeat Sample(after unsat.routine)'
Chlorinated:Yas' No ❑Distribution System`
Chlorine Residual:Total._Free__ Chlorinated:Yew_No
3.Row Water Source Sample Chlorine Residual:Total—Free,
❑;E...coll—'GWR'(AIP)
.❑Fecet-&arace.o s(nunaràn Unsatlefaetory ioutine lab number:
Fttere.d:Yeso:
❑Assessment Monitoring(Alp). Unsatisfactory routine collect dates it
❑Othei J l }
S•
4. Sample for Information Only
Inveetigalive )çCcnatructIon I Repeira Other
• LAB USE ONLY: DRINKING WATER RESULTS LA USEONLY
❑Unsatlafactory•Tolal.Col'l(orm Present and Satisfactory
'❑Ecollpresent ❑Ecoliabsent No. ` orm defected
ReplacementSample;Required:
Sample t000ld,(?30 hours) ❑TNTC• ❑
Bacterial Dens ftyResults Total Cotiform ItOOmL E.00ll /100m!.
Fecal Coifomt /100m1 Enterococci_ 1100 ml.
Method Code M 92238. ❑SM 9222D Data and TtmeaRe cod:6,
SM9215.B. ❑Enterotert�
Dalaand Tkne natyzed:: : Dale RePond. ,.t.l•a•b
Swn*mjgier(00Hmrberous t Leb Use 0nly
0' 8. 0 0.:zo'
DOHFem331S19(a aed J
P jAIJrt/• Ur.. r./ • I°IA i is